Why paracetamol (acetaminophen) is a suitable first choice for treating mild to moderate acute pain in adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, or who are older.

Acute pain is among the most common reasons that people consult primary care physicians, who must weigh benefits versus risks of analgesics use for each patient. Paracetamol (acetaminophen) is a first-choice analgesic for many adults with mild to moderate acute pain, is generally well tolerated at recommended doses (≤4 g/day) in healthy adults and may be preferable to non-steroidal anti-inflammatory drugs that are associated with undesirable gastrointestinal, renal, and cardiovascular effects. Although paracetamol is widely used, many patients and physicians still have questions about its suitability and dosing, especially for older people or adults with underlying comorbidities, for whom there are limited clinical data or evidence-based guidelines. Inappropriate use may increase the risks of both overdosing and inadequate analgesia. To address knowledge deficits and augment existing guidance in salient areas of uncertainty, we have researched, reviewed, and collated published evidence and expert opinion relevant to the acute use of paracetamol by adults with liver, kidney, or cardiovascular diseases, gastrointestinal disorders, asthma, or/and who are older. A concern is hepatotoxicity, but this is rare among adults who use paracetamol as directed, including people with cirrhotic liver disease. Putative epidemiologic associations of paracetamol use with kidney or cardiovascular disease, hypertension, gastrointestinal disorders, and asthma largely reflect confounding biases and are of doubtful relevance to short-term use (<14 days). Paracetamol is a suitable first-line analgesic for mild to moderate acute pain in many adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, and/or who are older. No evidence supports routine dose reduction for older people. Rather, dosing for adults who are older and/or have decompensated cirrhosis, advanced kidney failure, or analgesic-induced asthma that is known to be cross-sensitive to paracetamol, should be individualized in consultation with their physician, who may recommend a lower effective dose appropriate to the circumstances.

Humidification during mechanical ventilation to prevent endotracheal tube occlusion in critically ill patients: A case control study.

BACKGROUND: Endotracheal tube (ETT) occlusion is a potentially life-threatening event. This study describes a quality improvement project to prevent ETT occlusion in critically ill patients. METHODS: After a cluster of clinically significant ETT occlusion incidents at a tertiary-care intensive care unit (ICU), the root cause analysis suggested that the universal use of heat moisture exchangers (HMEs) was a major cause. Then, we prospectively audited new ETT occlusion incidents after changing our practices to evidence-based active and passive humidification during mechanical ventilation (MV). We also compared the outcomes of affected patients with matched controls. RESULTS: During 100 weeks, 18 incidents of clinically significant ETT occlusion occurred on a median of 7 days after intubation (interquartile range, 4.8-9.5): 8 in the 10 weeks before and 10 in the 90 weeks after changing humidification practices (8.1 vs. 1.0 incidents per 1000 ventilator days, respectively). The incidents were not suspected in 94.4%, the peak airway pressure was >30 cm H2O in only 25%, and 55.6% were being treated for pneumonia when ETT occlusion occurred. Compared with 51 matched controls, ETT occlusion cases had significantly longer MV duration (median of 13.5 vs. 4.0 days; P = 0.002) and ICU stay (median of 26.5 vs. 11.0 days; P = 0.006) and more tracheostomy (55.6% vs. 9.8%; P < 0.001). The hospital mortality was similar in cases and controls. CONCLUSIONS: The rate of ETT occlusion decreased after changing humidification practices from universal HME use to evidence-based active and passive humidification. ETT occlusion was associated with more tracheostomy and a longer duration of MV and ICU stay.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: To evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality. METHODS: The SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of "possible sepsis alert" to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days. DISCUSSION: The trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019.

Managing critical care during COVID-19 pandemic: The experience of an ICU of a tertiary care hospital.

