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Galili SF, Nikolajsen L, Bech BH, Kirkegaard H, Ahrensberg J. As-needed opioid dosing for emergency patients with a daily use of opioids. Acta Anaesthesiol Scand 2024; 68:410-416. [PMID: 37877497 DOI: 10.1111/aas.14351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/28/2023] [Accepted: 10/13/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Patients with a daily use of opioids have a higher risk of insufficient pain treatment during hospitalization than other patients. This study aimed to examine whether as-needed opioid doses (PRN) were adequately adjusted when patients were admitted to the emergency department (ED) with pain. METHODS Patients, with a daily use of opioids, who received PRN opioid within the first 3 h after admission at the ED at Aarhus University Hospital, Denmark, were prospectively included from February 2021 to June 2021. The primary outcome was the proportion of patients receiving an inadequate initial dose of PRN opioid, here defined as <15% of daily dose of opioids (DDO) based on sparse evidence, but aligning with the prevailing clinical practice. Secondary outcomes included risk of an inadequate PRN dose in relation to DDO (patients were dichotomized into two groups (DDO <60 or ≥60 mg/day). RESULTS Among 252 patients admitted to the ED with a daily use of opioids, 149 were admitted with pain and 82 received a PRN opioid dose within 3 h. Twenty-seven out of 82 (33%) patients received a PRN dose of <15% of DDO (95% CI: 23.7-43). When dichotomised; 10 out of 50 (20%) patients with a DDO <60 mg/day (95% CI: 10.0-33.7) versus 17 out of 32 (53.1%) patients with a DDO ≥60 mg/day (95% CI: 34.7-70.9) received an inadequate PRN dose (relative risk, RR: 2.65 [95% CI: 1.4-5.1]). CONCLUSIONS Patients with daily use of opioids presenting in the ED with acute pain had a high risk of inadequate PRN opioid dose, especially if the DDO was high. Awareness about and education focusing on sufficient PRN doses for patients with a daily use of opioids is (still) called for.
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Affiliation(s)
- Stine Fjendbo Galili
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Nikolajsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Bodil Hammer Bech
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Hans Kirkegaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jette Ahrensberg
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
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2
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Serra S, Spampinato MD, Riccardi A, Guarino M, Fabbri A, Orsi L, De Iaco F. Pain Management at the End of Life in the Emergency Department: A Narrative Review of the Literature and a Practical Clinical Approach. J Clin Med 2023; 12:4357. [PMID: 37445392 DOI: 10.3390/jcm12134357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Access to pain management is a fundamental human right for all people, including those who are at the end of life (EOL). In end-stage patients, severe and uncontrolled pain is a common cause of admission to the emergency department (ED), and its treatment is challenging due to its complex, often multifactorial genesis. The aim of this narrative review was to identify the available literature on the management of severe EOL pain in the ED. The MEDLINE, SCOPUS, EMBASE, and CENTRAL databases were searched from inception to 1 April 2023 including randomised controlled trials, observational studies, systemic or narrative reviews, case reports, and guidelines on the management of EOL pain in the ED. A total of 532 articles were identified, and 9 articles were included (5 narrative reviews, 2 retrospective studies, and 2 prospective studies). Included studies were heterogeneous on the scales used and recommended for pain assessment and the recommended treatments. No study provided evidence for a better approach for EOL patients with pain in the ED. We provide a narrative summary of the findings and a review of the management of EOL pain in clinical practice, including (i) the identification of the EOL patients and unmet palliative care needs, (ii) a multidimensional, patient-centred assessment of the type and severity of pain, (iii) a multidisciplinary approach to the management of end-of-life pain, including an overview of non-pharmacological and pharmacological techniques; and (iv) the management of special situations, including rapid acute deterioration of chronic pain, breakthrough pain, and sedative palliation.
