Acute opioid withdrawal syndrome from naloxone/naloxegol interaction.

Naloxegol is a new peripherally acting mu-opioid receptor antagonist to treat opioid-induced constipation with supposedly no effect on opioid analgesia. We present a patient with cancer-related pain who developed acute opioid withdrawal symptoms due to an interaction between the opioid antagonist naloxone and naloxegol. He was treated with oxycodone sustained release because of poor pain control. For opioid-related constipation, he had been receiving naloxegol. He complained about worsening pain and constipation and oxycodone was switched to oxycodone/naloxone. Shortly after intake, he experienced acute severe agitation, anxiety, sweating, tachycardia, disorientation and yawning without improvement after intravenous midazolam. Only after intravenous morphine administration, symptoms were controlled. He was switched back to the previous oxycodone dose without naloxone, with naloxegol being maintained. In the light of this case we suggest to avoid the use of naloxone and naloxegol in combination, or at least, to use it with extreme caution and monitorisation of tolerance.

Outcomes of early, late, and no admission to the intensive care unit for patients hospitalized with community-acquired pneumonia.

OBJECTIVES: The objective was to compare outcomes associated with early, late, and no admission to the intensive care unit (ICU) for patients hospitalized with community-acquired pneumonia (CAP). METHODS: This was a post hoc analysis of the original data from the Emergency Department Community-Acquired Pneumonia (EDCAP) and Pneumocom-1 prospective multicenter cohort studies of adult patients hospitalized with CAP. Propensity score-adjusted analysis was used to compare 28-day mortality and hospital length of stay (LOS) for 199, 144, and 2,215 patients with early (i.e., ICU admission on the day of emergency department [ED] presentation), late, and no ICU admission. RESULTS: Unadjusted 28-day mortality rates were 13.1, 19.4, and 5.7% for early, late, and no ICU admissions, respectively (p < 0.001). After adjusting for quintile of propensity score, the odds of 28-day mortality were higher for late ICU admissions relative to early ICU admissions (odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.42 to 4.90), and no ICU admissions (OR = 3.40; 95% CI = 2.11 to 5.48), but did not differ between early and no ICU admissions (OR = 1.29; 95% CI = 0.79 to 2.09). The median hospital LOS was 10 days for early (interquartile range [IQR] = 7 to 18), 15 days for late (IQR 9 to 23), and 6 days (IQR 4 to 9) for no ICU admissions (p < 0.001). CONCLUSIONS: This study suggests that late but not early admission to the ICU is associated with higher 28-day mortality for patients hospitalized with CAP. Patients admitted to the ICU have longer hospital LOS in comparison to those managed on the wards, particularly if they are admitted late to the ICU.

Association between timing of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia.

OBJECTIVE: To compare the 28-day mortality and hospital length of stay of patients with community-acquired pneumonia who were transferred to an intensive care unit on the same day of emergency department presentation (direct-transfer patients) with those subsequently transferred within 3 days of presentation (delayed-transfer patients). DESIGN: Secondary analysis of the original data from two North American and two European prospective, multicenter, cohort studies of adult patients with community-acquired pneumonia. PATIENTS: In all, 453 non-institutionalized patients transferred within 3 days of emergency department presentation to an intensive care unit were included in the analysis. Supplementary analysis was restricted to patients without an obvious indication for immediate transfer to an intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The sample consisted of 138 delayed-transfer and 315 direct-transfer patients, among whom 150 (33.1%) were considered to have an obvious indication for immediate intensive care unit admission. After adjusting for the quintile of propensity score, delayed intensive care unit transfer was associated with an increased odds ratio for 28-day mortality (2.07; 95% confidence interval, 1.12-3.85) and a decreased odds ratio for discharge from hospital for survivors (0.53; 95% confidence interval, 0.39-0.71). In a propensity-matched analysis, delayed-transfer patients had a higher 28-day mortality rate (23.4% vs. 11.7%; p = 0.02) and a longer median hospital length of stay (13 days vs. 7 days; p < .001) than direct-transfer patients. Similar results were found after excluding the 150 patients with an obvious indication for immediate intensive care unit admission. CONCLUSIONS: Our findings suggest that some patients without major criteria for severe community-acquired pneumonia, according to the recent Infectious Diseases Society of America/American Thoracic Society consensus guideline, may benefit from direct transfer to the intensive care unit. Further studies are needed to prospectively identify patients who may benefit from direct intensive care unit admission despite a lack of major severity criteria for community-acquired pneumonia based on the current guidelines.

Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule.

