1
|
Roy S, Bruehl S, Feng X, Shotwell MS, Van De Ven T, Shaw AD, Kertai MD. Developing a risk stratification tool for predicting opioid-related respiratory depression after non-cardiac surgery: a retrospective study. BMJ Open 2022; 12:e064089. [PMID: 36219738 PMCID: PMC9445779 DOI: 10.1136/bmjopen-2022-064089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Accurately assessing the probability of significant respiratory depression following opioid administration can potentially enhance perioperative risk assessment and pain management. We developed and validated a risk prediction tool to estimate the probability of significant respiratory depression (indexed by naloxone administration) in patients undergoing noncardiac surgery. DESIGN Retrospective cohort study. SETTING Single academic centre. PARTICIPANTS We studied n=63 084 patients (mean age 47.1±18.2 years; 50% men) who underwent emergency or elective non-cardiac surgery between 1 January 2007 and 30 October 2017. INTERVENTIONS A derivation subsample reflecting two-thirds of available patients (n=42 082) was randomly selected for model development, and associations were identified between predictor variables and naloxone administration occurring within 5 days following surgery. The resulting probability model for predicting naloxone administration was then cross-validated in a separate validation cohort reflecting the remaining one-third of patients (n=21 002). RESULTS The rate of naloxone administration was identical in the derivation (n=2720 (6.5%)) and validation (n=1360 (6.5%)) cohorts. The risk prediction model identified female sex (OR: 3.01; 95% CI: 2.73 to 3.32), high-risk surgical procedures (OR: 4.16; 95% CI: 3.78 to 4.58), history of drug abuse (OR: 1.81; 95% CI: 1.52 to 2.16) and any opioids being administered on a scheduled rather than as-needed basis (OR: 8.31; 95% CI: 7.26 to 9.51) as risk factors for naloxone administration. Advanced age (OR: 0.971; 95% CI: 0.968 to 0.973), opioids administered via patient-controlled analgesia pump (OR: 0.55; 95% CI: 0.49 to 0.62) and any scheduled non-opioids (OR: 0.63; 95% CI: 0.58 to 0.69) were associated with decreased risk of naloxone administration. An overall risk prediction model incorporating the common clinically available variables above displayed excellent discriminative ability in both the derivation and validation cohorts (c-index=0.820 and 0.814, respectively). CONCLUSION Our cross-validated clinical predictive model accurately estimates the risk of serious opioid-related respiratory depression requiring naloxone administration in postoperative patients.
Collapse
Affiliation(s)
- Sounak Roy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas Van De Ven
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio, USA
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
2
|
Erlenwein J, Maring M, Emons MI, Gerbershagen HJ, Waeschle RM, Saager L, Petzke F. [Critical incidents in acute pain management-A risk analysis of CIRS reports]. Anaesthesist 2022; 71:350-361. [PMID: 34613456 PMCID: PMC9068662 DOI: 10.1007/s00101-021-01041-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/24/2021] [Accepted: 08/10/2021] [Indexed: 10/28/2022]
Abstract
BACKGROUND Areas of activity with many intersections pose an increased risk for errors and critical incidents. Therefore, procedures for acute pain therapy are potentially associated with an increased risk for adverse patient outcomes. OBJECTIVE The aim was to identify and grade the risk of critical incidents in the context of acute pain management. MATERIAL AND METHODS The register of the nationwide reporting system critical incident reporting system of the Professional Association of German Anesthesiologists, the German Society for Anesthesiology and Intensive Care Medicine and the Medical Center for Quality in Medicine (CIRSmedical Anesthesiology) was screened for incidents concerning pain management. Out of 5365 cases reported nationwide up to 24 March 2020, 508 reports with the selection criterion "pain" could be identified and reviewed and 281 reports (55%) were included in a systematic analysis. RESULTS Of the 281 reports most came from anesthesiology departments (94%; 3% from surgery departments and 3% from other departments). The reported cases occurred most frequently on normal wards but a relevant proportion of the reports concerned intermediate and intensive care units or areas covered by a pain service (PS). Based on the description of the incident in the report, an involvement of the PS could be assumed for 42% of the cases. In terms of time, most of the events could be assigned to normal working hours (90%) and working days (84%; weekends 16%). The analyzed reports related to parenteral administration of analgesics (40%) and central (40%) or peripheral regional anesthesia procedures (23%) and 13% of the reports related to patient-controlled intravenous analgesia (PCIA; multiple answers possible). Most of the events were caused by technical errors, communication deficits and deviations from routine protocols. A relevant number of the cases were based on mix-ups in the administration route, the dosage, or the active agent. About one third of the sources of error were of an organizational nature, 59% of the cases posed a possible vital risk and in 16% of cases patients had vital complications. The risk grading by risk matrix resulted in an extremely high risk in 7%, a high risk in 62%, a moderate risk in 25% and a low risk in 6% of the cases. Comparing risk assessment of events with involvement of different analgesic methods, multiple medication, combination of analgesic methods or involvement of PS showed no significant differences. Likewise, no differences could be identified between the risk assessments of events at different superordinate cause levels. If more than one overriding cause of error had an impact, initially no higher risk profile was found. CONCLUSION Incidents in the context of acute pain management can pose high risks for patients. Incidents or near-incidents are mostly related to mistakes and lack of skills of the staff, often due to time pressure and workload as well as to inadequate organization.
Collapse
Affiliation(s)
- J Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - M Maring
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - M I Emons
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - H J Gerbershagen
- Klinik für Anästhesiologie, Operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Marienhospital, Gelsenkirchen, Deutschland
| | - R M Waeschle
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - L Saager
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - F Petzke
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| |
Collapse
|
3
|
Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study. Can J Anaesth 2020; 68:324-335. [PMID: 33205265 DOI: 10.1007/s12630-020-01864-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Patient-controlled oral analgesia (PCOA) is a novel method of oral opioid administration using set doses of short-acting oral opioids self-administered by patients with a "lockout" period as part of a multimodal regimen. Failure of PCOA can result in severe postoperative pain necessitating use of intravenous patient-controlled analgesia (IV-PCA) with its potential complications. This study evaluated factors related to success or failure of PCOA following total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS We conducted a retrospective cohort study of all adults who underwent THA and TKA at our institution by extracting data from the proprietary database of our acute pain service. Patient, anesthetic, and surgical variables associated with PCOA failure defined as inadequate analgesia requiring conversion to IV-PCA within 24 hr following THA and TKA were evaluated. Univariable and multivariable logistic regression analyses were performed to identify predictors of PCOA failure. RESULTS Of the 926 patients who underwent THA or TKA (n = 411 and 515, respectively), 147 (15.9%) patients (67 THA and 80 TKA patients) had PCOA failure with moderate-to-severe pain. Multivariable regression analysis showed that PCOA failure occurred in those with younger age (adjusted odds ratio [aOR] per year of age, 0.97; 99% CI, 0.95 to 0.99; P < 0.001), preoperative chronic use of controlled-release opioids (aOR, 3.45; 99% CI, 1.60 to 7.35; P < 0.001), and with the use of general anesthesia vs spinal anesthesia (aOR, 2.86; 99% CI, 1.20 to 6.84; P = 0.002). CONCLUSION The use of PCOA provides adequate analgesia to a majority of patients undergoing THA and TKA. Factors predictive for PCOA failure should be considered when choosing the primary breakthrough analgesic modality following THA/TKA.