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Affiliation(s)
- Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47521 Cesena, Italy
| | | | | | - Mario Guarino
- UOC MEU Ospedale CTO-AORN dei Colli Napoli, 80131 Napoli, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Luciano Orsi
- Palliative Care Physician and Scientific Director of "Rivista Italiane di Cure Palliative", 26013 Crema, Italy
| | - Fabio De Iaco
- Struttura Complessa di Medicina di Emergenza Urgenza Ospedale Maria Vittoria, ASL Città di Torino, 10144 Torino, Italy
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3
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Krishnamani PP, Qdaisat A, Wattana MK, Lipe DN, Sandoval M, Elsayem A, Cruz Carreras MT, Yeung SCJ, Chaftari PS. Characteristics and Outcomes of Patients with Cancer Pain Placed in an Emergency Department Observation Unit. Cancers (Basel) 2022; 14:cancers14235871. [PMID: 36497353 PMCID: PMC9738053 DOI: 10.3390/cancers14235871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/19/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022] Open
Abstract
Pain remains an undertreated complication of cancer, with poor pain control decreasing patients’ quality of life. Traditionally, patients presenting to an emergency department with pain have only had two dispositions available to them: hospitalization or discharge. A third emerging healthcare environment, the emergency department observation unit (EDOU), affords patients access to a hospital’s resources without hospitalization. To define the role of an EDOU in the management of cancer pain, we conducted a retrospective study analyzing patients placed in an EDOU with uncontrolled cancer pain for one year. Patient characteristics were summarized using descriptive statistics and predictors of disposition from the EDOU and were identified with univariate and multivariate analyses. Most patients were discharged home, and discharged patients had low 72-hour revisit and 30-day mortality rates. Significant predictors of hospitalization were initial EDOU pain score (odds ratio (OR) = 1.12; 95% CI 1.06−1.19; p < 0.001) and supportive care (OR = 2.04; 95% CI 1.37−3.04; p < 0.001) or pain service (OR = 2.67; 95% CI 1.63−4.40; p < 0.001) consultations. We concluded that an EDOU appears to be the appropriate venue to care for a subsegment of patients presenting to an emergency department with cancer pain, with patients receiving safe care as well as appropriate consultation and admission when indicated.
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Affiliation(s)
- Pavitra Parimala Krishnamani
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Monica Kathleen Wattana
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Demis N. Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- IQVIA Biotech, Morrisville, NC 27560, USA
| | - Marcelo Sandoval
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ahmed Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Maria Teresa Cruz Carreras
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Patrick S. Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence:
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4
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Gould Rothberg BE, Quest TE, Yeung SCJ, Pelosof LC, Gerber DE, Seltzer JA, Bischof JJ, Thomas CR, Akhter N, Mamtani M, Stutman RE, Baugh CW, Anantharaman V, Pettit NR, Klotz AD, Gibbs MA, Kyriacou DN. Oncologic emergencies and urgencies: A comprehensive review. CA Cancer J Clin 2022; 72:570-593. [PMID: 35653456 DOI: 10.3322/caac.21727] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.
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Affiliation(s)
- Bonnie E Gould Rothberg
- Yale Cancer Center Innovations Laboratory, Yale Comprehensive Cancer Center, New Haven, Connecticut
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lorraine C Pelosof
- Office of Oncologic Diseases, US Food and Drug Administration, Silver Spring, Maryland
| | - David E Gerber
- Division of Hematology-Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas
| | - Justin A Seltzer
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mira Mamtani
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robin E Stutman
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Venkataraman Anantharaman
- Department of Emergency Medicine, Singapore General Hospital, SingHealth Duke-National University of Singapore Academic Medical Center, Singapore, Singapore
| | - Nicholas R Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam D Klotz
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Gibbs
- Department of Emergency Medicine, Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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5