INTRODUCTION: To identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3. METHODS: Using the original data from four North American and European prospective multicentre cohort studies of patients with CAP, we derived and validated a prediction rule for ICU admission on days 1 to 3 of emergency department (ED) presentation, for patients presenting with no obvious reason for immediate ICU admission (not requiring immediate respiratory or circulatory support). RESULTS: A total of 6560 patients were included (4593 and 1967 in the derivation and validation cohort, respectively), 303 (4.6%) of whom were admitted to an ICU on days 1 to 3. The Risk of Early Admission to ICU index (REA-ICU index) comprised 11 criteria independently associated with ICU admission: male gender, age younger than 80 years, comorbid conditions, respiratory rate of 30 breaths/minute or higher, heart rate of 125 beats/minute or higher, multilobar infiltrate or pleural effusion, white blood cell count less than 3 or 20 G/L or above, hypoxaemia (oxygen saturation < 90% or arterial partial pressure of oxygen (PaO2) < 60 mmHg), blood urea nitrogen of 11 mmol/L or higher, pH less than 7.35 and sodium less than 130 mEq/L. The REA-ICU index stratified patients into four risk classes with a risk of ICU admission on days 1 to 3 ranging from 0.7 to 31%. The area under the curve was 0.81 (95% confidence interval (CI) = 0.78 to 0.83) in the overall population. CONCLUSIONS: The REA-ICU index accurately stratifies the risk of ICU admission on days 1 to 3 for patients presenting to the ED with CAP and no obvious indication for immediate ICU admission and therefore may assist orientation decisions.

La atención telefónica urgente especializada: una manera de mejora en la utilización de los servicios de urgencias hospitalarios / Specialized urgent telephone consultation: improving hospital emergency Department Usage

Fundamento y objetivo: La consulta telefónica urgente integrada dentro del funcionamiento de cada centro podría ser una herramienta útil en la gestión de las urgencias. El objetivo de este trabajo ha sido analizar la implementación de una central de llamadas(ICO24horas) para la atención de urgencias onco-hematológicas. Método: Estudio descriptivo y prospectivo de las consultas atendidas por ICO24horasdesde el 1 de octubre al 31 de diciembre del 2007. Para todas las llamadas se registraron variables socio-demográficas, clínicas y relacionadas con la consulta telefónica, y alas 24-72 horas se realizó una auditoría de calidad y satisfacción. Resultados: Se atendieron 656 llamadas, las cuales correspondieron a 498 casos médicos. Entre los motivos de consulta destacan: fiebre (12%), dolor (8%) y dudas terapéuticas(8%). El 60% fueron dados de alta telefónicamente, sin intervención de ningún otro nivel asistencial. En el control, el 100% de los pacientes afirmaron haberse sentido bien atendidos, y el 79% consideró que les habían resuelto el problema por el cual habían llamado. Conclusiones: ICO24horas es una herramienta eficaz y eficiente en la atención inicial de las urgencias oncológicas, que facilita el acceso a la consulta inmediata, evita desplazamientos innecesarios y contribuye a mejorar el uso de los servicios de urgencias hospitalarios (AU)

Background and objective: Urgent telephone consultation integrated into a hospital’s patient care routines can be a useful tool in the management of urgent cases. The objective of this study was to analyze the setting up of a 24-hour callcenter (ICO24horas) to attend urgent hematologic and oncologic consultations. Patients and methods: Prospective, descriptive study including all consultations to ICO24horas between October 1 and December 31, 2007. Social, demographic, and clinical variables were recorded; call details were also registered. All calls underwent a quality and satisfaction audit within 24 to 72 hours. Results: There were 656 calls concerning 498 patients. The main reasons for consultation were fever (12%), pain (8%),and doubts about treatment (8%). At the end of the call, 60% were considered resolved, with no need for the intervention of other care services. In the survey, all patients stated they felt well attended by the ICO24horas staff and79% considered that the problem about which they had rung had been resolved. Conclusions: ICO24horas is an effective and efficient tool in the initial response to urgent oncologic problems, providing access to immediate consultation, avoiding unnecessary journeys, and contributing to improving the use of hospital emergency services (AU)

Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study.