Collapse
|
4
|
Sng BL, Tan DJ, Tan CW, Han NLR, Sultana R, Sia ATH. A preliminary assessment of vital-signs-integrated patient-assisted intravenous opioid analgesia (VPIA) for postsurgical pain. BMC Anesthesiol 2020; 20:145. [PMID: 32513113 PMCID: PMC7278166 DOI: 10.1186/s12871-020-01060-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 05/28/2020] [Indexed: 02/07/2023] Open
Abstract
Background We developed a Vital-signs-integrated Patient-assisted Intravenous opioid Analgesia (VPIA) analgesic infusion pump, a closed-loop vital signs monitoring and drug delivery system which embodied in a novel algorithm that took into account patients’ vital signs (oxygen saturation, heart rate). The system aimed to allow responsive titration of personalized pain relief to optimize pain relief and reduce the risk of respiratory depression. Moreover, the system would be important to enable continuous monitoring of patients during delivery of opioid analgesia. Methods Nineteen patients who underwent elective gynecological surgery with postoperative patient controlled analgesia (PCA) with morphine were recruited. The subjects were followed up from their admission to the recovery room/ ward for at least 24 h until assessment of patient satisfaction on the VPIA analgesic infusion pump. Results The primary outcome measure of incidence of oxygen desaturation showed all patients had at least one episode of oxygen desaturation (< 95%) during the study period. Only 6 (31.6%) patients had oxygen desaturation that persisted for more than 5 min. The median percentage time spent during treatment that oxygen saturation fell below 95% was 1.9%. Fourteen (73.7%) out of 19 patients encountered safety pause, due to transient oxygen desaturation or bradycardia. The patients’ median [IQR] pain scores at rest and at movement after post-op 24 h were 0.0 [2.0] and 3.0 [2.0], respectively. The average morphine consumption in the first 24 h was 12.5 ± 7.1 mg. All patients were satisfied with their experience with the VPIA analgesic infusion pump. Conclusions The use of VPIA analgesic infusion pump, when integrated with continuous vital signs monitor and variable lockout algorithm, was able to provide pain relief with good patient satisfaction. Trial registration This study was registered on clinicaltrials.gov registry (NCT02804022) on 28 Feb 2016.
Collapse
Affiliation(s)
- Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore. .,Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore, Singapore.
| | - Daryl Jian'an Tan
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Chin Wen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore
| | - Nian-Lin Reena Han
- Division of Clinical Support Services, KK Women's and Children's Hospital, Singapore, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Alex Tiong Heng Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore.,Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| |
Collapse
|
5
|
CE: Original Research: Errors in Postoperative Administration of Intravenous Patient-Controlled Analgesia: A Retrospective Study. Am J Nurs 2020; 119:22-27. [PMID: 30864954 DOI: 10.1097/01.naj.0000554523.94502.4c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Background: Intravenous patient-controlled analgesia (IV PCA), which typically involves opioids, has become widely used in clinical settings as an effective method of pain management. Identifying errors in the administration of these drugs is essential to improving patient outcomes. This study sought to describe and analyze the errors associated with postoperative IV PCA. METHODS Relevant data were collected from the medical records of all patients who received IV PCA at a large academic medical center in South Korea during a three-year period. The study sample comprised 45,104 patients who used one of four types of IV PCA delivery devices. RESULTS Errors occurred in 406 cases (0.9%). Operator error was the most common type of error (54.7%), followed by device malfunction (32.3%), prescription error (12.3%), and patient error (0.7%). Of the 222 operator errors, the most frequent type was failure to begin IV PCA drug administration (28.8%), followed by programming errors by non-anesthesia providers who weren't authorized to program the device (24.8%) and wrong infusion rates set by anesthesia providers who were so authorized (24.8%). CONCLUSIONS The findings provide valuable information that can aid in the development of policy and procedures for safer, more effective postoperative administration of IV PCA. They also suggest that it's necessary not only to improve the operation of acute pain services teams, but also to ensure ongoing provider and patient education specific to IV PCA use.
Collapse
|
6
|
Son HJ, Kim SH, Ryu JO, Kang MR, Kim MH, Suh JH, Hwang JH. Device-Related Error in Patient-Controlled Analgesia: Analysis of 82,698 Patients in a Tertiary Hospital. Anesth Analg 2019; 129:720-725. [PMID: 31425211 DOI: 10.1213/ane.0000000000003397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patient-controlled analgesia (PCA) is one of the most popular and effective methods for managing postoperative pain. Various types of continuous infusion pumps are available for the safe and accurate administration of analgesic drugs. Here we report the causes and clinical outcomes of device-related errors in PCA. METHODS Clinical records from January 1, 2011 to December 31, 2014 were collected by acute pain service team nurses in a 2715-bed tertiary hospital. Devices for all types of PCA, including intravenous PCA, epidural PCA, and nerve block PCA, were included for analysis. The following 4 types of infusion pumps were used during the study period: elastomeric balloon infusers, carbon dioxide-driven infusers, semielectronic disposable pumps, and electronic programmable pumps. We categorized PCA device-related errors based on the error mechanism and clinical features. RESULTS Among 82,698 surgical patients using PCA, 610 cases (0.74%) were reported as human error, and 155 cases (0.19%) of device-related errors were noted during the 4-year study period. The most common type of device-related error was underflow, which was observed in 47 cases (30.3%). The electronic programmable pump exhibited the high incidence of errors in PCA (70 of 15,052 patients; 0.47%; 95% confidence interval, 0.36-0.59) among the 4 types of devices, and 96 of 152 (63%) patients experienced some type of adverse outcome, ranging from minor symptoms to respiratory arrest. CONCLUSIONS The incidence of PCA device-related errors was <0.2% and significantly differed according to the infusion pump type. A total of 63% of patients with PCA device-related errors suffered from adverse clinical outcomes, with no mortality. Recent technological advances may contribute to reducing the incidence and severity of PCA errors. Nonetheless, the results of this study can be used to improve patient safety and ensure quality care.