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Singh SA, Moreland RA, Fang W, Shaikh P, Perez JM, Morris AM, Dahshan B, Krc RF, Chandran D, Holbein M. Compassion Inequities and Opioid Use Disorder: A Matched Case-Control Analysis Examining Inpatient Management of Cancer-Related Pain for Patients With Opioid Use Disorder. J Pain Symptom Manage 2021; 62:e156-e163. [PMID: 33984461 PMCID: PMC8416788 DOI: 10.1016/j.jpainsymman.2021.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 11/24/2022]
Abstract
CONTEXT The opioid epidemic spurred guidelines intended to reduce inappropriate prescribing. Although acute cancer-related pain was excluded from these recommendations, studies demonstrate reduced opioid prescribing for patients hospitalized with advanced cancer. OBJECTIVES We performed a matched case-control analysis to determine how a history of opioid use disorder (OUD) affects inpatient management of cancer pain. METHODS Charts of patients with OUD admitted for cancer pain from 2015-2020 were retrospectively reviewed. Hospitalizations were matched 1:1 by patient age and sex. Home milligram-morphine equivalent per day (MME/day) was calculated from the home medication list. Admission MME/day was the average MME/day administered during hospitalization. RESULTS A total of 80 hospitalizations (40:40) were matched for 25 patients with a history of OUD and 31 patients with no history of OUD. Cancer was metastatic/relapsed for 70% of admissions. The median overall survival was 2.3 months (95% CI 0-5.21, P = 0.13). Patients with OUD had a significantly lower change from Home to Admission MME/day (-3 vs. 37, P < 0.01) and were less likely to have any increase in Admission MME/day (OR 0.1, 95% CI 0.02-0.43, P < 0.01). When considering opioids administered after pain specialty consultation, there was no difference between groups. CONCLUSION Our results suggest that patients with OUD receive lower quality inpatient management of cancer-related pain. Provider education and early involvement of pain specialists are crucial in delivering equitable and compassionate end-of-life care for patients with OUD.
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Affiliation(s)
- Sarah A Singh
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA.
| | - Rachel A Moreland
- Department of Psychiatry, West Virginia University, Morgantown, West Virginia, USA
| | - Wei Fang
- Department of Biostatistics, Clinical and Translational Science Institute, West Virginia University Health Sciences Center Erma Byrd Biomedical Research Center, Morgantown, West Virginia, USA
| | - Parvez Shaikh
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - John Michael Perez
- Department of Psychiatry, West Virginia University, Morgantown, West Virginia, USA
| | - Ann M Morris
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Basem Dahshan
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Rebecca F Krc
- Department of Radiation Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Dilip Chandran
- Department of Psychiatry, West Virginia University, Morgantown, West Virginia, USA
| | - Monika Holbein
- Department of Hematology and Oncology, West Virginia University, Morgantown, West Virginia, USA
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6
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Alsharawneh A, Hasan AAH. Cancer related emergencies with the chief complaint of pain: Incidence, ED recognition, and quality of care. Int Emerg Nurs 2021; 56:100981. [PMID: 33706045 DOI: 10.1016/j.ienj.2021.100981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/16/2021] [Accepted: 02/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pain is the most common reason for cancer-related emergency department (ED) visits and a precursor of the urgency of oncological emergencies. PURPOSE To identify the incidence of oncological emergencies with the chief complaint of pain and evaluate ED recognition and quality of care in managing the associated emergency. METHODS This was a retrospective observational study of cancer patients presented to three EDs during the four-year study period. RESULTS The study's sample consisted of 252 patients admitted with oncological emergencies with a chief complaint of pain. Some oncological emergencies were more likely to be prioritized appropriately, such as febrile neutropenia and increased intracranial pressure. However, most patients with spinal cord compression and cardiac tamponade were more likely to be triaged to less urgent triage categories. Timeliness of ED care was suboptimal for most patients, particularly among those assigned to less urgent triage categories. Indicators for the low quality of care extended beyond ED with multiple adverse events in the hospital. CONCLUSION Triage nurses are expected to use the oncological emergencies' prevalent symptoms to allocate the patients to high triage urgency accurately. Patient waiting to be seen expected to be reassessed periodically to ensure waiting remain safe. Hospitals can adopt or establish pathways, protocols, or standardized order sets to fast-track patients with oncological emergencies. The health information system should be available to monitor and improve the delivered care continuously.
