Intraoperative "Analgesia Nociception Index"-Guided Fentanyl Administration During Sevoflurane Anesthesia in Lumbar Discectomy and Laminectomy: A Randomized Clinical Trial.

BACKGROUND: The "Analgesia Nociception Index" (ANI; MetroDoloris Medical Systems, Lille, France) is a proposed noninvasive guide to analgesia derived from an electrocardiogram trace. ANI is scaled from 0 to 100; with previous studies suggesting that values ≥50 can indicate adequate analgesia. This clinical trial was designed to investigate the effect of intraoperative ANI-guided fentanyl administration on postoperative pain, under anesthetic conditions optimized for ANI functioning. METHODS: Fifty patients aged 18 to 75 years undergoing lumbar discectomy or laminectomy were studied. Participants were randomly allocated to receive intraoperative fentanyl guided either by the anesthesiologist's standard clinical practice (control group) or by maintaining ANI ≥50 with boluses of fentanyl at 5-minute intervals (ANI group). A standardized anesthetic regimen (sevoflurane, rocuronium, and nonopioid analgesia) was utilized for both groups. The primary outcome was Numerical Rating Scale pain scores recorded from 0 to 90 minutes of recovery room stay. Secondary outcomes included those in the recovery room period (total fentanyl administration, nausea, vomiting, shivering, airway obstruction, respiratory depression, sedation, emergence time, and time spent in the recovery room) and in the intraoperative period (total fentanyl administration, intraoperative-predicted fentanyl effect-site concentrations over time [CeFent], the correlation between ANI and predicted CeFent and the incidence of movement). Statistical analysis was performed with 2-tailed Student t tests, χ tests, ordinal logistic generalized estimating equation models, and linear mixed-effects models. Bonferroni corrections for multiple comparisons were made for primary and secondary outcomes. RESULTS: Over the recovery room period (0-90 minutes) Numerical Rating Scale pain scores were on average 1.3 units lower in ANI group compared to the control group (95% confidence interval [CI], -0.4 to 2.4; P= .01). Patients in the ANI group additionally had 64% lower recovery room total fentanyl administration (95% CI, -12% to 85%; P= .44, unadjusted P= .026), 82% lower nausea scores (95% CI, -19% to 96%; P= .43, unadjusted P= .03), and a reduced incidence of shivering (ANI 4%, control 27%, P= .80, unadjusted P= .047) compared to the control group. Intraoperatively, ANI group patients had on average 27% higher predicted CeFent levels during the highly nociceptive periods of intubation and first incision (5-30 minutes) compared with control group patients (95% CI, 3%-57%; P= .51, unadjusted P= .03). For a 1-unit decrease in ANI scores, predicted CeFent on average increased by an estimated 1.98% in the ANI group (95% CI, 1.7%-2.26%; P< .0001) and 1.08% in the control group (95% CI, 0.76%-1.39%; P< .0001). This correlation was significantly different between groups (0.9%, 95% CI, 0.5%-1.3%; P< .0001). Recovery room vomiting, airway obstruction, respiratory depression, sedation, emergence time, time spent in the recovery room as well as total intraoperative fentanyl administration, hypnotic parameters, and incidence of intraoperative movement were not different between groups. CONCLUSIONS: Patients receiving intraoperative ANI-guided fentanyl administration during sevoflurane anesthesia for lumbar discectomy and laminectomy demonstrated decreased pain in the recovery room, likely as a result of more objective intraoperative fentanyl administration.

Febrile neutropenia in EDs: the role of an electronic clinical practice guideline.

PURPOSE: Evidence-based clinical practice guidelines (CPGs) for managing febrile neutropenia (FN) are widely available; however, the integration of guidelines into routine practice is often incomplete. This study evaluated the uptake and clinical impact of implementing an electronic CPG on the management and outcomes of patients presenting with FN at 4 urban emergency departments (ED). METHODS: A retrospective chart review over a 3-year period at 4 hospitals in Edmonton, Alberta, was performed. Potentially eligible patient visits were identified by searching the Ambulatory Care Classification System database using International Classification of Diseases, 10th Edition, codes and ED physician diagnoses of FN. ED patients with fever (>38°C at home or in ED) and neutropenia (white blood cell count of <1000 cells/mm(3) or a neutrophil count of <500 cells/mm(3)) who received an ED diagnosis of FN were included. RESULTS: From 371 potential cases, 201 unique cases of FN were included. Overall, the electronic CPG was used in 76 (37.8%) of 201 patient visits; however, there were significant differences in CPG utilization between hospitals. Clinical practice guideline usage was greatest at the University of Alberta Hospital (57%). This finding correlated with a decrease in time from triage to first antibiotic by 1 hour compared to the 3 control hospitals (3.9 vs 4.9 hours, P = .022). CONCLUSIONS: The electronic CPG is a useful clinical tool that can improve patient management in the ED, and strategies to increase its utilization in this and other regions should be pursued.

Evaluating a clinical practice intervention to promote delivery of salbutamol by metered-dose inhalers with holding chambers in a pediatric emergency department.

