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2.
Clin Biochem ; 112: 6-10, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-36535386

RESUMO

BACKGROUND: Urine drug testing (UDT) monitors prescription compliance and/or drug abuse. However, interpretation of UDT results obtained by liquid chromatography-tandem mass spectrometry (LC-MS-MS) can be complicated by the presence of drug impurities that are detected by highly sensitive methods. Hydrocodone is a drug impurity that can be found as high as 1% in oxycodone pills. OBJECTIVES: We evaluated the frequency and concentration of hydrocodone and its metabolite, hydromorphone, in patients taking oxycodone to check if the ratio of hydrocodone or hydromorphone to oxycodone could distinguish between oxycodone only use from those consuming additional opiates. DESIGN & METHODS: We correlated LC-MS/MS results with medication records of 319 patients with positive oxycodone results over 7 months (4/2021-11/2021). RESULTS: Fifteen of 319 patients with positive oxycodone results were taking oxycodone only. For these 15 patients, the mean ratio of hydrocodone to oxycodone was 0.57% (range 0.05%-3.35%), and the mean ratio of hydromorphone to oxycodone was 0.81% (range 0.18-3.51%). CONCLUSIONS: Hydrocodone and/or hydromorphone are detectable in patients taking only oxycodone and can likely be identified as an impurity if their calculated ratio to oxycodone is <1 %. Further validation of the ratios in a larger sample size is recommended.


Assuntos
Hidrocodona , Transtornos Relacionados ao Uso de Opioides , Humanos , Hidrocodona/análise , Hidromorfona/análise , Oxicodona , Analgésicos Opioides , Cromatografia Líquida/métodos , Oximorfona , Espectrometria de Massas em Tandem/métodos
3.
JAMA Netw Open ; 5(12): e2244514, 2022 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-36454569

RESUMO

Importance: Postoperative sleep disturbance (PSD) is common in patients after surgery. Objective: To examine the effect of intraoperative esketamine infusion on the incidence of PSD in patients who underwent gynecological laparoscopic surgery. Design, Setting, and Participants: This single-center, double-blind, placebo-controlled randomized clinical trial was conducted from August 2021 to April 2022 in the First Affiliated Hospital of Zhengzhou University in China. Participants included patients aged 18 to 65 years with an American Society of Anesthesiologist Physical Status classification of I to III (with I indicating a healthy patient, II a patient with mild systemic disease, and III a patient with severe systemic disease) who underwent gynecological laparoscopic surgery. Patients were randomly assigned to either the esketamine group or control group. Data were analyzed using the per protocol principle. Interventions: Patients in the esketamine group received a continuous infusion of esketamine, 0.3 mg/kg/h, intraoperatively. Patients in the control group received an equivalent volume of saline. Main Outcomes and Measures: The primary outcome was the incidence of PSD on postoperative days (PODs) 1 and 3. Postoperative sleep disturbance was defined as a numeric rating scale score of 6 or higher or an Athens Insomnia Scale score of 6 points or higher. The secondary outcomes included postoperative anxiety and depression scores using the Hospital Anxiety and Depression Scale, postoperative pain using the visual analog scale, postoperative hydromorphone consumption, and risk factors associated with PSD. Results: A total of 183 female patients were randomized to the control group (n = 91; median [IQR] age, 45 [35-49] years) and the esketamine group (n = 92; median [IQR] age, 43 [32-49] years). The incidence of PSD in the esketamine group was significantly lower than in the control group on POD 1 (22.8% vs 44.0%; odds ratio [OR], 0.38 [95% CI, 0.20-0.72]; P = .002) and POD 3 (7.6% vs 19.8%; OR, 0.33 [95% CI, 0.13-0.84]; P = .02). There were no differences in postoperative depression and anxiety scores between the 2 groups. Postoperative hydromorphone consumption in the first 24 hours (3.0 [range, 2.8-3.3] mg vs 3.2 [range, 2.9-3.4] mg; P = .04) and pain scores on movement (3 [3-4] vs 4 [3-5] points; P < .001) were significantly lower in the esketamine group than in the control group. On multivariable logistic regression, preoperative depression (OR, 1.31; 95% CI, 1.01-1.70) and anxiety (OR, 1.67; 95% CI, 1.04-1.80) scores, duration of anesthesia (OR, 1.04; 95% CI, 1.00-1.08), and postoperative pain score (OR, 1.92; 95% CI, 1.24-2.96) were identified as risk factors associated with PSD. Conclusions and Relevance: Results of this trial showed the prophylactic effect of intraoperative esketamine infusion on the incidence of PSD in patients who underwent gynecological laparoscopic surgery. Further studies are needed to confirm these results. Trial Registration: Chinese Clinical Trial Registry Identifier: ChiCTR2100048587.