BACKGROUND: Although the Pneumonia Severity Index (PSI) has been extensively validated, little is known of the impact of its routine use as an aid to site-of-treatment decisions for patients with pneumonia who present to emergency departments (EDs). METHODS: A prospective, observational, controlled cohort study of patients with pneumonia was conducted in 8 EDs that used the PSI (PSI-user EDs) and 8 EDs that did not use the PSI (PSI-nonuser EDs) in France. The outcomes examined included the proportion of "low-risk" patients (PSI risk classes I-III) treated as outpatients, all-cause 28-day mortality, admission of inpatients to the intensive care unit, and subsequent hospitalization of outpatients. RESULTS: Of the 925 patients enrolled in the study, 472 (51.0%) were treated at PSI-user EDs, and 453 (49.0%) were treated at PSI-nonuser EDs; 449 (48.5%) of all patients were considered to be at low risk. In PSI-user EDs, 92 (42.8%) of 215 patients at low risk were treated as outpatients, compared with 56 (23.9%) of 234 patients at low risk in PSI-nonuser EDs. The adjusted odds ratios for outpatient treatment were higher for patients in PSI risk classes I and II who were treated in PSI-user EDs, compared with PSI-nonuser EDs (adjusted odds ratio, 7.0 [95% confidence interval, 2.0-25.0] and 4.6 [95% confidence interval, 1.3-16.2], respectively), whereas the adjusted odds ratio did not differ by PSI-user status among patients in risk class III or among patients at high risk. After adjusting for pneumonia severity, mortality was lower in patients who were treated in PSI-user EDs; other safety outcomes did not differ between patients treated in PSI-user and PSI-nonuser EDs. CONCLUSIONS: The routine use of the PSI was associated with a larger proportion of patients in PSI risk classes I and II who had pneumonia and who were treated in the outpatient environment without compromising their safety.

Benefits of a prehospital stroke code system. Feasibility and efficacy in the first year of clinical practice in Barcelona, Spain.

BACKGROUND AND OBJECTIVES: Hospital admission delay is a main limiting factor for effective thrombolytic therapy in stroke patients. We developed a stroke code system for rapid request of emergency transportation to the hospital and a priority availability of the attending neurologist on the patient's arrival at the Emergency Department (ED). METHODS: Over a 1-year period, a 24-hour telephone hotline between the attending neurologist and the Barcelona public emergency coordination service was established. Priority 1 (P1) was defined as a patient with symptoms suggestive of acute stroke with onset of less than 3 h, in which case immediate transportation service and rapid ED reception was organized. Data from patients in the P1 group (n = 39) and patients without activation of the stroke code (P0) (n = 181) were compared. RESULTS: There were significant differences between P1 and P0 groups in mean time from ED arrival to request for neurologic assessment (4.4 +/- 19.5 vs. 194.7 +/- 244.9 min, p < 0.001), from arrival to neurologic examination (12.6 +/- 21.1 vs. 225.3 +/- 258.2 min, p < 0.005), and from arrival to performance of brain CT scan (35.5 +/- 34.9 vs.120.3 +/- 143.2 min, p < 0.001), and also in the number of patients treated with thrombolytic agents (19 vs. 4.5%, p < 0.003). There were no differences between groups in the time elapsed from stroke onset to ED arrival. CONCLUSIONS: Activation of the stroke code was effective in increasing the percentage of patients treated with thrombolytic drugs and also in shortening the delay from ED arrival until neurologic assessment and from ED arrival until brain CT.

Outcome predictors of pneumonia in elderly patients: importance of functional assessment.

OBJECTIVES: To evaluate the outcome of elderly patients with community-acquired pneumonia (CAP) seen at an acute-care hospital, analyzing the importance of CAP severity, functional status, comorbidity, and frailty. DESIGN: Prospective observational study. SETTING: Emergency department and geriatric medical day hospital of a university teaching hospital. PARTICIPANTS: Ninety-nine patients aged 65 and older seen for CAP over a 6-month recruitment period. MEASUREMENTS: Clinical data were used to calculate Pneumonia Severity Index (PSI), Barthel Index (BI), Charlson Comorbidity Index, and Hospital Admission Risk Profile (HARP). Patients were then assessed 15 days later to determine functional decline and 30 days and 18 months later for mortality and readmission. Multiple logistic regression was used to analyze outcomes. RESULTS: Functional decline was observed in 23% of the 93 survivors. Within the 30-day period, case-fatality rate was 6% and readmission rate 11%; 18-month rates were 24% and 59%, respectively. Higher BI was a protective factor for 30-day and 18-month mortality (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.94-0.98 and OR=0.97, 95% CI=0.95-0.99, respectively; P<.01), and PSI was the only predictor for functional decline (OR=1.03, 95% CI=1.01-1.05; P=.01). Indices did not predict readmission. Analyses were repeated for the 74 inpatients and indicated similar results except for 18-month mortality, which HARP predicted (OR=1.73; 95% CI=1.16-2.57; P<.01). CONCLUSION: Functional status was an independent predictor for short- and long-term mortality in hospitalized patients whereas CAP severity predicted functional decline. Severity indices for CAP should possibly thus be adjusted in the elderly population, taking functional status assessment into account.

