Search

Background: Few Australian studies have examined the incidence of prescribed opioid use prior to primary total knee or total hip arthroplasty (TKA, THA) and whether it predicts post-surgery outcomes. A recent Australian study demonstrated that the prevalence of pre-arthroplasty opioid use was approximately 16%. In the United States, approximately 24% of people undergoing TKA or THA are chronic opioid users preoperatively. Purpose: This study aimed to determine (i) the proportion of TKA and THA patients who use prescribed opioids regularly (daily) before surgery (i.e., opioid use reported between the time of waitlisting and any time up to 3 months before surgery), (ii) if opioid use before surgery predicts (a) complication/readmission rates to 6-months post-surgery, and (b) patient-reported outcomes to 6-months post-surgery. Methods: A retrospective cohort study of patients who underwent TKA or THA between January 2013 and June 2018 from two Australian public hospitals was undertaken utilizing linked individual patient-level data from two prospectively collected independent databases comprising approximately 3,500 and 9,500 people (database contained known opioid usage data within the 5-year time frame). Inclusion criteria included (i) primary diagnosis of osteoarthritis of the index joint, (ii) primary elective THA or TKA, and (iii) age ≥ 18 years. Exclusion criteria included (i) revision arthroplasty, (ii) non-elective arthroplasty, (iii) hip hemiarthroplasty, (iv) uni-compartmental knee arthroplasty, and (v) previous unilateral high tibial osteotomy. Results: Analysis was completed on 1,187 study participants (64% female, 69% TKA, mean (SD) age 67 [9.9]). 30% were using regular opioids preoperatively. Adjusted regression analyses controlling for multiple co-variates indicated no significant association between preoperative opioid use and complications/readmission rates or patient-reported outcomes to 6 months post-surgery. Model diagnostics produced poor discrimination for area under the curves and non-significant goodness of fit tests. Pre-arthroplasty opioid use was associated with lower health-related quality of life (EuroQol-Visual Analogue Scale) compared to non-opioid users undergoing primary THA (mean difference -5.04 [-9.87, -0.22], P = 0.04, Adjusted R2 = 0.06) Conclusion: In this study, 30% of patients were using prescribed opioids daily prior to primary TKA or THA. Pre-arthroplasty opioid use was not associated with postoperative adverse events or patient-reported pain, function, or global perceived improvement up to six months post-surgery. [ABSTRACT FROM AUTHOR]

Opioid analgesics prescribed for the management of acute pain following orthopaedic surgery may lead to unintended long-term opioid use and associated patient harms. This study aimed to examine the prevalence of opioid use at 90 days after elective orthopaedic surgery across major city, regional and rural locations in New South Wales, Australia. We conducted a prospective, observational cohort study of patients undergoing elective orthopaedic surgery at five hospitals from major city, regional, rural, public and private settings between April 2017 and February 2020. Data were collected by patient questionnaire at the pre-admission clinic 2–6 weeks before surgery and by telephone call after 90 days following surgery. Of the 361 participants recruited, 54% (195/361) were women and the mean age was 67.7 years (standard deviation 10.1 years). Opioid use at 90 or more days after orthopaedic surgery was reported by 15.8% (57/361; 95% confidence interval (CI) 12.2–20%) of all participants and ranged from 3.5% (2/57) at a major city location to 37.8% (14/37) at an inner regional location. Predictors of long-term postoperative opioid use in the multivariable analysis were surgery performed at an inner regional location (adjusted odds ratio 12.26; 95% CI 2.2–68.24) and outer regional location (adjusted odds ratio 5.46; 95% CI 1.09–27.50) after adjusting for known covariates. Long-term opioid use was reported in over 15% of patients following orthopaedic surgery and appears to be more prevalent in regional locations in Australia. [ABSTRACT FROM AUTHOR]

Introduction: The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). Methods: We analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014--June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE. Results: A total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference = - 10.3%, 95% confidence interval (CI), - 14.8% to - 5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference = - 10.7%, 95% CI, - 17.3% to - 4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference = - 21.4%, 95% CI, - 27.0% to - 16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21 - 0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19 - 0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11 - 0.33]. Conclusion: FPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials. [ABSTRACT FROM AUTHOR]

