Opioid use in older orthopedic rehabilitation inpatients: a retrospective study.

BACKGROUND: While there is much evidence about pain management for orthopedic patients in the immediate perioperative setting, little is known about how opioids are used during inpatient rehabilitation, particularly in older adults. A safe upper limit of 50 mg oral morphine equivalents (OME) is frequently cited in guidelines. AIM: The aim of this study was to characterize the dosing of opioids in an older adult population undergoing inpatient orthopedic rehabilitation (IOR). DESIGN: Retrospective observational study. SETTING: Inpatient units at an academic rehabilitation hospital in Toronto, Canada. POPULATION: All adults aged ≥50 years old admitted for orthopedic rehabilitation between November 2019 and June 2021 following acute care admissions for either a surgical or non-surgical orthopedic indication. METHODS: Participants were divided into groups of prior opioids users, new opioids users, and opioid non-users during IOR. Demographic, clinical, and medication administration data were collected through the electronic health record and manual chart review. Average daily opioid dose for the first seven days of each stay was characterized using OME. Linear regression was used to assess for variables independently associated with opioid dose. RESULTS: A total of 643 patients undergoing orthopedic rehabilitation were included: 125 (19.4%) were prior opioid users, 416 (64.7%) were new opioid users, and 102 (15.9%) were non-users, with median age respectively of 72, 79, and 83. Median daily OME over the first week for prior users was 30.3 and for new users was 6.9. Opioid dose was inversely associated with age and admission for a non-surgical indication; it was positively associated with reported pain (as defined by day 3 pain score) and admission for knee replacement. CONCLUSIONS: Opioids are frequently but heterogeneously used in older adults undergoing IOR. Median OME use in this cohort of older adults was substantially lower than the 50 OME threshold suggested in guidelines, particularly for new opioid users. CLINICAL REHABILITATION IMPACT: Older adults require much lower opioid doses than younger patients. Pain management in older orthopedic rehabilitation inpatients is distinct from the perioperative setting and deserves tailored guidance, with a focus on using the lowest effective dose.

Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit.

BACKGROUND: In 2013, the Society of Critical Care Medicine published a revised version of the ICU Pain, Agitation, and Delirium (PAD) guidelines. Immobility and sleep were subsequently added in 2018. Despite the well-established advantages of implementing these guidelines, adoption and adherence remain suboptimal. This is especially true in community settings, where PAD assessment is performed less often, and the implementation of PAD guidelines has not yet been studied. The purpose of this prospective interventional study is to evaluate the effect of a multifaceted nurse engagement intervention on PAD assessment in a community intensive care unit (ICU). METHODS: All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by the intervention, and a 20-week postintervention audit. The intervention consisted of a survey, focus groups and education sessions. Primary outcomes included rates of daily PAD assessment using validated tools. RESULTS: There were improvements in the number of patients with at least one assessment per day of pain (67.5% vs 59.3%, p=0.04), agitation (93.1% vs 78.7%, p<0.001) and delirium (54.2% vs 39.4%, p<0.001), and the number of patients with target Richmond Agitation-Sedation Scale ordered (63.1% vs 46.8%, p=0.002). There was a decrease in the rate of physical restraint use (10.0% vs 30.9%, p<0.001) and no change in self-extubation rate (0.9% vs 2.5%, p=0.2). CONCLUSION: The implementation of a multifaceted nurse engagement intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses and families to close the observed care gap.

Propofol administration by endoscopists versus anesthesiologists in gastrointestinal endoscopy: a systematic review and meta-analysis of patient safety outcomes.