Coordinación entre servicios de urgencias. Un modelo eficaz en la planificación sanitaria / Coordination among emergency services. An effective model for healthcare planning

Objetivo: Evaluar, mediante un estudio de intervención con controles históricos, la optimización del traslado de pacientes desde el servicio de urgencias de un hospital de alta complejidad -centro emisor (CE)- a un hospital de menor complejidad -centro receptor (CR)- durante el invierno. Material y método: La intervención consistió en la creación de los siguientes recursos y dispositivos: criterios de selección de pacientes aptos para ser trasladados, sistema exclusivo de comunicación, un horario de traslados, obtención de resultados pendientes de pruebas efectuadas en el CE, una unidad de hospitalización específica en el CR, circuito de altas y prealtas en el CR, normas escritas de coordinación entre la unidad asistencial, la Unidad de Trabajo Social y el Servicio de Farmacia Hospitalaria, hoja de acogida y un circuito de información a las residencias sanitarias. Resultados: Se trasladó a 247 pacientes. Ningún paciente permaneció en el área de urgencias del CR. No hubo ninguna desprogramación de ingresos en el CR. El índice de reingreso a los 30 días fue del 2,4 por ciento. La estancia media en el CR fue de 5,63 días. El índice funcional fue de 0,6; la razón de funcionamiento estándar, 0,6; la diferencia atribuible al funcionamiento, 4,0 y el impacto, 706.Conclusiones: La intervención en el traslado de pacientes desde un servicio de urgencias de un centro de alta complejidad a un centro de menor complejidad, para evitar el colapso del primero, mejora la calidad asistencial de los pacientes trasladados y evita mermar la del hospital receptor (AU)

La antibioterapia en monodosis: una opción de mejora en las neumonías adquiridas en la comunidad / Single-dosse antibiotic therapy: an option for improvement in community-acquired pneumonias

Introducción: El tratamiento de las neumonías adquiridas en la comunidad (NAC) con antibióticos en monoterapia y monodosis (MM) ha demostrado la misma efectividad clínica que las pautas clásicas de antibioterapia fraccionada, a la vez que disminuye la estancia hospitalaria. Esto hace que la MM constituya una opción de mejora. Objetivo: Comprobar sí las características del tratamiento de las NAC con MM eran exportables a un hospital diferente de aquellos en los que se habían descrito inicialmente. Material y método. Estudio de intervención para la mejora de la calidad, en el período de enero a mayo de 1999. Tipo de muestreo: consecutivo. Datos recogidos: edad, sexo, puntuación APACHE II e índice de Charlson para comorbilidades, tiempo de estancia, mortalidad a 30 días, reingresos en los 10 días siguientes del alta hospitalaria, tiempos de enfermería en preparar y suministrar el tratamiento. En la etapa I se compararon las pautas de MM con levofloxacino o ceftriaxona frente a la pauta clásica de cefotaxima cada 6 h acompañada de un macrólido cada 12 h. En la etapa II se compararon entre sí las pautas de MM: levofloxacino frente a ceftriaxona. Durante todo el estudio se aplicaron guías de práctica clínica comunes a todos los pacientes con NAC. En la etapa III, según los resultados obtenidos y a las evidencias bibliográficas, el grupo de expertos seleccionó la pauta definitiva. Resultados: En la etapa I el tiempo medio ñ desviación estándar (DE) de estancia de las NAC tratadas con MM fue de 151 ñ 80,6 h frente a 204 ñ 110,4 horas en el tratamiento clásico, siendo la diferencia estadísticamente significativa y clínicamente relevante. No se detectaron diferencias en la mortalidad y reingresos; el tiempo de enfermería fue de 4 min/paciente/día en la MM frente a 16 minutos en el tratamiento clásico. En la segunda etapa no se detectaron diferencias entre los dos tipos de MM empleadas; si bien no se alcanzó el tamaño adecuado de la muestra. El grupo de expertos seleccionó la MM con levofloxacino por permitir un tratamiento secuencia¡ sin cambio de fármaco y porque su biodisponibilidad oral próxima al cien por cien permite iniciar el tratamiento oral rápidamente. Comentario: Nuestros resultados ponen de manifiesto que la MM supone una opción de mejora en nuestro hospital, dado que al disminuir los tiempos de estancia por paciente junto con un ahorro en el tiempo de enfermería mejora la utilización de las camas sin incrementar los riesgos para el paciente (AU)