Collapse
Affiliation(s)
- Hyo-Jung Son
- From the Charité International Academy, Charite Universitätmedizi, Berlin, Germany
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ok Ryu
- Department of Nursing, Acute Pain Service Team, Asan Medical Center, Seoul, Republic of Korea
| | - Mi-Ra Kang
- Department of Nursing, Acute Pain Service Team, Asan Medical Center, Seoul, Republic of Korea
| | - Myeong-Hee Kim
- Department of Nursing, Acute Pain Service Team, Asan Medical Center, Seoul, Republic of Korea
| | - Jeong-Hun Suh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
7
|
Suess TM, Beard JW, Trohimovich B. Impact of Patient-Controlled Analgesia (PCA) Smart Pump-Electronic Health Record (EHR) Interoperability with Auto-Documentation on Chart Completion in a Community Hospital Setting. Pain Ther 2019; 8:261-269. [PMID: 31350711 PMCID: PMC6857105 DOI: 10.1007/s40122-019-0132-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Complete and accurate documentation of opioids administered by patient-controlled analgesia (PCA) pumps is critical for ensuring a high-quality medication record and an accurate conversion of the intravenous (IV) regimen to oral therapy. Incomplete charting of PCA usage through a manual process may be associated with fragmented documentation of delivered therapy affecting the completeness of the medical record and the IV to oral dose conversion. This study is the first to evaluate the association between auto-documentation of opioid administration provided by PCA smart pump-electronic health record (EHR) interoperability and the completion of PCA opioid administration charting tasks. METHODS This retrospective cohort study was conducted at Lancaster General Hospital, Lancaster, Pennsylvania. Patients were assigned to pre-auto-documentation (n = 55) or post-auto-documentation groups (n = 58) based on whether they received PCA therapy prior to or after PCA-EHR interoperability was implemented. Charting of PCA therapy included documentation of the number of patient attempts, number of doses given, and total volume infused for both pre- and post-auto-documentation groups. In addition, total dose delivered was documented for the post-auto-documentation group. The overall chart-field completion rate was evaluated as the primary outcome. Individual chart completion percentages were assessed by stratified groups as secondary outcomes. RESULTS PCA smart pump-EHR interoperability with auto-documentation was associated with an increase in overall chart-field completion rate from 69.9 to 97.0% (p < 0.001). Auto-documentation was also associated with an increase in fully completed charts from 38 to 91% (139.3% increase, p < 0.001) and reductions of incomplete records in each stratified group (p < 0.001). CONCLUSIONS PCA smart pump-EHR interoperability with auto-documentation is associated with significant improvements in the completion of opioid administration chart-fields. Improved documentation of PCA administered opioids may have implications for the safety of opioid administration. Additional studies will be needed to assess the potential clinical impact of these results. FUNDING ICU Medical, Inc.
Collapse
|
8
|
Leykin Y, Laudani A, Busetto N, Chersini G, Lorini LF, Bugada D. Sublingual sufentanil tablet system for postoperative analgesia after gynecological surgery. Minerva Med 2019; 110:209-215. [DOI: 10.23736/s0026-4806.19.05992-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
9
|
Santangelo D, Page CR, Danesi H, Jones JB, Joshi N, Wilcox SB, Sneeringer P, Phipps JB. Human Factors Results for Fentanyl Iontophoretic Transdermal System (ITS) With Enhanced Controller for Postoperative Pain Management. J Perianesth Nurs 2018; 33:537-550. [PMID: 30077298 DOI: 10.1016/j.jopan.2016.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 03/08/2016] [Accepted: 03/16/2016] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this analysis was to conduct summative usability evaluations, including behavioral and subjective evaluations, for the fentanyl iontophoretic transdermal system (ITS). DESIGN Four usability studies were conducted in representative users. METHODS The first three studies were conducted with (1) health care professionals (HCPs; N = 31), (2) patients who received placebo fentanyl ITS (N = 30), and (3) healthy volunteers (N = 30), and focused on the understanding and use of fentanyl ITS. The fourth study included HCPs (N = 31) and healthy volunteers (N = 30), and focused on the effectiveness of formal training regarding the use of fentanyl ITS. FINDINGS Overall, user groups found the fentanyl ITS easy to use. There were no use errors that could potentially have safety implications. In the three early studies, there were some minor difficulties experienced; however, the introduction of a structured training reduced these difficulties. CONCLUSIONS Patients, nurses, and pharmacists were able to use fentanyl ITS with ease.
Collapse
|
10
|
Mohanty M, Lawal OD, Skeer M, Lanier R, Erpelding N, Katz N. Medication errors involving intravenous patient-controlled analgesia: results from the 2005-2015 MEDMARX database. Ther Adv Drug Saf 2018; 9:389-404. [PMID: 30364852 PMCID: PMC6199682 DOI: 10.1177/2042098618773013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of this study was to determine the current magnitude and characteristics of intravenous patient-controlled analgesia (IV-PCA) errors, and to identify opportunities for improving the PCA modality. METHODS We conducted a descriptive analysis of IV-PCA medication errors submitted to the MEDMARX database. Events were restricted to those occurring in inpatient hospital settings between 1 January 2005 and 31 December 2015. IV-PCA errors were classified by error category, cause of error, error type, level of care rendered, and actions taken. RESULTS A total of 1948 IV-PCA errors were identified as potential errors (3.9%), nonharmful errors (89.5%), or harmful errors (6.7%) based on the National Coordinating Council for Medication Error Reporting and Prevention taxonomy for categorizing medication errors. Of these, 19.1% required a clinical intervention to address the deleterious effects of the error, indicating an underestimation of the risks associated with IV-PCA errors. The most frequent types of errors were improper dose/quantity (43.2%) and omission errors (19.9%). While human performance deficit was the leading cause of error (50.2%), other common causes included failure to follow procedure and protocol (42.2%) and improper use of the pump (22.7%). Although remedial actions were often taken to prevent error recurrence, actions were taken to rectify the systemic deficits that led to errors in only a minority of cases (11.8%). CONCLUSION Preventable errors continue to pose unnecessary risks to patients receiving IV-PCA. Multimodal analgesic regimens and novel PCA systems that reduce human error are needed to prevent errors while preserving the advantages of PCA for the management of acute pain.