OBJECTIVE: The primary objective of this study was to quantify the impact of a clinical practice intervention to promote the delivery of salbutamol by metered-dose inhaler (MDI) in a pediatric emergency department (PED). A secondary objective was to retrospectively document the components of the intervention. METHODS: PED inventory data for salbutamol inhalation solution (nebules), MDIs, and holding chambers were obtained from the pharmacy department. Patient data were obtained from the hospital's decision support unit. Interrupted time series analysis was used to evaluate trends in salbutamol inventory data, patient triage acuity, and hospital admissions from January 1, 2003, to May 31, 2010. Interviews and administrative documents were used to identify components of the intervention, which began in 2006. RESULTS: There was a 1,215% increase in the proportion of salbutamol delivered as MDIs compared to total inhaled salbutamol (MDI plus nebulization solution) following the intervention (95% CI 1,032% to 1,396%, p < 0.001). Increases in salbutamol MDI use were associated with the implementation of an institution-specific asthma care map. A relative decrease of 32% in the hospital admission rate (absolute -7.25%: 95% CI -8.31 to -6.19, p < 0.001) was associated with the change in salbutamol MDI use and the use of the asthma care map. CONCLUSIONS: A multifaceted intervention, designed and implemented by local PED clinical leaders, resulted in a pronounced change in salbutamol inhalation practice, with an associated decrease in admission rates. This intervention demonstrated many of the criteria for successful health system change. Findings from this research may be contextualized to inform change elsewhere.

Medication records in the emergency department: agreement between paper-based charts and automated dispensing device.

BACKGROUND: Research exploring the agreement between traditional medication records and electronic records generated by an automated dispensing device has been limited. OBJECTIVE: To evaluate the extent of agreement between medication administration records written in paper-based emergency department charts and records generated by an automated dispensing device with regard to the presence or absence of a single, prespecified medication. METHODS: Medication administration records in paper-based emergency department charts and medication dispensation records generated by an automated dispensing device were evaluated for concordance. The primary outcome measure was agreement between the 2 sources with regard to the presence or absence of a record for salbutamol by metered-dose inhaler (MDI) for randomly selected patients who presented to a pediatric emergency department with wheeze-related illness from January 1, 2008, to December 31, 2009. RESULTS: In total, 1172 patient visits met the inclusion criteria. Of these, records for 1013 visits showed agreement between the paper-based emergency department chart and the dispensation record of the automated dispensing device (kappa = 0.71, 95% confidence interval 0.67-0.75). This value did not meet the target kappa of 0.80. Stratification by time of day, day of week, month, season, or year of presentation at triage or by triage level or disposition (whether or not the patient was admitted to the hospital ward) did not significantly affect the level of agreement between the 2 sources. CONCLUSIONS: Agreement between records of salbutamol MDI administration in paper-based charts and dispensation records from an automated dispensing device was substantial, but discrepancies were present. There are significant quality management, legal, clinical, and research reasons to strive for concordance between multiple records with respect to medication use in the emergency department. Data generated by automated dispensing devices have potential value for research, but their strengths and limitations need to be understood.

Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature.

OBJECTIVES: The objective was to examine the effectiveness of corticosteroid treatment for the relief of pain associated with acute pharyngitis potentially caused by group A beta-hemolytic Streptococcus (GABHS). METHODS: This was a systematic review of the literature. Data sources used were electronic databases (Cochrane Library, MEDLINE, EMBASE, Biosis Previews, Scopus, and Web of Science), controlled trial registration websites, conference proceedings, study references, experts in the field, and correspondence with authors. Selection criteria consisted of randomized controlled trials (RCTs) in which corticosteroids, alone or in combination with antibiotics, were compared to placebo or any other standard therapy for treatment of acute pharyngitis in adult patients, pediatric patients, or both. Two reviewers independently assessed for relevance, inclusion, and study quality. Weighted mean differences (WMDs) were calculated and are reported with corresponding 95% confidence intervals (CIs). RESULTS: From 272 potentially relevant citations, 10 studies met the inclusion criteria. When compared to placebo, corticosteroids reduced the time to clinically meaningful pain relief (WMD = -4.54 hours; 95% CI = -7.19 to -1.89); however, they provided only a small reduction in pain scores at 24 hours (WMD = -0.90 on a 0-10 visual analog scale; 95% CI = -1.5 to -0.3). Heterogeneity among pooled studies was identified for both outcomes (I(2) = 81 and 74%, respectively); however, the GABHS-positive subgroup receiving corticosteroid treatment did have a significant mean reduction in time to clinically meaningful pain relief of 5.22 hours (95% CI = -7.02 to -3.42; I(2) = 0%). Short-term side effect profiles between corticosteroids and placebo groups were similar. CONCLUSIONS: Corticosteroid administration for acute pharyngitis was associated with a relatively small effect in time to clinically meaningful pain relief (4.5-hour reduction) and in pain relief at 24 hours (0.9-point reduction), with significant heterogeneity in the pooled results. Decision-making should be individualized to determine the risks and benefits; however, corticosteroids should not be used as routine treatment for acute pharyngitis.

Oxygen uptake and heart rate kinetics during heavy exercise: a comparison between arm cranking and leg cycling.

This study examined the oxygen uptake (VO(2)) and heart rate (HR) kinetics during arm cranking and leg cycling at work rates above the anaerobic threshold (AT). Ten untrained male subjects [21.6 (1.3) years] completed two 7 min 15 s constant-load arm cranking and two leg cycling tests at a power output halfway between the mode-specific AT and peak VO(2). The time constants for phase II VO(2) (tau) and HR (tau) kinetics were determined by fitting a monoexponential curve from the end of phase I until 3 min of exercise. VO(2) tau and HR tau values were significantly (P < 0.001) slower in arm cranking [VO(2) tau = 66.4 (3.0) s; HR tau = 74.7 (4.4) s] than in leg cycling [VO(2) tau = 42.0 (1.9) s; HR tau = 55.6 (3.5) s]. The VO(2) slow component (VO(2SC)) accounted for a significantly (P < 0.001) greater percentage of the total exercise response during arm cranking [23.8 (1.6)%] than during leg cycling [14.2 (1.5)%]. The greater relative VO(2SC) and the slower VO(2) tau with arm exercise are consistent with a greater recruitment of metabolically inefficient type II muscle fibres during arm cranking than during leg cycling.