Background: At this time, there are no studies evaluating the risk of delirium or coma with the use of ketamine in mechanically ventilated adult patients, compared to conventional therapies such as propofol or dexmedetomidine. Objective: The objective of this study was to evaluate the number of days alive without delirium or coma in mechanically ventilated patients in the intensive care unit receiving analgosedation infusions with ketamine versus without ketamine. Methods: This was a retrospective cohort study conducted at an academic medical center in the United States. Consecutive mechanically ventilated adult patients between November 2015 and April 2017 were evaluated. Patients were divided into 2 groups based on the sedative regimen used: ketamine based or nonketamine based. The primary outcome was the number of days alive without delirium or coma. The secondary outcomes were incidence of delirium, incidence of coma, and ventilator-free days at day 28. Results: The study cohort consisted of 79 patients, of which 39 received ketamine- and 40 received nonketamine-based sedation. The number of days alive without delirium or coma was 6 days (interquartile range [IQR]: 2-9 days) with ketamine and 4 days (IQR: 3-7 days) with nonketamine (P =.351). Delirium occurred in 29 (74%) of 39 patients with ketamine and 34 (85%) of 40 patients with nonketamine (P =.274). Coma occurred in 16 (41%) of 39 patients with ketamine and 6 (15%) of 40 patients with nonketamine (P =.013). The median ventilator-free days were 13 days (IQR: 0-23 days) with ketamine and 21 days (0-25 days) with nonketamine (P =.229). Conclusions: Sustained ketamine-based sedation in mechanically ventilated patients may be associated with a higher rate of observed coma but similar delirium- and coma-free days compared nonketamine-based regimens. [ABSTRACT FROM AUTHOR]

Introduction: Airway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period. Methods: An airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means. Results: EM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference = -7.9%, 95% CI -13.4% to -2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%). Conclusion: The use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events. [ABSTRACT FROM AUTHOR]

Background The objective was to determine the impact of a soiled airway on firstpass success when using the GlideScope video laryngoscope or the direct laryngoscope for intubation in the emergency department ( ED). Methods Data were prospectively collected on all patients intubated in an academic ED from July 1, 2007, to June 30, 2016. Patients ≥ 18 years of age, who underwent rapid sequence intubation by an emergency medicine resident with the GlideScope or the direct laryngoscope, were included in the analysis. Data were stratified by device used (GlideScope or direct laryngoscope). The primary outcome was firstpass success. Patients were categorized as those without blood or vomitus ( CLEAN) and those with blood or vomitus ( SOILED) in their airway. Multivariate regression models were developed to control for confounders. Results When using the GlideScope, the firstpass success was lower in the SOILED group (249/306; 81.4%) than the in CLEAN group (586/644, 91.0%; difference = 9.6%; 95% confidence interval [ CI] = 4.7%-14.5%). Similarly, when using the direct laryngoscope, the firstpass success was lower in the SOILED group (186/284, 65.5%) than in the CLEAN group (569/751, 75.8%; difference = 10.3%; 95% CI = 4.0%-16.6%). The SOILED airway was associated with a decreased firstpass success in both the GlideScope cohort (adjusted odds ratio [ aOR] = 0.4; 95% CI = 0.3-0.7) and the direct laryngoscope cohort ( aOR = 0.6; 95% CI = 0.5-0.8). Conclusion Soiling of the airway was associated with a reduced firstpass success during emergency intubation, and this reduction occurred to a similar degree whether using either the GlideScope or the direct laryngoscope. [ABSTRACT FROM AUTHOR]

Objectives The objective of this study was to determine if physicians would alter their prescribing preferences after sampling liquid formulations of medications for common pediatric diagnoses. Methods This was a prospective interventional before/after study conducted at an academic medical center in the United States. The participants of interest included emergency, family medicine, and pediatric physicians. Participants initially completed a brief survey for their primary oral liquid medication of choice for the treatment of selected disease states. These included otitis media, sinusitis, cellulitis, asthma, colitis, and pneumonia. Participants were asked to choose one of the medication options for each disease and then were given all medications to sample for a taste test. The prescribing preference survey was then repeated. The primary outcome was change in prescribing. McNemar's test was used to evaluate change in proportion of medications chosen before and after taste testing. Results There were 101 physicians who participated in the study. There were three conditions for which participants changed their prescribing preferences significantly. These were otitis media (change from amoxicillin to cefdinir, difference = 13.2%, 95% confidence interval [ CI] = 5.5% to 21.0%), asthma exacerbation (change from dexamethasone or prednisone to prednisolone, 28%, 95% CI = 15.9% to 40.1%), and pneumonia (change from azithromycin to amoxicillin, 16.0%, 95% CI = 6.4% to 25.6%). There was no significant change with respect to the other scenarios. Conclusions Physicians showed preferences for certain pediatric medications based on taste and showed significant changes in prescribing preferences for some common pediatric diagnoses after tasting different medications for these conditions. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients boarded in the emergency department (ED) with psychiatric complaints may be at risk for medication errors. However, no studies exist to characterize the types of errors and risk factors for errors in these patients. OBJECTIVE: To characterize medication errors in psychiatric patients boarded in ED, and to identify risk factors associated with these errors. METHODS: A prospective observational study conducted in a community ED included all patients seen in the ED for primary psychiatric complaints and remained in the ED pending transfer to a psychiatric facility. An investigator recorded all medication errors requiring an intervention by an emergency pharmacist. RESULTS: A total of 288 medication errors in 100 patients were observed. Overall, 65 patients had one or more medication errors. The majority of errors (n = 256, 89%) were due to errors of omission. The final severity classification of the medication errors was: Insignificant (n = 77), significant (n = 152), and serious (n = 3). In the multivariate analysis (R-squared 19.6%), increasing number of home medications (OR 1.17, 95% CI 1.01 to 1.36; p = 0.035), and increasing number of comorbidities (OR 1.89, 95% CI 1.10 to 3.27; p = 0.022) were associated with the occurrence of medication errors. CONCLUSION: Psychiatric patients boarded in the ED commonly have medication errors that require intervention. [ABSTRACT FROM AUTHOR]