Collapse
Affiliation(s)
| | | | - Margie Skeer
- Associate Professor of Public Health and
Community Medicine, Tufts University School of Medicine, Boston, MA,
USA
| | | | | | - Nathaniel Katz
- Analgesic Solutions, LLC, 321 Commonwealth Road,
Suite 204, Wayland, MA 01778, USA
| |
Collapse
|
11
|
Morlion B, Schäfer M, Betteridge N, Kalso E. Non-invasive patient-controlled analgesia in the management of acute postoperative pain in the hospital setting. Curr Med Res Opin 2018; 34:1179-1186. [PMID: 29625532 DOI: 10.1080/03007995.2018.1462785] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Acute postoperative pain is experienced by the majority of hospitalized patients undergoing surgical procedures, with many reporting inadequate pain relief and/or high levels of dissatisfaction with their pain management. Patient-controlled analgesia (PCA) ensures patient involvement in acute pain control, a key component for implementing a quality management system. This narrative article overviews the clinical evidence for conventional PCA and briefly discusses new, non-invasive PCA systems, namely the sufentanil sublingual tablet system (SSTS) and the fentanyl iontophoretic transdermal system (FITS). METHODS A Medline literature search ("patient-controlled analgesia" and "acute postoperative pain") was conducted to 1 April 2017; results from the main clinical trials are discussed. Additional literature was identified from the reference lists of cited publications. RESULTS Moderate to low quality evidence supports opioid-based intravenous PCA as an efficacious alternative to non-patient-controlled systemic analgesia for postoperative pain. However, despite the benefits of PCA, conventional intravenous PCA is limited by system-, drug- and human-related issues. The non-invasive SSTS and FITS have demonstrated good efficacy and safety in placebo- and intravenous morphine PCA-controlled trials, and are associated with high patient/healthcare practitioner satisfaction/ease of care ratings and offer early patient mobilization. CONCLUSIONS Evidence-based guidelines for acute postoperative pain management support the use of multimodal regimens in many situations. As effective and safe alternatives to conventional PCA, and with the added benefits of being non-invasive, easy to use and allowing early patient mobilization, the newer PCA systems may complement multimodal approaches, or potentially replace certain regimens, in hospitalized patients with acute postoperative pain.
Collapse
Affiliation(s)
- Bart Morlion
- a Leuven Centre for Algology & Pain Management , University Hospitals Leuven, KU Leuven , Leuven , Belgium
| | - Michael Schäfer
- b Department of Anaesthesiology and Intensive Care Medicine , Charité University Berlin, Campus Virchow Klinikum , Berlin , Germany
| | | | - Eija Kalso
- d Pain Clinic, Departments of Anaesthesiology, Intensive Care, and Pain Medicine , Helsinki University Central Hospital , Helsinki , Finland
| |
Collapse
|
12
|
Scardino M, D'Amato T, Martorelli F, Fenocchio G, Simili V, Di Matteo B, Bugada D, Kon E. Sublingual sufentanil tablet system Zalviso® for postoperative analgesia after knee replacement in fast track surgery: a pilot observational study. J Exp Orthop 2018; 5:8. [PMID: 29557999 PMCID: PMC5861254 DOI: 10.1186/s40634-018-0123-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/08/2018] [Indexed: 02/03/2023] Open
Abstract
Background Currently many TKA protocols rely on multimodal analgesic protocols with patient-controlled analgesia systems that administer opioids through a patient controlled IV infusion pump, in addition to concomitant peripheral nerve blocks and local anesthetics. Although effective, PCA IV opioids do not provide optimal results with fast track rehabilitation protocols. Methods The present is a retrospective study comparing the novel sublingual sufentanil PCA system (SSTS) to our standard of care foreseeing continuous femoral nerve block (cFNB) within a multimodal analgesic in a TKA fast-track protocol. The study evaluated 95 patients on SSTS (SSTS group) and 87 on cFNB (cFNB/control group) and collected data on numeric rating scores for pain from day 1–3 after surgery (T1, T2, T3), both at rest (NRS) and during movement (mNRS), patient’s ability to walk, need for supplementary analgesia (rescue dose), occurrence of adverse effects, length of hospital stay, and usability rating for SSTS by both patients and hospital staff. Results NRS at rest was lower in the cFNB than in the SSTS group for all 3 days after surgery, whereas mNRS scores were lower in the SSTS group at all time points measured. Adverse effects were significantly fewer among patients of the SSTS group (6% patients) than those of the cFNB (74% patients) (p < 0.001). Rescue doses were needed by 5% of SSTS patients vs 60% of cFNB. The fewer adverse events and lower pain scores for the SSTS group were associated to a notably better ability to ambulate, with all patients (100%) of the SSTS group being able to stand and walk for 10 m from T1 on; patients in the cFNB group showed a slower recovery with only 40% being able to stand and walk on T1, 70% on T2 and 85% on T3. All patients of the SSTS group had a length of stay of 4 days (day of surgery plus 3 after) as foreseen by the fast track protocol, in comparison only 36% of cFNB. Lastly, patient and nursing staff judged SSTS easy to use. Conclusion Our experience suggests that SSTS is a valuable strategy for routine postoperative analgesia following TKA in the context of a multimodal analgesic approach within the fast-track setting.
Collapse
Affiliation(s)
- Marco Scardino
- Department of Anesthesia, Humanitas Research Hospital, Via Manzoni, 56, Rozzano, Milan, Italy
| | - Tiziana D'Amato
- Department of Anesthesia, Humanitas Research Hospital, Via Manzoni, 56, Rozzano, Milan, Italy
| | - Federica Martorelli
- Department of Anesthesia, Humanitas Research Hospital, Via Manzoni, 56, Rozzano, Milan, Italy
| | - Giorgia Fenocchio
- Department of Anesthesia, Humanitas Research Hospital, Via Manzoni, 56, Rozzano, Milan, Italy
| | - Vincenzo Simili
- Department of Anesthesia, Humanitas Research Hospital, Via Manzoni, 56, Rozzano, Milan, Italy
| | - Berardo Di Matteo
- Center for functional and biologic reconstruction of the Knee, Humanitas Clinical and Research Institute, Via Manzoni 113, 20089, Rozzano, Italy.