BACKGROUND: The COVID-19 pandemic has strained ICUs worldwide. To learn from our experience, we described the critical care response to the outbreak. METHODS: This is a case study of the response of the Intensive Care Department (75-bed capacity) at a tertiary-care hospital to COVID-19 pandemic, which resulted in a high number of critically ill patients. RESULTS: Between March 1 and July 31, 2020, 822 patients were admitted to the adult non-cardiac ICUs with suspected (72%)/confirmed (38%) COVID-19. At the peak of the surge, 125 critically ill patients with COVID-19 were managed on single day. To accommodate these numbers, the bed capacity of 4 ICUs was increased internally from 58 to 71 beds (+40%) by cohorting 2 patients/room in selected rooms; forty additional ICUs beds were created in 2 general wards; one cardiac ICU was converted to managed non-COVID-19 general ICU patients and one ward was used as a stepdown for COVID-19 patients. To manage respiratory failure, 53 new ICU ventilators, 90 helmets for non-invasive ventilation and 47 high-flow nasal cannula machines were added to the existing capacity. Dedicated medical teams cared for the COVID-19 patients to prevent cross-contamination. The nurse-to-patient and RT-to-patient ratio remained mostly 1:1 and 1:6, respectively. One-hundred-ten ward nurses were up-skilled to care for COVID-19 and other ICU patients using tiered staffing model. Daily executive rounds were conducted to identify patients for transfer and at least 10 beds were made available for new COVID-19 admissions/day. The consumption of PPE increased multiple fold compared with the period preceding the pandemic. Regular family visits were not allowed and families were updated daily by videoconferencing and phone calls. CONCLUSIONS: Our ICU response to the COVID-19 pandemic required almost doubling ICU bed capacity and changing multiple aspects of ICU workflow to be able to care for high numbers of affected patients.

Nursing strategic pillars to enhance nursing preparedness and response to COVID-19 pandemic at a tertiary care hospital in Saudi Arabia.

BACKGROUND: COVID-19 pandemic caused enormous implications on the frontline staff. The objective was to share our nursing experience in responding to COVID-19 pandemic at a large hospital and its impact on nursing safety and healthcare services. METHODS: Six nursing strategic pillars were implemented. Pillar 1: establishing corona command centre. Pillar 2: limiting exposure by virtual care model, strict infection control measures, altered patient flow, active surveillance, and contact tracing. Pillar 3: maintaining sufficient supplies of personal protective equipment. Pillar 4: creating surge capacity by establishing dedicated COVID-19 units and increasing critical care beds. Pillar 5: training and redeployment of nurses and implementing alternate staffing models. Pillar 6: monitoring staff wellbeing, establishing mental health support hotline and clinic, providing hotel self-quarantine, and financial incentives. RESULTS: Out of 5483 nurses, 543 (10%) were trained for redeployment, mainly at acute and intensive care units. After serving 11,623 infected patient including 1646 hospitalizations during the first 9 months of the pandemic, only 385 (7.0%) nurses were infected with COVID-19. Out of them, only 10 (2.6%) required hospitalization, one (0.3%) required ICU admission, and none died. Although the number of patients hospitalized at our hospital during the current pandemic was 17 folds higher than the 2015 outbreak of middle East respiratory syndrome coronavirus, the hospital administration did not have to close the hospital as they did in 2015. CONCLUSIONS: Proactive nursing leadership and implementation of multiple nursing pillars enabled the facility to maintain the safety of nursing workforce while serving large influx of COVID-19 patients.

Nortriptyline for pain in knee osteoarthritis: a double-blind randomised controlled trial in New Zealand general practice.

BACKGROUND: Osteoarthritis (OA) of the knee is a common cause of chronic pain. Analgesics that are currently available have limited efficacy and may be poorly tolerated. Tricyclic antidepressants are used as analgesics for other chronic conditions, but they have not been evaluated as analgesics in OA. AIM: To investigate the analgesic efficacy of nortriptyline in people with knee OA. DESIGN AND SETTING: A two-arm, parallel-group, 1:1, double-blind, randomised, placebo-controlled trial in Christchurch, New Zealand. METHOD: Participants were recruited from orthopaedic outpatient clinics, primary care, and through public advertising. Adults with knee OA and a pain score of ≥20 points on the 50-point Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain subscale were randomised to receive either nortriptyline or identical placebo for 14 weeks. The primary outcome was knee pain at 14 weeks measured using the WOMAC pain subscale. Secondary outcomes included: function; stiffness; non-steroidal anti-inflammatory drug, opioid, and/or paracetamol use; each participant's global assessment; and adverse effects at 14 weeks. RESULTS: Of the 205 randomised participants, 201 (98.0%) completed follow-up at 14 weeks. The baseline-adjusted mean WOMAC pain subscale score at week 14 was 6.2 points lower (95% confidence interval = -0.26 to 12.6, P = 0.06) in the nortriptyline arm versus the placebo arm. Differences in secondary outcomes generally favoured the nortriptyline arm, but were small and unlikely to be clinically relevant. However, the following were all more commonly reported by participants taking nortriptyline than those taking a placebo: dry mouth (86.9% versus 51.0%, respectively, P<0.001), constipation (58.6% versus 30.4%, respectively, P<0.001), and sweating (31.3% versus 20.6%, respectively, P = 0.033). CONCLUSION: This study suggests nortriptyline does not significantly reduce pain in people with knee OA. The adverse effect profile was as expected.