Propofol use may lead to hypotension in trauma patients intubated in the emergency department. In this study, predictors of hypotension were identified. We hypothesized that demographic variables could be associated with hypotension. Hypotension occurred in 33 of 200 patients. In the multivariate analysis, hypotension was associated with patient age greater than 55 years (odds ratios [OR], 3.61; 95% confidence interval [CI], 1.32-9.86; P = .012), obesity (OR, 2.66; 95% CI, 1.08-6.55; P = .034), and lower baseline blood pressure (OR, 1.59 [per 10-mm Hg decrease]; 95% CI, 1.29-1.96; P = .000). Age greater than 55 years, obesity, and lower baseline systolic blood pressure are associated with a higher risk of propofol-induced hypotension in trauma patients. [ABSTRACT FROM AUTHOR]

The analgesic response and safety of intravenous morphine versus fentanyl for adult trauma patients who presented to the emergency department (ED) were evaluated. Median pain reduction on the numeric rating scale (0-10; 0 = no pain and 10 = worst possible pain) after opioid administration was similar between the groups (2 vs 2; P = .67). The lowest postdose pain score was recorded sooner in the fentanyl group than in the morphine group (22 vs 47 minutes, respectively; P < .001). There were no significant differences in drug-induced adverse effects between groups. Fentanyl produced a similar but more rapid analgesic response compared with morphine in trauma patients. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to determine the effect of paralytic type and dose on first-attempt rapid sequence intubation (RSI) success in the emergency department (ED). Methods: This was a retrospective evaluation of information collected prospectively in a quality improvement database between July 1, 2007, and October 31, 2008. Information regarding all intubations performed in a tertiary care ED was recorded in this database. All RSI performed using succinylcholine or rocuronium were included. Logistic regression was used to analyze the effect of paralytic type and dosing, as well as age, sex, body mass index, physician experience, device type, and presence of difficult airway predictors on first attempt RSI success. Results: A total of 327 RSI were included in the final analyses. All patients received etomidate as the induction sedative and were successfully intubated. Of these, 113 and 214 intubations were performed using succinylcholine and rocuronium, respectively. The rate of first-attempt intubation success was similar between the succinylcholine and rocuronium groups (72.6% vs. 72.9%, p = 0.95). Median doses used for succinylcholine and rocuronium were 1.65 mg/ kg (interquartile range [IQR] = 1.26-1.95 mg/ kg) and 1.19 mg/ kg (IQR = 1-1.45 mg/ kg), respectively. In the univariate logistic regression analyses, variables predictive of first-attempt intubation success were laryngeal view (more success if Grade 1 or 2 compared to Grade 3 or 4 of the Cormack-Lehane classification, odds ratio [OR] = 55.18, 95% confidence interval [CI] = 18.87 to 161.39), intubation device (less success if direct laryngoscopy, OR = 0.57, 95% CI = 0.34 to 0.96), and presence of a difficult airway predictor (OR = 0.55, 95% CI = 0.31 to 0.99). In the multivariate analysis, the only variable predictive of first-attempt intubation success was laryngeal view. Conclusions: Succinylcholine and rocuronium are equivalent with regard to first-attempt intubation success in the ED when dosed according to the ranges used in this study. [ABSTRACT FROM AUTHOR]

Objective: The primary objective of this study was to determine the effectiveness of a lower dose of levetiracetam (500 mg every 12 hours) to prevent early seizures after traumatic brain injury (TBI). It was hypothesized that the seizure rate would be low and comparable to previous studies using phenytoin. Methods: This was a retrospective cohort study conducted in a tertiary care, academic institution that is designated as a level 1 trauma centre in the US. Consecutive patients with TBI were evaluated. Patients who were given a levetiracetam dose of 500 mg every 12 hours were included. The primary outcome was the occurrence of a seizure within 7 days of TBI. Results: There were a total of 169 patients included in the study, who were treated with levetiracetam 500 mg every 12 hours. The median time to first dose of levetiracetam was 3.5 hours after injury (interquartile range = 1–13 hours). After initiation of levetiracetam, there were four (2.4%) patients who had a seizure within 7 days. This was not significantly different than the hypothesized population value of 3.6% (p= 0.390). Conclusions: A lower dose of levetiracetam 500 mg every 12 hours after TBI may be effective for early seizure prevention after TBI. [ABSTRACT FROM AUTHOR]