| | - Dario Bugada
- Department of Medicine and Surgery, Parma University, Parma, Italy.,Department of Anesthesia, ICU and Pain Medicine, Parma University Hospital, Parma, Italy
| | - Elizaveta Kon
- Center for functional and biologic reconstruction of the Knee, Humanitas Clinical and Research Institute, Via Manzoni 113, 20089, Rozzano, Italy
| |
Collapse
|
13
|
Lawal OD, Mohanty M, Elder H, Skeer M, Erpelding N, Lanier R, Katz N. The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. Expert Opin Drug Saf 2018; 17:347-357. [DOI: 10.1080/14740338.2018.1442431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | | | - Harrison Elder
- Consulting Unit, Analgesic Solutions, LLC, Wayland, MA, USA
| | - Margie Skeer
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | | | - Ryan Lanier
- Consulting Unit, Analgesic Solutions, LLC, Wayland, MA, USA
| | - Nathaniel Katz
- Consulting Unit, Analgesic Solutions, LLC, Wayland, MA, USA
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA, USA
| |
Collapse
|
14
|
Boytim J, Ulrich B. Factors Contributing to Perioperative Medication Errors: A Systematic Literature Review. AORN J 2018; 107:91-107. [DOI: 10.1002/aorn.12005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
15
|
Campoe KR, Giuliano KK. Impact of Frequent Interruption on Nurses' Patient-Controlled Analgesia Programming Performance. HUMAN FACTORS 2017; 59:1204-1213. [PMID: 28925730 DOI: 10.1177/0018720817732605] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The purpose was to add to the body of knowledge regarding the impact of interruption on acute care nurses' cognitive workload, total task completion times, nurse frustration, and medication administration error while programming a patient-controlled analgesia (PCA) pump. BACKGROUND Data support that the severity of medication administration error increases with the number of interruptions, which is especially critical during the administration of high-risk medications. Bar code technology, interruption-free zones, and medication safety vests have been shown to decrease administration-related errors. However, there are few published data regarding the impact of number of interruptions on nurses' clinical performance during PCA programming. METHOD Nine acute care nurses completed three PCA pump programming tasks in a simulation laboratory. Programming tasks were completed under three conditions where the number of interruptions varied between two, four, and six. Outcome measures included cognitive workload (six NASA Task Load Index [NASA-TLX] subscales), total task completion time (seconds), nurse frustration (NASA-TLX Subscale 6), and PCA medication administration error (incorrect final programming). RESULTS Increases in the number of interruptions were associated with significant increases in total task completion time ( p = .003). We also found increases in nurses' cognitive workload, nurse frustration, and PCA pump programming errors, but these increases were not statistically significant. APPLICATIONS Complex technology use permeates the acute care nursing practice environment. These results add new knowledge on nurses' clinical performance during PCA pump programming and high-risk medication administration.
Collapse
|
16
|
Adamson RT, Lew I, Beyzarov E, Amara S, Reitan J. Clinical and Economic Impact of Intra- and Postoperative Use of Opioids and Analgesic Devices. Hosp Pharm 2017. [DOI: 10.1310/hpj4606-s1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Indu Lew
- Saint Barnabas Health Care System, South Plainfield, New Jersey
| | - Elena Beyzarov
- Saint Barnabas Health Care System, South Plainfield, New Jersey
| | - Shilpa Amara
- Saint Barnabas Health Care System, South Plainfield, New Jersey
| | | |
Collapse
|
17
|
Adamson RT, Lew I, Beyzarov E, Amara S, Reitan J. Clinical and Economic Implications Related to Postsurgical Analgesic Devices. Hosp Pharm 2017. [DOI: 10.1310/hpj4606-s12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Indu Lew
- Saint Barnabas Health Care System, South Plainfield, New Jersey
| | - Elena Beyzarov
- Saint Barnabas Health Care System, South Plainfield, New Jersey
| | - Shilpa Amara
- Saint Barnabas Health Care System, South Plainfield, New Jersey
| | | |
Collapse
|
18
|
Pestano CR, Lindley P, Ding L, Danesi H, Jones JB. Meta-Analysis of the Ease of Care From the Nurses' Perspective Comparing Fentanyl Iontophoretic Transdermal System (ITS) Vs Morphine Intravenous Patient-Controlled Analgesia (IV PCA) in Postoperative Pain Management. J Perianesth Nurs 2016; 32:329-340. [PMID: 28739065 DOI: 10.1016/j.jopan.2015.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this meta-analysis was to compare the ease of care (EOC) of fentanyl iontophoretic transdermal system (ITS) vs the morphine intravenous patient-controlled analgesia (IV PCA) as assessed by the nurse. DESIGN Meta-analysis of three phase 3B randomized active-comparator trials. METHODS This meta-analysis according to Cochrane's approach assessed EOC using a validated nurse questionnaire (22 items grouped into three subscales, which include time efficiency, convenience, and satisfaction) in adult patients treated with fentanyl ITS or morphine IV PCA for postoperative pain management. The weighted mean difference (WMD) between treatments was calculated. FINDING EOC analyses were based on responses to questionnaires from 848 (fentanyl ITS) and 761 (morphine IV PCA) nurses. Fentanyl ITS was reported to provide significant advantages compared with morphine IV PCA in terms of nurses' overall EOC (WMD = -0.57, P < .0001) and each of the subscales: time efficiency (WMD = -0.58, P < .0001), convenience (WMD = -0.57, P < .0001), and satisfaction (WMD = -0.47, P < .0001). CONCLUSIONS In this meta-analysis, fentanyl ITS is associated with a superior EOC profile from the nurses' perspective than morphine IV PCA.
Collapse
|
19
|
Lindley P, Ding L, Danesi H, Jones JB. Meta-Analysis of the Ease of Care From a Patients' Perspective Comparing Fentanyl Iontophoretic Transdermal System Versus Morphine Intravenous Patient-Controlled Analgesia in Postoperative Pain Management. J Perianesth Nurs 2016; 32:320-328. [PMID: 28739064 DOI: 10.1016/j.jopan.2015.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this meta-analysis was to evaluate patients' assessment of fentanyl iontophoretic transdermal system (ITS) and morphine intravenous patient-controlled analgesia (IV PCA) ease of care (EOC) using a validated patient EOC questionnaire. Fentanyl ITS is a preprogrammed, needle-free PCA system used for the management of acute pain in postoperative patients. METHODS This meta-analysis assessed the patient EOC of fentanyl ITS and morphine IV PCA using data from three randomized, active-comparator trials in adult postoperative patients with moderate-to-severe pain. All three studies utilized a validated patient EOC questionnaire which consists of 23 items grouped into seven subscales (confidence with device, comfort with device, movement, dosing confidence, pain control, knowledge/understanding, and satisfaction). Each item is scored on a six-point Likert scale. The weighted mean difference between treatments was calculated for the overall EOC and for each of the seven subscales. RESULTS The EOC analyses were based on responses to questionnaires from 1,943 patients treated with either fentanyl ITS (n = 961) or morphine IV PCA (n = 982). There was a statistically significant advantage in favor of fentanyl ITS over morphine IV PCA in terms of overall EOC (weighted mean difference = 0.28; 95% confidence interval (0.22 to 0.34); P < 0.0001). Five of the seven subscales (confidence with device, comfort with device, movement, dosing confidence, and knowledge/understanding) on the patient EOC questionnaire showed a statistically significant advantage for fentanyl ITS versus morphine IV PCA. The two subscales that did not show any difference were pain control (P = 0.7303) and satisfaction (0.0561). CONCLUSION In this meta-analysis, fentanyl ITS is associated with some advantages in terms of an EOC profile from a patients' perspective when compared with morphine IV PCA.
