Liposomal bupivacaine reduces narcotic use and time to flatus in a retrospective cohort of patients who underwent laparotomy.

INTRODUCTION: Sustained release liposomal bupivacaine (LB) is a new pain control option that can reduce opioid use after laparotomy, which is known to prolong ileus, length of stay. METHODS: Sixty-one consecutive patients undergoing laparotomy were treated with a standardized multi-modal therapy (MMT) consisting of IV tylenol, toradol, and morphine/dilaudid PCA. Thirty-one of those patients were additionally treated with LB infiltrated during fascial closure. Endpoints were opioid use, time to flatus, length of stay, and complications. RESULTS: Overall opioid use for 72 h was 78 mg of morphine for the MMT + LB group and 112 mg in the MMT control group (p = 0.04). During 0-24 h s PCA use was similar. However, during 24-48 h PCA use was decreased by 46% in the MMT + LB group (p = 0.038), and decreased by 55% during the 48-72 h period (p = 0.019). Time to flatus was decreased by 1.0 days in the MMT + LB group (p = 0.005). CONCLUSION: Use of LB in laparotomy patients decreases opioid use, time to flatus, and should be considered as a component of post-operative pain control.

Best Practices for Medication Utilization Evaluations in Postsurgical Pain Management.

PURPOSE: The purpose of this review is to provide guidance that aids in the practical design, implementation, and analysis of medication use evaluations (MUEs) for postsurgical pain management. SUMMARY: Clinicians have long employed drug use evaluations or drug utilization reviews to ensure the safe and appropriate use of medications in a hospital, medical practice, or other healthcare setting. Although these approaches are valuable, there is a growing trend toward replacing these methods with the MUE, a performance improvement tool that focuses on assessing and improving medication use processes or medication treatment response with the goal of optimizing patient outcomes. Utilizing MUEs to assess patient outcomes and quality of life can be challenging in certain therapeutic areas such as pain management, where measurements of pain can be quantitative but are inherently subjective. Currently, there is little guidance on the development of MUEs that balance subjective and objective outcomes. CONCLUSION: MUEs continue to become the standard for quality improvement for optimizing care and ensuring optimal outcomes. This review of the literature provides guidance in post-surgical pain management, an area that requires measurement of both subjective and objective outcomes.

Adjunct Analgesic Use for Acute Pain in the Emergency Department.

Purpose: Multimodal analgesia is common practice in the postoperative setting, but the utility of adjunctive analgesia in the emergency department (ED) is less understood. The primary objective of this study was to analyze ED prescriber ordering habits for adjunct nonopioid pain medication for opioid-naïve patients who require intravenous (IV) morphine or hydromorphone for acute pain. Secondary objectives were to assess initial and total opioid consumption in morphine equivalent units (MEU), pain scores, and ED length of stay (LOS) between groups. Methods: A retrospective chart review of adult patients who presented to the ED at a large academic medical center and received IV morphine or hydromorphone for acute pain was conducted. Patients were analyzed according to initial opioid received and presence or absence of adjunct nonopioid analgesics. Results: A total of 102 patient charts were analyzed. Adjunctive nonopioid analgesics were ordered on 38% of patients. Patients who received an adjunct nonopioid analgesic received a smaller mean initial opioid dose than those who did not (4.73 vs 5.48 MEU, p = .08). Initial pain score reduction on the 11-point Numeric Rating Scale (NRS) did not differ between patients who received adjunct analgesics versus those who did not (3 vs 4, p = .75). Patients who received adjunct analgesics were associated with a decreased ED LOS (294 vs 342 minutes, p = .04). Conclusion: A small proportion of patients with acute pain received a nonopioid analgesic in conjunction to IV opioids. Further studies are warranted to assess the impact of adjunct analgesics for patients with acute pain.

Use of naloxone for reversal of life-threatening opioid toxicity in cancer-related pain.

