RESUMEN
CONTEXT: Inadequate training of medical practitioners is a key factor responsible for inappropriate use of opioid analgesics. AIMS: We assessed the current knowledge, attitude, prescribing practices, and barriers perceived by the Indian medical practitioners in three tertiary care hospitals toward the use of opioid analgesics. SUBJECTS AND METHODS: Web-based survey of registered medical practitioner employed at three chosen tertiary health care institutions in New Delhi. STATISTICAL ANALYSIS USED: Descriptive analysis of survey responses was carried out. Comparative analysis was done using Chi-square test, independent samples t-test, and Pearson correlation coefficient. RESULTS: The response rate was 10.4% (n = 308). Two-thirds of the participants (61.7%) had never received formal pain management training, and 86.7% participants would like further training. Most participants (71.1%) agreed that opioids should be prescribed in cancer pain, while 26.3% agreed that opioids should be prescribed in noncancer pain. Half of the participants agreed that SOS (if necessary) dosing schedule (48.4%), low dosage (61.7%), and short duration of use (51.4%) could decrease the harmful effect of opioids. Lack of information about opioid-related policies and addiction potential were identified as the most common barriers to prescribing opioids. Those seeing more patients with chronic noncancer pain come across opioid misuse and diversion more often (P = 0.02). Those who understood addiction were more likely to agree that patients of chronic cancer pain with substance use disorders should be prescribed opioid analgesics (P < 0.01). CONCLUSIONS: Indian medical practitioners felt the need for formal pain management training. There is a lack of consensus on how to manage the pain using opioid analgesics. Tough regulations on medical and scientific use of opioids are the most commonly reported barrier to prescribing them.
RESUMEN
BACKGROUND: Gross physiological perturbations necessitating the Intensive Care Unit (ICU) admission might exacerbate the already existing or initiate bothersome symptoms among cancer patients. There is a lack of conclusive evidence concerning the symptomatic experience among this subgroup of cancer patients particularly so in the Indian population. The aim of this prospective observational study was to elucidate the symptom prevalence and overall symptomatic distress among critically ill cancer patients at the time of admission to a medical ICU. METHODS: We prospectively evaluated 110 consecutive cancer patients at the time of admission to our medical ICU for the presence and intensity of symptoms using a modified Edmonton Symptom Assessment Scale (ESAS). The patients/caregivers were also enquired regarding the most bothersome symptom in the past 1 week and the presence of "symptom associated sleep disturbance." The primary outcome was the prevalence of patients with moderate (ESAS ≥ 40) and severe (ESAS ≥ 70) symptomatic distress. RESULTS: The average age was 52.49 years with 75.45% of the respondents in the economically productive age group (21-60 years). Carcinoma breast (19.35%) and lung (14.58%) were the most common cancers among females and males, respectively. 87.27% and 60% of the patients had advanced cancer and multi-organ dysfunction, respectively. About 76.36% patients were able to complete ESAS either by themselves or with caregiver's assistance within first 24 h of ICU admission. The mean ESAS distress score was 48.04 (0-81) with 72.72% of the patients having moderate-severe symptomatic distress. Loss of appetite (92.73%) and nausea (54.55%) were the most common and the least common reported symptoms, respectively. Pain was the most common and "most distressing symptom" reported by 40% of patients with 64.55% patients reporting one or more symptoms severe enough to interfere with their sleep. CONCLUSION: ESAS is a user-friendly cognitive aid to make the healthcare team cognizant of the symptom existence and overall symptomatic burden among cancer patients with gross physiological perturbations. The high prevalence of moderate-severe symptom distress requires the concomitant provision of palliative and intensive care among this group of cancer patients.
RESUMEN
CONTEXT: Pain is a distressing symptom common to all stages and ubiquitous at all levels of care in cancer patients. However, there is a lack of scientific literature on prevalence, severity, predictors, and the quality of pain in cancer patients admitted to an Intensive Care Unit (ICU). OBJECTIVES: To elucidate the prevalence of pain, moderate to severe pain, neuropathic pain, chronic pain, and pain as the most distressing symptom in critically ill-cancer patients at the time of ICU admission. METHODS: We prospectively interviewed 126 patients within first 24 h of admission to a medical ICU. The patients were assessed for the presence of pain, its severity, sites, duration, nature, and its impact as a distressing symptom. Numerical Rating Scale and self-report version of Leeds Assessment of Neuropathic Signs and Symptoms were used to elucidate intensity of pain and neuropathic pain, respectively. Demographic characteristics such as age and sex, primary site, and stage of cancer were considered for a possible correlation with the prevalence of pain. RESULTS: Of 126 patients included in the study 95 (75.40%), 79 (62.70%), 34 (26.98%), and 17 (13.49%) patients had pain, moderate-severe, chronic, and neuropathic pain, respectively. The average duration of pain was 171.16 ± 716.50 days. Totally, 58 (46.03%) and 42 (42.01%) patients had at least one and more than equal to 2 neuropathic pain symptoms, respectively. The primary malignancies associated with the highest prevalence of pain were genitourinary, hematological, and head and neck whereas breast and lung cancers were associated with the highest prevalence of neuropathic and chronic pain, respectively. CONCLUSION: The prevalence of pain among critically ill-cancer patients is high. Assessment for pain at the time of ICU admission would ensure appropriate assessment for the presence, type, severity, and the significance imparted to it.
RESUMEN
INTRODUCTION: Pulse oximetry is a widely used tool, unfortunately there is a paucity of data investigating its accuracy in Intensive Care Units (ICU) and if they are able to meet mandated FDA criteria as claimed by them in critically ill patients. AIM: To assess bias, precision and accuracy of pulse oximeters used in ICU and factors affecting them. MATERIALS AND METHODS: A prospective cohort study, including 129 patients admitted to the ICU of a tertiary referral centre. Pulse oximetry and blood gas were done simultaneously. Pulse oximetry was done using two pulse oximetres: Nonin and Philips. All physiological variables like haemoglobin, lactate, use of vasopressors and blood pressure were recorded. Bland Altman curves were constructed to determine bias and limits of agreement. Effect of physiological variables on bias and difference between performance characteristics of bias was determined using SPSS. RESULTS: Pulse oximetry overestimated arterial oxygen saturation (SaO2) by 1.44%. There was negative correlation between bias and SaO2 (r=-0.32) and positive correlation with lactate (r=0.16). The Philips pulse oximeter had significant higher bias and variability than Nonin pulse oximeter. (2.49±2.99 versus 0.46±1.68, mean difference = 1.98, 95% C.I. = 1.53 - 2.43, p-value <0.001). CONCLUSION: Pulse oximetry overestimates SaO2. Bias tends to increase with rising lactate and hypoxia. There is heterogeneity in performance of various pulse oximetry devices in ICU.