Collapse
|
20
|
Langford RM, Chang KY, Ding L, Abraham J. Comparison of fentanyl iontophoretic transdermal system and routine care with morphine intravenous patient-controlled analgesia in the management of early postoperative mobilisation: results from a randomised study. Br J Pain 2016; 10:198-208. [PMID: 27867509 DOI: 10.1177/2049463716668905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Fentanyl iontophoretic transdermal system (ITS) (IONSYS®, The Medicines Company, Parsippany, NJ, USA) and morphine intravenous (IV) patient-controlled analgesia (PCA) have demonstrated equivalent pain control in several published studies. The primary objective of the current study was to compare fentanyl ITS with morphine IV PCA with regard to the patient's ability to mobilise with acute postoperative pain. METHODS In this multicentre, open-label, randomised, active-controlled, prospective phase IV study, postoperative patients initially received IV morphine and were titrated to pain score ⩽ 4out of 10 on a Numeric Rating Scale (NRS) and then received fentanyl ITS (up to 240 µg (6 doses)/hour; up to a maximum of 3.2 mg (80 doses)/24 hours) or morphine IV PCA (doses up to 20 mg morphine/2 hours, up to 240 mg/24 hours). The primary efficacy measure was ability to mobilise, assessed using patient responses to three validated questions regarding mobility on a 6-point Likert scale (0 = no difficulty to mobilise to 5 = a very great deal of difficulty to mobilise). The study was originally planned to include ~200 patients. However, following the early suspension and termination of the study, a total of 108 patients were randomised to study treatment. RESULTS One hundred and eight patients were recruited prior to undergoing surgical procedures (orthopaedic surgical procedures (72%) or underwent major abdominal procedures (28%)). Postoperatively, 58 were randomised to receive fentanyl ITS, and 50 to morphine IV PCA. Fentanyl ITS patients had a greater ability to mobilise at the time of stopping study drug, with an adjusted mean ability to mobilise score (95% confidence interval (CI)) of 0.14 (-0.19, 0.47) for fentanyl ITS patients and 2.37 (1.98, 2.76) for morphine IV PCA patients (p < 0.001). CONCLUSION Patients treated with fentanyl ITS reported that they were better able to mobilise than patients treated with morphine IV PCA, at all time-points following surgery out to 24 hours.
Collapse
Affiliation(s)
- Richard M Langford
- Pain and Anaesthesia Research Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Kuang-Yi Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li Ding
- The Medicines Company, Parsippany, NJ, USA
| | | |
Collapse
|
21
|
|
22
|
Golembiewski J, Dasta J, Palmer PP. Evolution of Patient-Controlled Analgesia: From Intravenous to Sublingual Treatment. Hosp Pharm 2016; 51:214-229. [PMID: 38745577 PMCID: PMC11089629 DOI: 10.1310/hpj5103-214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Opioid administration delivered intravenously (IV) by patient-controlled analgesia (PCA) devices has been an important development in addressing insufficient management of acute pain in the postsurgical setting. However, IV PCA has several disadvantages, including operator error, risk of patient exposure to analgesic gaps, IV line patency issues, and risk of catheter-related infection, all of which contribute to the total cost of care. Morphine, the most commonly used opioid in IV PCA, has a relatively slow onset of analgesia, which may leave patients with inadequate initial pain control and at risk of opioid dose-stacking. Sufentanil is an opioid with no major active metabolites and a rapid onset of analgesia. The sufentanil sublingual tablet system (SSTS) with a 20-minute lockout and other safety features is a novel noninvasive PCA system in development for on-demand relief of moderate to severe acute pain in the hospital setting. Data from phase 3 trials of the use of SSTS after elective major open abdominal and orthopedic surgery show that analgesia is rapidly achieved, with a longer mean interdosing interval compared with IV PCA morphine (81 vs 47 minutes) and a high level of patient and nurse satisfaction. These data suggest that SSTS may also aid in the avoidance of some of the pitfalls inherent with IV PCA, which may help reduce hospital costs associated with IV PCA-related issues. This article describes the evolution, benefits, issues, and costs associated with IV PCA and reviews data from preclinical studies of sufentanil through SSTS phase 3 trials.
Collapse
Affiliation(s)
- Julie Golembiewski
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Joseph Dasta
- Health Outcomes and Pharmacy Practice, University of Texas at Austin, Hutto, Texas
| | | |
Collapse
|
23
|
Kim KM, Noh GJ. A comparative clinical study on the accuracy and efficacy of Accumate® 1100, an infusion pump for patient-controlled analgesia. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.1.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Gyu-Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology, Seoul Asan Hospital, Seoul, Korea
| |
Collapse
|
24
|
Saffer CS, Minkowitz HS, Ding L, Danesi H, Jones JB. Fentanyl iontophoretic transdermal system versus morphine intravenous patient-controlled analgesia for pain management following gynecological surgery: a meta-analysis of randomized, controlled trials. Pain Manag 2015; 5:339-48. [DOI: 10.2217/pmt.15.29] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Aim: To compare the efficacy and safety of patient-controlled fentanyl iontophoretic transdermal system (ITS) with morphine intravenous (iv.) patient-controlled analgesia (PCA) for pain management following gynecological surgery. Methods: Two-open-label, multicenter, randomized, active-controlled, parallel-group studies (n = 1142) were conducted that compared fentanyl ITS with morphine iv. PCA for postoperative pain. The subgroup of gynecological surgery patients from each trial was utilized for this meta-analysis (n = 604). Of these patients, 295 received fentanyl ITS (40 μg/dose) and 309 received morphine iv. PCA (1 mg/dose) for up to 72 h. Efficacy measures included the patient global assessment (PGA) and the investigator global assessment (IGA) of the method of pain control. Results: Gynecological surgery patients (n = 604) included in this meta-analysis had a mean age of 45 years, were predominantly Caucasian (65%) and had a mean body mass index of 29 mg/kg2. There were statistically significantly more patients treated with fentanyl ITS and more investigators who rated their pain control method as ‘excellent’ on the PGA at 24 h (49.3 vs 37.4%, respectively; p = 0.0029) and IGA at the last assessment (59.5 vs 38.0%, respectively; p < 0.0001), respectively, compared with morphine iv. PCA at the last assessment. Conclusion: Following gynecological surgery, patients and investigators were more satisfied (had a higher percent of an ‘excellent’ rating on the PGA and IGA, respectively) with fentanyl ITS than morphine iv. PCA as a method of pain control.
