Mitigating opioid errors in inpatient palliative care: A qualitative study

BackgroundOpioids are a high-risk medicine used in high doses and volumes in specialist palliative care inpatient services to manage palliative patients’ pain and other symptoms. Despite the high volume of opioid use in this care setting, serious errors with opioids are exceedingly rare. However, little is known about the factors that mitigate opioid errors in specialist palliative care inpatient services.AimTo explore palliative care clinicians’ perceptions of factors that mitigate opioid errors in specialist palliative care inpatient services.Methods and designA qualitative study using focus groups and semi-structured interviews.Participants and settingRegistered nurses, doctors, and/or pharmacists (‘clinicians’) who were involved with and/or had oversight of the services’ opioid delivery and/or opioid quality and safety processes, employed by one of three specialist palliative care inpatient services in metropolitan NSW.FindingsFifty-eight participants took part in this study, three-quarters (76%) of which were palliative care nurses. A positive opioid safety culture was central to mitigating opioid errors in specialist palliative care inpatient services. This culture of opioid safety was founded on clear and consistent safety messages from leadership, clinicians empowered to work together and practise safely, and a non-punitive approach to errors when they occurred. The clinical nurse educator was seen as pivotal to shaping, driving and reinforcing safe opioid delivery practices across the palliative care service.ConclusionCreating and sustaining a positive opioid safety culture, and promoting a non-punitive approach to opioid error and reporting, is essential to mitigating opioid errors in the specialist palliative care inpatient setting.     

Electroencephalogram spectral edge frequency,lower esophageal contractility,and autonomic responsiveness during general anesthesia

Both the electroencephalogram (EEG) spectral edge frequency (SEF) and lower esophageal contractility (LEC) indices have been reported to be useful indicators of anesthetic depth. We designed a prospective study to evaluate the relationship between changes in these two variables and objective measurements of physiologic responsiveness to surgical stress (i.e., changes in hemódynamic variables and plasma levels of norepinephrine, epinephrine, total catecholamines, and vasopressin). Eighty-nine consenting adult males undergoing radical prostatectomy procedures under a standardized general anesthetic technique were studied according to a randomized, single-blinded protocol. General anesthesia was induced with 30 µg/kg intravenous (IV) alfentanil, 2.5 mg/kg IV thiopental, and 0.1 mg/kg IV vecuronium, and subsequently maintained with 0.5 µg/kg/min alfentanil, nitrous oxide (N₂O) 67% in oxygen, and 0.8 µg/kg/min vecuronium. Following retropubic dissection, 81 patients (92%) manifested acute hypertensive responses, with mean arterial pressure increasing from 90±14 to 122±14 mm Hg (mean ± SD). This acute hypertensive response was treated with one of three different treatment modalities (20 to 60 µg/kg IV alfentanil, 0.5 to 2.0% inspired isoflurane, or 0.05 to 0.15 mg/kg IV trimethaphan) to return the mean arterial pressure to within 10% of the preincisional (baseline) value within 5 to 10 minutes. Although the mean arterial pressure, heart rate, and plasma levels of catecholamines and vasopressin significantly increased following the surgical stimulus, and decreased after adjunctive therapy, the EEG-SEF and LEC index (LECI) values did not significantly change during these study intervals. Furthermore, using a logistic regression analysis, we observed that preincision EEG-SEF and LECI values could not predict whether patients would manifest a hypertensive response. Therefore, the EEG-SEF and LECI were unreliable indicators of anesthetic depth.This study was supported in part by a grant from the Ambulatory Anesthesia Research Foundation, Los Altos, CA. (Dr White is a member of the Board of Directors.)The authors would like to thank Dan Kuni (Baxter Healthcare) for his assistance in obtaining the equipment used to perform the study; Vinod Kothapa, MD, for his valuable assistance with the anesthetic management of the study patients; Alex K. Mills, MD, for his assistance with the EEG interpretation; and Steven A. Bai, PhD, for his assistance with the plasma alfentanil analyses.     

地佐辛与喷他佐辛在结直肠癌手术中的麻醉效果比较

[目的] 比较地佐辛和喷他佐辛在结直肠癌手术中的麻醉效果.[方法] 本院行手术治疗的结直肠癌患者90例,随机分为对照组(n=45)和观察组(n=45).对照组采用喷他佐辛麻醉,观察组采用地佐辛麻醉,比较两组麻醉效果及安全性.[结果] 两组麻醉起效时间比较差异无显著性(P>0.05);观察组苏醒时间、定向力恢复时间,短于对照组(P<0.05);观察组丙泊酚用药量少于对照组(P<0.05);两组术前术后12 h视觉模拟评分(VAS)相比较差异无显著性(P>0.05);观察组术后1 h、2 h及4 h VAS评分显著低于对照组(P<0.05);观察组术后并发症发生率8.89%(4/45),低于对照组的17.78%(8/45)(P<0.05).[结论] 结直肠癌根治手术患者采用地佐辛麻醉效果理想,安全性较高,值得推广应用.     

Long-term outcome of patients with headache and drug abuse after inpatient withdrawal: five-year follow-up

Thirty-eight patients with "chronic daily" headache and ergotamine and/or analgesics abuse according to the criteria proposed by the international Headache Society were re-investigated 5 years after inpatient drug withdrawal. At the end of the observation period, 19 patients (50.0%) had their headaches on only 8 days per month or less, 18 patients (47.4%) were free of symptoms or had only mild headaches. A close correlation was found between the frequency of headache and the duration of drug abuse, as well as between the intensity of headache and the number of tablets taken per month. Frequency and intensity of headache had changed within the first 2 years after withdrawal, but remained stable afterwards. Fifteen patients (39.5%) reported on recurrent drug abuse. Patients with migraine showed a tendency towards a better prognosis compared to patients with tension-type headache or with combined migraine and tension-type headache. The results of this study highlight the long-term efficacy of inpatient drug withdrawal in patients with headache and ergotamine and/or analgesics abuse.     

Sedation in the ICU

The effect of midazolam on the induction dose-response curve for alfentanil was studied in non-premedicated ASA physical status I or II patients. The response to the verbal command was used as an end point of anaesthesia. Dose-response curves for midazolam, alfentanil, and their combination were determined with a probit procedure, and compared with algebraic (fractional) analysis of drug interaction. Interaction between midazolam and alfentanil was found to be synergistic (supra-additive). The results suggest that the use of this combination is advantageous not only because it helps to achieve different anaesthetic goals with specific drugs (a benzodiazepine for unconsciousness and an opioid for blockade of the responses to noxious stimulation), but also because its components are complementary for unconsciousness.     

布托啡诺镇痛对清宫术后子宫收缩痛的影响

目的评价布托啡诺镇痛减轻清宫术后子宫收缩痛的效果。方法 ASAⅠ~Ⅱ级清宫手术患者120例,随机分为B组(60例)和P组(60例)。B组先缓慢静脉注射布托啡诺0.5 mg,2 min后静脉注射丙泊酚2~2.5 mg/kg;P组单独静脉注射丙泊酚2~2.5 mg/kg。两组丙泊酚静注速率均为200 mg/min。结果 B组患者苏醒即刻、苏醒后15 min及30 min宫缩痛的VAS评分分别为(2.1±0.9)、(6.5±1.4)及(1.2±0.6)分,明显低于P组的(8.9±1.7)(、34.4±2.5)及(6.1±1.6)分(P0.05)。结论布托啡诺镇痛能减轻清宫术后的子宫收缩痛。