Epidurals in patients receiving thromboprophylaxis with unfractionated heparin three times a day: the value of activated partial thromboplastin time testing.

BACKGROUND: Dosing subcutaneous (SC) unfractionated heparin (UFH) 3 times a day (TID) for deep venous thrombosis prophylaxis is used for patients in the United States undergoing nonorthopedic surgery. There is a lack of data on the risks of neuraxial techniques in patients receiving TID SC UFH; however, concerns have been raised about higher bleeding risks. In this prospective study, we evaluated the value of activated partial thromboplastin time (aPTT) testing at the time of removal of epidural catheters as a risk-reduction strategy for this population. METHODS: We collected data from our electronic hospital databases for all patients receiving epidural analgesia in conjunction with 5000 units TID or twice daily dosing (BID) SC UFH from December 2011 to December 2013. Our cohort received aPTT testing before removal of the catheter in all patients receiving TID SC UFH. An aPTT was ordered for patients receiving BID SC UFH only if risk factors for abnormal coagulation variables were identified. Chart reviews were performed on all patients with abnormal aPTT values to evaluate contributing risk factors. RESULTS: Over a 2-year period, 3523 epidurals were placed at our institution, including 714 (20.3%) for patients receiving TID SC UFH, and 1594 (45.2%) for patients receiving BID SC UFH. Of those patients receiving BID SC UFH, 186 (11.7%) had aPTT values drawn on the basis of risk factors. Ten (5.4 %, 95% CI: 2.6%-9.7%) of those patients had an aPTT value of greater than 35 seconds on the date of epidural removal. Of those patients receiving TID SC UFH, 20 (2.8%, 95% CI: 1.7%-4.3%) had an initial aPTT value of more than 35 seconds on the date of epidural removal. All patients who had abnormal aPTT values on TID heparin dosing were identified as having obvious concomitant risk factors for coagulation parameter abnormalities. There were no epidural hematomas in patients receiving either BID or TID dosing (95% CI: 0%-0.001%). CONCLUSIONS: The routine use of aPTT testing on patients receiving TID SC UFH at the time of removal of epidural catheters as a risk-reduction strategy is not supported by our results, where only 2.8% (95% CI: 1.7%-4.3%) of these patients had abnormal aPTT values. Our study adds to the limited data currently available on the safety of epidural analgesia in patients receiving TID SC UFH. Given the rare incidence of neuraxial hematoma (95% CI: 0%-0.001%), definitive conclusions on the risks of TID SC UFH administration in patients receiving epidural analgesia cannot be drawn based on our sample size.

Elevated lidocaine serum levels following the use of a needle free device in healthy adult volunteers.

There is increased concern regarding circulating levels of lidocaine immediately after the use of a needle-free device with buffered lidocaine. As a result, we conducted a prospective study to assess lidocaine circulation after the use of a needle-free device for the delivery of a local anesthetic in 10 healthy adult subjects. After informed consent, 2 peripheral intravenous catheters were placed in the antecubital fossa of each arm. Two milligrams of 1% buffered lidocaine was administered by the study physician via the needle-free device on the dorsum of the subject's hand. Within 2 minutes, a third intravenous catheter was placed in the location of the lidocaine administration and 5 mL of blood was collected from all 3 sites. If blood samples returned positive for lidocaine, they were also collected 1 hour and 2 hours after administration. Toxic levels of lidocaine were found in blood drawn from 2 subjects immediately after lidocaine administration. Results also showed that certain subjects had increasing levels of lidocaine over time. Other subjects also had increasing lidocaine serum levels from blood drawn on the arm opposite the administration site. We concluded that there may be systemic lidocaine levels with the administration of the needle-free device and that these levels may reach the toxic range in adults. Further investigation will be required to determine whether this finding has clinical significance, especially considering the smaller body mass of children.

Incidence of serotonin syndrome in patients treated with fentanyl on serotonergic agents.

BACKGROUND: There has been a recent surge in the literature highlighting the association of fentanyl as precipitating serotonin syndrome in patients on a serotonergic agent. OBJECTIVE: The purpose of our study was to understand the incidence of serotonin syndrome in patients who receive fentanyl while on serotonergic agents. STUDY DESIGN: This retrospective analysis was conducted from 2012 to 2013 after approval from the Institutional Review Board. We searched for all patients that had received a serotonergic agent and were admitted to the hospital during the study period. Next, we split these patients into 2 groups by placing all patients who had received fentanyl and a serotonergic agent into one group. We then searched for any of the Hunter Serotonin Toxicity Criteria in the records of patients that had received both fentanyl and a serotonergic agent. Further, we searched for all patients with serotonin syndrome mentioned in their records. SETTING: This study was conducted at a 900 bed tertiary care academic center. RESULTS: Over the 2 year study period, 112,045 patients were on a serotonergic agent, and 4,538 of these patients were treated with both fentanyl and a serotonergic agent. A search for Hunter's Criteria through the records of the patients receiving both fentanyl and a serotonergic agent revealed 23 patients had been documented with some of these symptoms. On detailed chart review, only 4 [95% CI 1 - 10] of these patients truly met Hunter's Criteria for serotonin syndrome. We then searched all admissions for a diagnosis code of serotonin syndrome during the study period. Five additional cases of serotonin syndrome were found, but none of these patients were treated with fentanyl. LIMITATIONS: Some of the limitations of our study include that it represents a single institution, although it is a large academic center. An inherent limitation may be the under diagnosis of serotonin syndrome. CONCLUSION: The incidence of serotonin syndrome in patients who receive both fentanyl and a serotonergic agent is low.