Collapse
Affiliation(s)
| | - Harold S Minkowitz
- Department of Anesthesiology, Memorial Hermann Memorial City Medical Center, Houston, TX 77024, USA
| | - Li Ding
- The Medicines Company, Parsippany, NJ 07054, USA
| | | | | |
Collapse
|
25
|
Sufentanil Sublingual Tablet System for the Management of Postoperative Pain after Knee or Hip Arthroplasty. Anesthesiology 2015; 123:434-43. [DOI: 10.1097/aln.0000000000000746] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Background:
Complications with IV patient-controlled analgesia include programming errors, invasive access, and impairment of mobility. This study evaluated an investigational sufentanil sublingual tablet system (SSTS) for the management of pain after knee or hip arthroplasty.
Methods:
This prospective, randomized, parallel-arm, double-blind study randomized postoperative patients at 34 U.S. sites to receive SSTS 15 μg (n = 315) or an identical placebo system (n = 104) and pain scores were recorded for up to 72 h. Adult patients with American Society of Anesthesiologists status 1 to 3 after primary total unilateral knee or hip replacement under general anesthesia or with spinal anesthesia that did not include intrathecal opioids were eligible. Patients were excluded if they were opioid tolerant. The primary endpoint was the time-weighted summed pain intensity difference to baseline over 48 h. Secondary endpoints included total pain relief, patient and healthcare professional global assessments, and patient and nurse ease-of-care questionnaires.
Results:
Summed pain intensity difference (standard error) was higher (better) in the SSTS group compared with placebo (76 [7] vs. −11 [11], difference 88 [95% CI, 66 to 109]; P < 0.001). In the SSTS group, more patients and nurses responded “good” or “excellent” on the global assessments compared with placebo (P < 0.001). Patient and nurse ease-of-care ratings for the system were high in both groups. There was a higher incidence of nausea and pruritus in the SSTS group.
Conclusion:
SSTS could be an effective patient-controlled pain management modality in patients after major orthopedic surgery and is easy to use by both patients and healthcare professionals.
Collapse
|
26
|
Halawi MJ, Grant SA, Bolognesi MP. Multimodal Analgesia for Total Joint Arthroplasty. Orthopedics 2015; 38:e616-25. [PMID: 26186325 DOI: 10.3928/01477447-20150701-61] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/17/2014] [Indexed: 02/03/2023]
Abstract
Optimal perioperative pain control for total joint arthroplasty remains a challenge. Whereas traditional regimens have relied heavily on opioids, newer multimodal pathways are increasingly gaining popularity as safer and more effective alternatives. The main premise of multimodal analgesia is decreased consumption of opioids, and hence lesser opioid-related adverse events. Other reported advantages include lower pain scores, faster functional recovery, higher patient satisfaction, and shorter length of hospital stay. Unfortunately, despite the advent of numerous analgesic techniques, the multimodal approach has remained widely variable, making direct comparison between studies difficult to interpret. This article provides an extensive review of traditional and modern perioperative interventions in pain management for total joint arthroplasty, including intravenous patient-controlled analgesia, epidural infusion, oral opioids, nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks, periarticular infiltration, steroids, anticonvulsants, and long-acting local anesthetics. Emphasis is placed on pathophysiology, clinical evidence, and timing. A standardized multimodal analgesia protocol is also proposed based on best available evidence. In addition to pharmacologic interventions, patient education and interdisciplinary collaboration among the care teams play an important role in the success of any treatment pathway. With a growing demand for total joint arthroplasty in an era of bundled payments and accountable care, there has never been a greater need for a standardized multimodal analgesia pathway.
Collapse
|
27
|
Tighe P, Buckenmaier CC, Boezaart AP, Carr DB, Clark LL, Herring AA, Kent M, Mackey S, Mariano ER, Polomano RC, Reisfield GM. Acute Pain Medicine in the United States: A Status Report. PAIN MEDICINE 2015; 16:1806-26. [PMID: 26535424 DOI: 10.1111/pme.12760] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. METHODS A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education. RESULTS The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM. CONCLUSION This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.
Collapse
Affiliation(s)
- Patrick Tighe
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Evolving Role of Local Anesthetics in Managing Postsurgical Analgesia. Clin Ther 2015; 37:1354-71. [DOI: 10.1016/j.clinthera.2015.03.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 02/09/2015] [Accepted: 03/11/2015] [Indexed: 11/20/2022]
|
29
|
Messerer B, Grögl G, Stromer W, Jaksch W. [Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. Schmerz 2015; 28:43-64. [PMID: 24550026 DOI: 10.1007/s00482-013-1384-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.
Collapse
Affiliation(s)
- B Messerer
- Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Graz, LKH-Universitätsklinikum Graz, Auenbruggerplatz 29, 8036, Graz, Österreich,
| | | | | | | |
Collapse
|
30
|
Foinard A, Décaudin B, Barthélémy C, Lebuffe G, Debaene B, Odou P. Impact of infusion set characteristics on the accuracy of patient-controlled morphine administration: a controlled in-vitro study. Anaesthesia 2014; 69:131-6. [DOI: 10.1111/anae.12523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 11/30/2022]
Affiliation(s)
- A. Foinard
- Department of Biopharmacy, Galenic and Hospital Pharmacy; Lille 2 University; UDSL; EA GRIIOT; UFR Pharmacie; Lille France
| | - B. Décaudin
- Department of Biopharmacy, Galenic and Hospital Pharmacy; Lille 2 University; UDSL; EA GRIIOT; UFR Pharmacie; Lille France
- Pharmacy; Lille University Hospital; CHU Lille; Lille France
| | - C. Barthélémy
- Department of Biopharmacy, Galenic and Hospital Pharmacy; Lille 2 University; UDSL; EA GRIIOT; UFR Pharmacie; Lille France
| | - G. Lebuffe
- Department of Anaesthesia and Intensive Care Department; Lille University Hospital; EA1046 Lille France
| | - B. Debaene
- Department of Anaesthesia and Intensive Care Department; Poitiers University Hospital; INSERM U1070; Poitiers France
| | - P. Odou
- Department of Biopharmacy, Galenic and Hospital Pharmacy; Lille 2 University; UDSL; EA GRIIOT; UFR Pharmacie; Lille France
- Pharmacy; Lille University Hospital; CHU Lille; Lille France
| |
Collapse
|
31
|
Martin DP, Bhalla T, Beltran R, Veneziano G, Tobias JD. The safety of prescribing opioids in pediatrics. Expert Opin Drug Saf 2013; 13:93-101. [PMID: 24073760 DOI: 10.1517/14740338.2013.834045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Pain management has become a widely discussed topic throughout all medical subspecialties. Although pediatric pain management has evolved significantly in its recent history, there is continued interest in the adequacy of pain treatment, both in the acute inpatient setting as well as the postoperative and chronic pain management setting. Although health care providers are becoming more aggressive concerning prompt and effective treatment of acute and chronic pain, safety data and adverse effects of narcotic analgesics may be overlooked. AREAS COVERED The authors review the current paradigm of acute pain management with an emphasis on oral narcotic medications, and the safety data available concerning prescribing these medications. EXPERT OPINION Further, the authors present their opinions concerning current and future practices regarding the prescribing practice of opiate analgesics, as well as a step-wise approach for acute oral pain management.