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Affiliation(s)
| | - Abd Al-Hadi Hasan
- Fakeeh College for Medical Sciences, P.O. box 2537, Jeddah 21461, Saudi Arabia
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7
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Coyne CJ, Reyes-Gibby CC, Durham DD, Abar B, Adler D, Bastani A, Bernstein SL, Baugh CW, Bischof JJ, Grudzen CR, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Pallin DJ, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Caterino JM. Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN). Support Care Cancer 2021; 29:4543-4553. [PMID: 33483789 DOI: 10.1007/s00520-021-05987-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/04/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. METHODS We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. RESULTS The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). CONCLUSIONS Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.
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Affiliation(s)
- Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, 200 W. Arbor Dr. #8676, San Diego, CA, 92103, USA.
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Danielle D Durham
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital - Troy Campus, Troy, MI, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, NY, USA
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Troy E Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Richard J Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Charles R Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Sciences University, Portland, OR, USA
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine and Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey M Caterino
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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8
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Intrathecal delivery of hydromorphone vs morphine for refractory cancer pain: a multicenter, randomized, single-blind, controlled noninferiority trial. Pain 2020; 161:2502-2510. [DOI: 10.1097/j.pain.0000000000001957] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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9
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Abstract
This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY, 11367, United States.
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10
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Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs 2019; 80:9-21. [DOI: 10.1007/s40265-019-01236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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11
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The Use of Ketamine as an Adjunct to Treating Opioid Refractory Cancer-Related Pain in the Emergency Department. Adv Emerg Nurs J 2019; 41:101-106. [PMID: 31033656 DOI: 10.1097/tme.0000000000000244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Research to Practice column is designed to provide advanced practice registered nurses (APRNs) with an analysis of a current research topic with implications for practice change within the emergency care settings. This review examines a recent study conducted by entitled "Ketamine as an adjunct to opioids for acute pain in the emergency department: A randomized controlled trial." The authors conducted a randomized, double-blinded, placebo-controlled trial at a single academic emergency department (ED) to compare standard opioid pain control in the ED population to the use of ketamine in conjunction with opioids in the same population. Participants were randomized into either the ketamine group, receiving 0.1 mg/kg of ketamine in conjunction with an intravenous opioid, or to the control group, receiving an equivalent volume of normal saline in addition to an intravenous opioid. Participants were evaluated for adequacy of pain control, side effects, and level of sedation every 30 min up to the 120-min time point. Data revealed that patients receiving ketamine had a statistically significant lower mean pain score, 0.6512 (p = 0.0083), compared with patients in the control group. The data also showed that patient satisfaction with pain control was similar for the ketamine group and the control group. These and other associated findings have implications for APRN practice, including managing acute pain in the ED setting and preventing hospital admission of acute-on-chronic pain exacerbations in the ED.
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12
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Caterino JM, Adler D, Durham DD, Yeung SCJ, Hudson MF, Bastani A, Bernstein SL, Baugh CW, Coyne CJ, Grudzen CR, Henning DJ, Klotz A, Madsen TE, Pallin DJ, Reyes-Gibby CC, Rico JF, Ryan RJ, Shapiro NI, Swor R, Venkat A, Wilson J, Thomas CR, Bischof JJ, Lyman GH. Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments. JAMA Netw Open 2019; 2:e190979. [PMID: 30901049 PMCID: PMC6583275 DOI: 10.1001/jamanetworkopen.2019.0979] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. OBJECTIVE To provide a benchmark description of patients who present to the ED with active cancer. DESIGN, SETTING, AND PARTICIPANTS This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. MAIN OUTCOMES AND MEASURES The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. RESULTS Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. CONCLUSIONS AND RELEVANCE This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.
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Affiliation(s)
- Jeffrey M. Caterino
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - Danielle D. Durham
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Sai-Ching Jim Yeung
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Matthew F. Hudson
- Greenville Health System Cancer Institute, Greenville, South Carolina
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital–Troy Campus, Troy, Michigan
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Troy E. Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Cielito C. Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa
| | - Richard J. Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa
| | - Charles R. Thomas
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health & Sciences University, Portland
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Gary H. Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Department of Medicine, University of Washington School of Medicine, Seattle
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