How do patients and General Practitioners talk about pain and negotiate empathy in consultations? A direct observational study.

The objective of this qualitative study in New Zealand was to investigate how general practitioners and patients discuss chronic pain in consultations. Chronic pain is a complex condition that defies many commonsense understandings. It is challenging to manage and patients can come to conclude that there is an empathy deficit. To our knowledge most, if not all, studies on this topic have recruited participants whose main presenting complaint is chronic pain. Forms of chronic pain are relatively common in the population and we thought it likely that at least some discussions may be rendered invisible via these recruiting practices. The study analysed data from the Applied Research on Communication in Health repository of audio transcripts and video-recorded consultations collected from a range of studies on a variety of topics, none of which were about chronic pain specifically. We searched the 256 transcripts looking for key words that might indicate that pain was at least part of the consultation. This yielded a large number of potentially relevant transcripts. These transcripts were assessed and reduced to 18 by excluding those that were about non-physical pain or pain that was expected to resolve relatively quickly. A medical specialist in chronic pain reviewed the resulting 18 and excluded two further transcripts giving us a final sample of 16. We conducted in-depth analysis of these consultations. Rather than confirming an empathy deficit, we found a much more complex deployment of empathy in the space where the two complex systems of chronic pain and general practice meet. These findings highlight the utility of analysing data originally generated for other purposes, with permission, and in a practical sense, highlight the importance of understanding empathy as highly contextual in 'real world' practice.

Nonprescription drugs recommended in guidelines for common pain conditions.

Evidence-based pain guidelines allow recommendation of nonprescription analgesics to patients, facilitating self-care. We researched clinical practice guidelines for common conditions on websites of pain associations, societies, health institutions and organizations, PubMed, ProQuest, Embase, Google Scholar until April 2019. We wanted to determine whether there is a consensus between guidelines. From 114 identified guidelines, migraine (27) and osteoarthritis (26) have been published most around the world, while dysmenorrhea (14) is mainly discussed in developing countries. Specific recommendations to pregnant women, children and older people predominantly come from the UK and USA. We found that acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) represent first-line management across all pain conditions in adults and children. In osteoarthritis, topical NSAIDs should be considered before oral NSAIDs. This knowledge might persuade patients that using these drugs first could enable fast and effective pain relief.

Implementing the comprehensive unit-based safety program model to improve the management of mechanically ventilated patients in Saudi Arabia.

BACKGROUND: Ventilator-associated events are common in mechanically ventilated patients. They are associated with more days on mechanical ventilation, longer intensive care unit (ICU) stay, and increased risk of mortality. Theoretically, interventions that prevent ventilator-associated events should also reduce associated morbidity. We evaluated the Comprehensive Unit-based Safety Program approach to improve the care of mechanically ventilated patients. METHODS: All mechanically ventilated patients admitted to the ICU between October 1, 2015, and October 31, 2016, were prospectively monitored for the development of ventilator-associated events according to the National Healthcare Safety Network criteria. A process care bundle (endotracheal intubation with subglottic suctioning, head-of-bed elevation ≥30°, target sedation scores, daily spontaneous awakening trials, spontaneous breathing trials), daily delirium assessment, and an early mobility protocol were instituted. The bundle compliance, ventilator-associated events rates, ICU length of stay, and mortality rate were noted. The database allowed viewing of current rates, trends, and averages of all participating sites. RESULTS: In the study period, 2,321 patients were admitted to the ICU, and 1,231 required mechanical ventilation (10,342 ventilator days). There were 115 ventilator-associated events: 82 ventilator-associated conditions, 15 infection-related ventilator-associated conditions, and 18 possible cases of ventilator-associated pneumonia. The ICU mortality rate was 13.3%, compared with 28.7% for those mechanically ventilated patients with ventilator-associated events (P = .0001). There was increased compliance for spontaneous awakening trials (51.5%-76.9%, P = .0008) and spontaneous breathing trials (54.2%-72.2%, P = .02) and a decrease in infection-related ventilator-associated conditions (4.2-3.5 per 1,000 days), possible cases of ventilator-associated pneumonia (2.1-1.7 per 1,000 days), ICU mortality (45.3%-19.1%, P = .045), and ventilator-associated events associated mortality rates (33.3%-8.3%, P < .37). Physical therapy participation and mobility were 60.8% and 26.4%, respectively. CONCLUSION: The implementation of a multipronged program like the Comprehensive Unit-based Safety Program could improve the care processes and outcomes of mechanically ventilated patients.

The critical care response to a hospital outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: an observational study.