Collapse
Affiliation(s)
- David P Martin
- Ohio State University, Nationwide Children's Hospital, Department of Anesthesiology and Pain Medicine , 700 Children's Drive, Columbus, OH 43205 , USA +1 614 722 4200 ; +1 614 722 4203 ;
| | | | | | | | | |
Collapse
|
32
|
Seidling HM, Lampert A, Lohmann K, Schiele JT, Send AJF, Witticke D, Haefeli WE. Safeguarding the process of drug administration with an emphasis on electronic support tools. Br J Clin Pharmacol 2013; 76 Suppl 1:25-36. [PMID: 24007450 DOI: 10.1111/bcp.12191] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 03/20/2013] [Indexed: 12/24/2022] Open
Abstract
AIMS The aim of this work is to understand the process of drug administration and identify points in the workflow that resulted in interventions by clinical information systems in order to improve patient safety. METHODS To identify a generic way to structure the drug administration process we performed peer-group discussions and supplemented these discussions with a literature search for studies reporting errors in drug administration and strategies for their prevention. RESULTS We concluded that the drug administration process might consist of up to 11 sub-steps, which can be grouped into the four sub-processes of preparation, personalization, application and follow-up. Errors in drug handling and administration are diverse and frequent and in many cases not caused by the patient him/herself, but by family members or nurses. Accordingly, different prevention strategies have been set in place with relatively few approaches involving e-health technology. CONCLUSIONS A generic structuring of the administration process and particular error-prone sub-steps may facilitate the allocation of prevention strategies and help to identify research gaps.
Collapse
Affiliation(s)
- Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medizinische Klinik, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | | | | | | | | | | | | |
Collapse
|
33
|
Ratrout HF, Hamdan-Mansour AM, Seder SS, Salim WM. Patient satisfaction about using patient controlled analgesia in managing pain post surgical intervention. Clin Nurs Res 2013; 23:353-68. [PMID: 23729021 DOI: 10.1177/1054773813488418] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Management of postoperative pain using patient controlled analgesia (PCA) has increased for its proven advantages over conventional methods of pain control. The purpose of this study was to investigate patients' satisfaction about using PCA post surgical intervention among patients at Saudi health care settings. A cross-sectional, descriptive correlational design was used to collect data from patients using PCA post surgical interventions. The analysis showed that patients had a moderate to high level of perception about efficacy of PCA, and had a moderate level of knowledge about PCA use and its function. The duration of using a PCA pump, patients' age, gender, marital status, educational level, type of surgery, and their work status were significant predictors (F 7, 76 = 5.13, p < .001; R(2) = 0.59). PCA offers patients with an individualized analgesic therapy that meets the patients' demand of pain control. The implications for nurses and medical staff are discussed.
Collapse
Affiliation(s)
- Hamza F Ratrout
- Faculty of Nursing-King Saud University, Riyadh, Saudi Arabia
| | | | - Samer S Seder
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Wisam M Salim
- Faculty of Nursing-King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
34
|
Kessler ER, Shah M, K. Gruschkus S, Raju A. Cost and Quality Implications of Opioid-Based Postsurgical Pain Control Using Administrative Claims Data from a Large Health System: Opioid-Related Adverse Events and Their Impact on Clinical and Economic Outcomes. Pharmacotherapy 2013; 33:383-91. [DOI: 10.1002/phar.1223] [Citation(s) in RCA: 215] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- E. Richard Kessler
- Xcenda Global Health Economics and Outcomes Research; Palm Harbor; Florida
| | - Manan Shah
- Xcenda Global Health Economics and Outcomes Research; Palm Harbor; Florida
| | | | - Aditya Raju
- Xcenda Global Health Economics and Outcomes Research; Palm Harbor; Florida
| |
Collapse
|
35
|
Yi Y, Kang S, Hwang B. Drug overdose due to malfunction of a patient-controlled analgesia machine -A case report-. Korean J Anesthesiol 2013; 64:272-5. [PMID: 23560197 PMCID: PMC3611081 DOI: 10.4097/kjae.2013.64.3.272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/20/2012] [Accepted: 05/23/2012] [Indexed: 11/10/2022] Open
Abstract
Patient-controlled analgesia (PCA) provides excellent pain control and high stability, thereby minimizing the incidence of adverse effects. However, one of our patients experienced respiratory depression and hypotension within 30 minutes of initiation of PCA therapy. We discovered that machine malfunction caused continuous activation of the PCA button, resulting in a drug overdose. The PCA machine was sent to the manufacturer, who found an electrical short in the PCA button. All PCA units of the same make and model were immediately removed from hospitals and replaced with redesigned units without defects in the PCA button. We have used the improved machines without any problems. The purpose of this report is to raise awareness of this type of malfunction in PCA units in order to help prevent adverse events in the future.
Collapse
Affiliation(s)
- Yuri Yi
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, Korea
| | | | | |
Collapse
|
36
|
Tran M, Ciarkowski S, Wagner D, Stevenson JG. A Case Study on the Safety Impact of Implementing Smart Patient-Controlled Analgesic Pumps at a Tertiary Care Academic Medical Center. Jt Comm J Qual Patient Saf 2012; 38:112-9. [DOI: 10.1016/s1553-7250(12)38015-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
37
|
|
38
|
Pham JC, Andrawis M, Shore AD, Fahey M, Morlock L, Pronovost PJ. Are Temporary Staff Associated with More Severe Emergency Department Medication Errors? J Healthc Qual 2011; 33:9-18. [DOI: 10.1111/j.1945-1474.2010.00116.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
39
|
|
40
|
Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|