Background: Although the C-MAC (Karl Storz, Tuttlingen, Germany) is a video laryngoscope (VL), it can also be used as a direct laryngoscope (DL).Objective: The goal of this study was to evaluate the utility of the C-MAC as a DL for intubations in the emergency department (ED).Methods: This was an analysis of prospectively collected continuous quality-improvement data during the 6-year period from February 1, 2009 to January 31, 2015, when both the C-MAC and Macintosh DL (Mac DL) were clinically available in our ED. This analysis included adult patients who underwent rapid sequence intubation by an emergency medicine resident in the ED with a C-MAC initially used as a DL or a Mac DL. The primary outcome measure was the first pass success (FPS).Results: When the C-MAC was used as a DL, the initial DL attempt was successful in 199 of 346 (57.6%) cases. When the attempt could not be completed using the C-MAC as a DL, the operator utilized the video monitor and successfully completed the intubation using VL in 104 of 134 (77.6%) cases, thus achieving an overall FPS of 303 of 346 (87.6%). When the Mac DL was used, the FPS was 505 of 671 (75.3%).Conclusions: The C-MAC is a useful device for DL because in the event of a failed DL attempt, operators have the option of switching to the video monitor to successfully complete the intubation using VL without having to make a second attempt. [ABSTRACT FROM AUTHOR]

Purpose. Results of a comparison of blood product use and cost outcomes with use of 3-factor versus 4-factor prothrombin complex concentrate (PCC) for indications other than warfarin reversal are presented. Methods. Consecutive patients who received 3-factor PPC (PCC3) or 4-factor PCC (PCC4) for non--warfarin-related indications at 2 U.S. hospitals during a 19-month period were identified. The primary outcome was in-hospital blood product use, with a focus on plasma use. Total hemostasis costs, intensive care unit (ICU) and hospital lengths of stay, and other outcomes were evaluated. Results. Indications for PCC3 use (n = 118) or PCC4 use (n = 64) included intraoperative bleeding, nonintraoperative bleeding, coagulopathy of liver disease, and reversal of direct-acting oral anticoagulant effects. The proportion of patients who received plasma was 56.8% with PCC3 use versus 53.1% with PCC4 use (p = 0.643); the corresponding median volumes of plasma received were 638 mL (interquartile range [IQR], 550-1,355 mL) and 656 mL (IQR, 532-1,136 mL), respectively. The median total hemostasis costs were $5,559 (IQR, $3,922-$8,159) with PCC3 use and $7,771 (IQR, $6,366-$9,205) with PCC4 use (p < 0.001). Conclusion. PCC3 use and PCC4 use were associated with similar blood product use, ICU length of stay, hospital length of stay, and in-hospital mortality when given for non--warfarin-related indications. However, relative to PCC3 use, PCC4 use was associated with an increase in costs that was primarily due to drug costs. [ABSTRACT FROM AUTHOR]

To identify predictors of patient satisfaction with pain control measured after emergency department (ED) discharge. This was a prospective, cross-sectional study conducted in an academic, urban ED in the United States. Adult patients with a pain-related complaint were interviewed via telephone within 72 hr of discharge from the ED. A standardized questionnaire was used to obtain demographic and clinical information. The primary outcome of interest was patient satisfaction with pain management in the ED measured using the following question: "How often was your pain well controlled in the ED?" (0-10 scale; 0 = never, 10 = always). Linear regression analyses were used to identify predictors of pain satisfaction. The study included 75 patients. The mean age of patients was 43 ± 18 years, and the majority of patients were female (n = 47; 63%). There were 24 patients (32%) who had chronic pain conditions, 23 (31%) with depression, and 2 patients who admitted to using heroin. In the multivariate regression analysis, patient perception of enough pain medication provision (coefficient = 2.81; 95% CI [1.35, 4.26]; p < 0.001), staff helpfulness (coefficient = 0.35; 95% CI [0.10, 0.59]; p = 0.006), report of generalized pain (coefficient = -1.62; 95% CI [-2.87, -0.36]; p = 0.013), and lowest pain score achieved in the ED (coefficient=-0.30; 95% CI [-0.53, -0.04]; p = 0.021) was significantly associated with patient satisfaction (model R² = 0.57). Patient perception of enough pain medication provision, staff helpfulness, lowest pain scores achieved, and patient report of generalized pain were associated with satisfaction with pain management in the ED. [ABSTRACT FROM AUTHOR]