BACKGROUND: Middle East respiratory syndrome coronavirus (MERS-CoV) has caused several hospital outbreaks, including a major outbreak at King Abdulaziz Medical City, a 940-bed tertiary-care hospital in Riyadh, Saudi Arabia (August-September 2015). To learn from our experience, we described the critical care response to the outbreak. METHODS: This observational study was conducted at the Intensive Care Department which covered 5 ICUs with 60 single-bedded rooms. We described qualitatively and, as applicable, quantitatively the response of intensive care services to the outbreak. The clinical course and outcomes of healthcare workers (HCWs) who had MERS were noted. RESULTS: Sixty-three MERS patients were admitted to 3 MERS-designated ICUs during the outbreak (peak census = 27 patients on August 25, 2015, and the last new case on September 13, 2015). Most patients had multiorgan failure. Eight HCWs had MERS requiring ICU admission (median stay = 28 days): Seven developed acute respiratory distress syndrome, four were treated with prone positioning, four needed continuous renal replacement therapy and one had extracorporeal membrane oxygenation. The hospital mortality of ICU MERS patients was 63.4 % (0 % for the HCWs). In response to the outbreak, the number of negative-pressure rooms was increased from 14 to 38 rooms in 3 MERS-designated ICUs. Patients were managed with a nurse-to-patient ratio of 1:0.8. Infection prevention practices were intensified. As a surrogate, surface disinfectant and hand hygiene gel consumption increased by ~30 % and 17 N95 masks were used per patient/day on average. Family visits were restricted to 2 h/day. Although most ICU staff expressed concerns about acquiring MERS, all reported to work normally. During the outbreak, 27.0 % of nurses and 18.4 % of physicians working in the MERS-designated ICUs reported upper respiratory symptoms, and were tested for MERS-CoV. Only 2/196 (1.0 %) ICU nurses and 1/80 (1.3 %) physician tested positive, had mild disease and recovered fully. The total sick leave duration was 138 days for nurses and 30 days for physicians. CONCLUSIONS: Our hospital outbreak of MERS resulted in 63 patients requiring organ support and prolonged ICU stay with a high mortality rate. The ICU response required careful facility and staff management and proper infection control and prevention practices.

Nortriptyline in knee osteoarthritis (NortIKA Study): study protocol for a randomised controlled trial.

BACKGROUND: Osteoarthritis (OA) is a common cause of pain and disability. Currently available analgesics are often insufficiently effective or have unacceptable adverse effects. Tricyclic antidepressants may offer a useful centrally-acting analgesic. Nortriptyline is a readily-available, cheap and comparatively well-tolerated tricyclic antidepressant. METHODS/DESIGN: We will conduct a parallel group, two-arm, participant and investigator-blinded, randomised controlled superiority trial comparing nortriptyline with placebo. Two hundred participants with primary knee OA will be enrolled. Participants will take study medication for 14 weeks. The primary outcome is difference between treatment arms in mean pain score measured on the Western Ontario and McMaster Universities (WOMAC) pain scale at 14 weeks. DISCUSSION: This protocol describes the first randomised controlled trial of a tricyclic antidepressant in the treatment of OA. The results of the study may have significant implications for the management of this common and painful condition. TRIAL REGISTRATION: The trial was registered with the Australian New Zealand Clinical Trials Registry on 27 June 2014. The trial registration number is: ACTRN12614000683639 .

Patient expectations for chronic pain management.

INTRODUCTION: In New Zealand, one in six people report chronic pain, but the literature indicates only a 30% pain reduction is typically achieved in about half of treated patients. Most patients expecting a cure of their pain, or even substantial pain reduction, are therefore likely to be disappointed. It is important to align patient expectations with this reality. METHODS: This study analysed the responses of 250 patients referred to a Pain Management Centre to the free-text question: 'What are your main goals or reasons for attending the Pain Management Centre?' Free-text comments were analysed using ethnographic content analysis, an inductive approach in which the themes and subthemes are not predetermined, but emerge from the data during analysis, and thus reflect the issues of importance to patients themselves. FINDINGS: Three themes emerged from the analysis: patients' desire to understand their pain, regain 'normality', and concerns about medication. Responses were divided into those with an expectation of cure, and those who seemed to be more accepting of their pain and who desired management. CONCLUSION: Patients hope to return to what they perceive as normal and to have clear, relevant information about their diagnosis, prognosis and medications. Those desiring cure, or significant pain reduction, present more of a challenge to their general practitioners and the Pain Management Centre. When referring a patient for chronic pain management, there is a need to align patient expectations at the point of referral with what can realistically be achieved.