OBJECTIVE: To review the emergency-based approach to opioid toxicity reversal in cancer-related pain patients. DATA SOURCE: A MEDLINE and PubMed search was conducted (1966 to May 2014) using the terms opioids, cancer, naloxone, respiratory depression, morphine, morphine derivatives, emergency, and anaphylaxis. METHODS OF STUDY SELECTION: English articles in human subjects identified from the MEDLINE and PubMed search were evaluated. Citations were excluded if they addressed acute overdoses, non-cancer pain, and/or acute, non-chronic pain. DATA EXTRACTION AND SYNTHESIS: Pain is a common occurrence in the oncology population. Although toxicity from opioids is common, life-threatening toxicities are not. The use of naloxone in this particular patient population occurs frequently for any perceived opioid-related effect and can be detrimental to the oncology patient's care and quality of life. Difficulties exist when attempting to separate opioid toxicity from disease progression or metastases and, therefore, a thorough history is needed prior to complete opioid reversal in this population. Severity of the opioid intoxication should dictate reversal strategy. Dosing strategies that take into account both the treatment of the opioid-related effects as well as the negative effects reversal will have on the patient are offered. We also review the pre-hospital setting and identified the need for protocols that not only take the patient's symptoms into account, but also the patient's cancer history. CONCLUSION: Opioid reversal protocols should be developed by a multi-disciplinary team. Each protocol should differentiate those toxicities which are life-threatening and require complete opioid reversal with toxicities that require small aliquots of naloxone to mitigate the presenting symptoms.

Case Reports of Aripiprazole Causing False-Positive Urine Amphetamine Drug Screens in Children.

Urine drug screens (UDSs) are used to identify the presence of certain medications. One limitation of UDSs is the potential for false-positive results caused by cross-reactivity with other substances. Amphetamines have an extensive list of cross-reacting medications. The literature contains reports of false-positive amphetamine UDSs with multiple antidepressants and antipsychotics. We present 2 cases of presumed false-positive UDSs for amphetamines after ingestion of aripiprazole. Case 1 was a 16-month-old girl who accidently ingested 15 to 45 mg of aripiprazole. She was lethargic and ataxic at home with 1 episode of vomiting containing no identifiable tablets. She remained sluggish with periods of irritability and was admitted for observation. UDS on 2 consecutive days came back positive for amphetamines. Case 2 was of a 20-month-old girl who was brought into the hospital after accidental ingestion of an unknown quantity of her father's medications which included aripiprazole. UDS on the first day of admission came back positive only for amphetamines. Confirmatory testing with gas chromatography-mass spectrometry (GC-MS) on the blood and urine samples were also performed for both patients on presentation to detect amphetamines and were subsequently negative. Both patients returned to baseline and were discharged from the hospital. To our knowledge, these cases represent the first reports of false-positive amphetamine urine drug tests with aripiprazole. In both cases, aripiprazole was the drug with the highest likelihood of causing the positive amphetamine screen. The implications of these false-positives include the possibility of unnecessary treatment and monitoring of patients.

Use of an automated drug distribution cabinet system in a disaster response mobile emergency department.

OBJECTIVE: This article describes the innovative use of an automated drug distribution cabinet system for medication supply in a disaster response mobile Emergency Department vehicle. Prior to the use of the automated drug distribution cabinet system described in this article, the mobile hospitals were stocked as needed with drugs in individual boxes and draws. Experience with multiple deployments found this method to be very cumbersome and labor intensive, both in preparation, operational use, and demobilization. SETTING: For a recent deployment to provide emergency medical care at the 2014 Super Bowl football event, the automated drug distribution cabinet system in the Institution's main campus Emergency Department was duplicated and incorporated into the mobile Emergency Department. RESULTS: This method of drug stocking and dispensing was found to be far more efficient than gathering and placing drugs in onboard draws and racks. CONCLUSIONS: Automated drug distribution cabinet systems can be used to significantly improve patient care and overall efficiency in mobile hospital deployments.

Pharmacy collected medication histories in an observation unit.

BACKGROUND: Clear processes to facilitate medication reconciliation in a hospital setting are still undefined. The observation unit allows for a high patient turnover rate, where obtaining accurate medication histories is critical. OBJECTIVES: The objective of this study was to assess the ability of pharmacists and student pharmacists to identify discrepancies in medication histories obtained at triage in observation patients. METHODS: Pharmacists and student pharmacists obtained a medication history for each patient placed in observation status. Patients were excluded if they were unable to provide a medication history and family, caregiver, or community pharmacy was also unable to provide the history. A comparison was made between triage and pharmacy collected medication histories to identify discrepancies. RESULTS: A total of 501 medications histories were collected, accounting for 3213 medication records. There were 1176 (37%) matched medication records and 1467 discrepancies identified, including 808 (55%) omissions, 296 (20.2%) wrong frequency, 278 (19%) wrong dose, 51 (3.5%) discontinued, and 34 (2.3%) wrong medication. There was an average of 2.9 discrepancies per patient profile. In all, 76 (15%) of the profiles were matched. The median time to obtain a medication history was 4 min (range: 1-48 min). CONCLUSION: Pharmacy collected medication histories in an observation unit identify discrepancies that can be reconciled by the interdisciplinary team.