BACKGROUND: With a growing demand for endoscopic services, the role of anesthesiologists in endoscopy units must be reassessed. The aim of this study was to compare patient outcomes in non-anesthesiologist-administered propofol (NAAP) versus anesthesiologist-administered propofol (AAP) during routine endoscopy. METHODS: We systematically searched MEDLINE, CINAHL, Embase, Web of Science, CENTRAL and the grey literature for studies comparing NAAP and AAP. Primary outcomes included endoscopy- and sedation-related complications. Secondary outcomes included measures of endoscopy quality and of patient and endoscopist satisfaction. We reported treatment effects using random-effects models. RESULTS: Of 602 articles identified, 5 met the inclusion criteria. Most studies included only patients with an American Society of Anesthesiologists (ASA) classification of I or II. Non-anesthesiologist-administered propofol did not result in increased rates of airway intervention (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.29 to 3.95; 3443 patients) or hypotension (OR 1.47, 95% CI 0.40 to 5.41; 17 978 patients) but did result in higher rates of bradycardia (OR 3.68, 95% CI 1.65 to 8.17; 17 978 patients). Nonanesthesiologists administered lower propofol dosages than anesthesiologists (mean difference -61.79, 95% CI -114.46 to -9.12; 3443 patients), and their patients more commonly experienced awareness with recall (OR 19.99, 95% CI 7.88 to 50.76; 2090 patients). However, NAAP neither compromised patient willingness to repeat the procedure (OR 0.42, 95% CI 0.10 to 1.83; 2367 patients) nor lengthened total procedure time (mean difference -0.08, 95% CI -3.51 to 3.34; 2367 patients). CONCLUSION: Endoscopists may safely administer propofol without compromising procedural quality in patients classified as ASA I or II undergoing routine endoscopy. The results of this meta-analysis are limited by a lack of available high-quality studies. Further, large-scale studies are needed for definitive conclusions.

CONTEXTE: Étant donné que les services endoscopiques sont de plus en plus demandés, le rôle des anesthésiologistes dans les unités d'endoscopie doit être réévalué. Le but de cette étude était de comparer les résultats cliniques chez les patients selon que le propofol était administré par des non-anesthésiologistes (NAAP, pour non-anesthesiologist-administered propofol) ou par des anesthésiologistes (AAP, pour anesthesiologist-administered propofol). MÉTHODES: Nous avons procédé à une revue systématique des réseaux MEDLINE, CINAHL, Embase, Web of Science et CENTRAL et de la littérature grise pour recenser les études ayant comparé les méthodes NAAP et AAP. Les paramètres principaux incluaient les complications liées à l'endoscopie et à la sédation, et les paramètres secondaires incluaient les mesures de la qualité de l'endoscopie et la satisfaction des patients et des endoscopistes. Nous avons fait état des effets des traitements à l'aide de modèles à effets aléatoires. RÉSULTATS: Sur les 602 articles recensés, 5 répondaient aux critères d'inclusion. La plupart des études incluaient uniquement des patients présentant une classe ASA (American Society of Anesthesiologists) I ou II. Le propofol administré par des non-anesthésiologistes n'a pas donné lieu à un taux accru d'interventions touchant les voies respiratoires (rapport des cotes [RC] 1,07, intervalle de confiance [IC] de 95 %, 0,29 à 3,95; 3443 patients) ou d'hypotension (RC 1,47, IC de 95 %, 0,40 à 5,41; 17 978 patients), mais a donné lieu à des taux plus élevés de bradycardie (RC 3,68, IC de 95 %, 1,65 à 8,17; 17 978 patients). Comparativement aux anesthésiologistes, les non-anesthésiologistes ont administré des doses de propofol plus faibles (différence moyenne -61,79, IC de 95 %, -114,46 à -9,12; 3443 patients) et leurs patients ont plus souvent gardé conscience, avec souvenirs post-intervention (RC 19,99, IC à 95 %, 7,88 à 50,76; 2090 patients). Toutefois, la méthode NAAP n'a ni compromis la volonté des patients à répéter l'intervention (RC 0,42, IC à 95 %, 0,10 à 1,83; 2367 patients) ni prolongé la durée totale de l'intervention (différence moyenne −0,08, IC à 95 %, −3,51 à 3,34; 2367 patients). CONCLUSION: Les endoscopistes peuvent administrer le propofol de manière sécuritaire sans compromettre la qualité de l'intervention chez les patients de classe ASA I ou II soumis à une endoscopie de routine. Les résultats de cette méta-analyse sont limités par l'absence d'études de grande qualité. En outre, des études de plus grande envergure sont requises pour arriver à des conclusions définitives.