Morphine versus Hydromorphone: Does Choice of Opioid Influence Outcomes?

Morphine has traditionally been considered the first line agent for analgesia in hospitals; however, in the last few years there has been a shift towards the use of hydromorphone as a first line agent. We conducted a hospital population based observational study to evaluate the increasing use of hydromorphone over morphine in both medical and surgical populations. Additionally, we assessed the effect of this trend on three key outcomes, including adverse events, length of stay, and readmission rates. We evaluated data from the University Health Systems Consortium. Data from 38 hospitals from October 2010 to September 2013 was analyzed for patients treated with either hydromorphone or morphine. The use of morphine steadily decreased while use of hydromorphone increased in both medical and surgical groups. Rescue drugs were used more frequently in patients treated with hydromorphone in comparison to patients treated with morphine (p < 0.01). Patients receiving morphine tended to stay in the hospital for almost one day longer than patients receiving hydromorphone. However, 30-day all cause readmission rates were significantly higher in patients treated with hydromorphone (p < 0.01). Our study highlights that the choice of hydromorphone versus morphine may influence outcomes. There are implications related to resource utilization and these outcomes.

Pain Management in Pregnancy: Multimodal Approaches.

Nonobstetrical causes of pain during pregnancy are very common and can be incapacitating if not treated appropriately. Recent reports in the literature show that a significant percentage of pregnant women are treated with opioids during pregnancy. To address common pain conditions that present during pregnancy and the available pharmacological and nonpharmacological treatment options, for each of the pain conditions identified, a search using MEDLINE, PubMed, Embase, and Cochrane databases was performed. The quality of the evidence was evaluated in the context of study design. This paper is a narrative summary of the results obtained from individual reviews. There were significant disparities in the studies in terms of design, research and methodology, and outcomes analyzed. There is reasonable evidence available for pharmacological approaches; however, these are also associated with adverse events. Evidence for nonpharmacological approaches is limited and hence their efficacy is unclear, although they do appear to be primarily safe. A multimodal approach using a combination of nonpharmacological and pharmacological options to treat these pain conditions is likely to have the most benefit while limiting risk. Research trials with sound methodology and analysis of outcome data are needed.

Opioid tolerance--a predictor of increased length of stay and higher readmission rates.

The increasing use of opioids to manage pain in the United States over the last decade has resulted in a subset of our population developing opioid tolerance. While the management of opioid tolerant patients during acute episodes of care is well known to be a challenge amongst health care providers, there is little in the literature that has studied opioid tolerance as a predictor of outcomes. We conducted a review on all admissions to Massachusetts General Hospital over a period of 6 months, from January 2013 to June 2013, and identified opioid tolerant patients at admission using the FDA definition of opioid tolerance. To compare risk adjusted groups, we placed opioid tolerant patients and control patients into groups determined by expected length of stay of less than 2 days, 2 to 5 days, 5 to 10 days, and greater than 10 days. Opioid tolerant patients were then compared to the control for outcomes measures including observed length of stay and readmission rates. Our results show that all opioid tolerant patients have a significantly longer length of stay and a greater 30 day all cause readmission rate than the control group (P < 0.01). This trend was found in the first 3 risk adjusted groups, but not in the fourth group where expected length of stay was greater than 10 days. The opioid tolerant population is at risk given the poorer outcomes and higher health care costs associated with their care. It is imperative that we identify opportunities for improvement and delineate specific pathways for the care of these patients.

Use of targeted transversus abdominus plane blocks in pediatric patients with anterior cutaneous nerve entrapment syndrome.

Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly overlooked source of chronic abdominal wall pain. A diagnosis of ACNES should be considered in cases of severe, localized abdominal pain that is accentuated by physical activity. Providers should consider diagnosing ACNES once a patient has both a positive result from a Carnett's test and precise localization of pain. We describe the use of transversus abdominus plane (TAP) blocks to treat ACNES in the pediatric patient population. TAP blocks are a treatment modality which have been described less frequently in the management of this syndrome, with rectus sheath blocks being used more commonly. TAP blocks can be used effectively for ACNES by targeting the site of maximal tenderness, which was identified using ultrasound guidance. Moreover, TAP blocks are an attractive procedure option for ACNES as they are less invasive than other commonly used techniques. We present 3 case series reports of pediatric patients evaluated at our institution for severe abdominal pain to describe the clinical manifestations, sequelae, and outcome of ACNES. Though the exact incidence of ACNES in the pediatric population is unknown, this condition has significant implications from chronic pain. Chronic pain can lead to significant emotional and social impacts on these pediatric patients, as well as their on their families. Further, the extensive utilization of health care resources is impacted when children with undiagnosed ACNES undergo invasive treatments when ACNES is not in the early differential. The purpose of this case series report is to prompt better recognition of the condition ACNES, and to highlight the efficacy of TAP blocks as a management strategy.

Intrathecal Drug Delivery (ITDD) systems for cancer pain.

Intrathecal drug delivery is an effective pain management option for patients with chronic and cancer pain. The delivery of drugs into the intrathecal space provides superior analgesia with smaller doses of analgesics to minimize side effects while significantly improving quality of life. This article aims to provide a general overview of the use of intrathecal drug delivery to manage pain, dosing recommendations, potential risks and complications, and growing trends in the field.