Assuntos
Laparoscopia , Transtornos do Sono-Vigília , Humanos , Feminino , Pessoa de Meia-Idade , Adulto , Hidromorfona , Transtornos do Sono-Vigília/tratamento farmacológico , Transtornos do Sono-Vigília/epidemiologia , Transtornos do Sono-Vigília/etiologia , Laparoscopia/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Sono
4.
Medicine (Baltimore) ; 101(48): e31901, 2022 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-36482626

RESUMO

To evaluate the analgesic effect of butorphanol tartrate combined with hydromorphone on the patients with cesarean section, we conducted a prospective cohort study. A total of 90 patients were given patient-controlled intravenous analgesia (PCIA) with hydromorphone for 24 hours after the cesarean section. After stopping PCIA, they were divided into 2 groups randomly. The cases treated with butorphanol tartrate intravenous drip were evaluated as the butorphanol group (n = 45) and the cases treated with saline were evaluated as the control group (n = 45). We compared the vital signs, analgesic effect, adverse reactions, the bladder and gastrointestinal function recovery, and neonatal jaundice between the 2 groups. The visual analog score in butorphanol group was significantly lower than that of control group at 3 and 4 hours after stopping PCIA (P < .05), but there was no significant difference in visual analog score at 6 and 12 hours after stopping PCIA. The first time of getting out of bed and urination in butorphanol group was significantly later than that in control group while there was no significant difference in the first anal ventilation and the neonatal jaundice index between the 2 groups. We should pay attention to the pain of patients with cesarean section after stopping PCIA. The combination of butorphanol tartrate and hydromorphone play a good effect to relieve the pain while nursing care should be strengthened to urge patients to take early activities to reduce the occurrence of urinary retention.


Assuntos
Hidromorfona , Icterícia Neonatal , Gravidez , Recém-Nascido , Humanos , Feminino , Hidromorfona/uso terapêutico , Butorfanol/uso terapêutico , Cesárea/efeitos adversos , Estudos Prospectivos , Dor
5.
BMJ Open ; 12(11): e064581, 2022 11 16.
Artigo em Inglês | MEDLINE | ID: mdl-36385038

RESUMO

INTRODUCTION: When patients receive patient-controlled intravenous analgesia (PCIA), no basal infusion is always recommended, as the addition of a basal infusion increases the occurrence of postoperative opioid-induced respiratory depression. However, few studies have investigated whether low basal infusions increase the incidence of postoperative hypoxaemia relative to no basal infusion. We intend to conduct a clinical trial to test the hypothesis that PCIA with a low basal infusion does not increase the occurrence of postoperative hypoxaemia relative to PCIA with no basal infusion. METHODS AND ANALYSIS: This single-centre parallel randomised controlled clinical trial will be conducted with 160 patients undergoing gastrointestinal tumour surgery. The assigned nurse will set analgesic pumps (low or no basal infusion PCIA) according to block-based randomisation sequence. Other investigators and all participants will be blinded to intervention allocation. All patients will be monitored continuously with the ep pod, a wireless wearable device, recording of oxygen saturation (SpO2) and daily ambulation duration for 48 hours postoperatively. Three follow-up evaluations will be conducted to assess the analgesic effect (Numeric Rating Scale (NRS) pain score) and opioid-related side effects (Overall Benefit of Analgesic Score (OBAS)). The primary outcome will be the area under the curve for hypoxaemia (defined as SpO2<95%) per hour. The secondary outcomes will be the areas under the curve for hypoxaemia defined as SpO2<90% and <85% per hour, hydromorphone consumption, OBASs at 24 and 48 hours postoperatively, NRS scores at 4, 24 and 48 hours postoperatively, and the ambulation time per hour over 48 hours. ETHICS AND DISSEMINATION: The study has been approved by the Xijing Hospital Ethics Committee (KY20212163-F-1). Written informed consent will be obtained from all patients or their authorised surrogates. All data will be managed with confidentiality. Findings will be disseminated at international conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ChiCTR2100054317.


Assuntos
Analgesia Controlada pelo Paciente , Hidromorfona , Humanos , Analgesia Controlada pelo Paciente/métodos , Hidromorfona/uso terapêutico , Analgésicos Opioides/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Hipóxia/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto
6.
Harm Reduct J ; 19(1): 113, 2022 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-36229831

RESUMO

BACKGROUND AND AIMS: Given the ongoing opioid crisis, novel interventions to treat severe opioid use disorder (OUD) are urgently needed. Injectable opioid agonist therapy (iOAT) with diacetylmorphine or hydromorphone is effective for the treatment of severe, treatment-refractory OUD, however barriers to implementation persist. Intravenous buprenorphine for the treatment of OUD (BUP iOAT) has several possible advantages over traditional iOAT, including a safety profile that might enable take-home dosing. We aimed to characterize injecting practices among real-world populations of persons who regularly inject buprenorphine, as well as associated adverse events reported in order to inform a possible future BUP iOAT intervention. METHODS: We conducted a systematic review. We searched MEDLINE, EMBASE, and PsycINFO from inception through July 2020 and used backwards citation screening to search for publications reporting on dose, frequency among persons who regularly inject the drug, or adverse events associated with intravenous use of buprenorphine. The review was limited to English language publications and there was no limitation on study type. Study quality and risk of bias was assessed using the Mixed Methods Appraisal Tool. Narrative synthesis was used in reporting the results. RESULTS: Eighty-eight studies were included in our review. Regular injection of buprenorphine was identified across diverse settings world-wide. Daily dose of oral buprenorphine injected was < 1-12 mg. Frequency of injection was 0-10 times daily. Adverse events could be characterized as known side effects of opioids/buprenorphine or injection-related complications. Most studies were deemed to be of low quality. CONCLUSIONS: Extramedical, intravenous use of buprenorphine, continues to be documented. BUP iOAT may be feasible and results may inform the development of a study to test the efficacy and safety of such an intervention. Future work should also examine acceptability among people with severe OUD in North America. Our review was limited by the quality of included studies.


Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/efeitos adversos , Buprenorfina/uso terapêutico , Heroína/uso terapêutico , Humanos , Hidromorfona/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etiologia
7.
J Opioid Manag ; 18(5): 467-474, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36226786

RESUMO

This study sought to determine if there were any changes in opioid prescribing habits of providers at a single institution after the implementation of legislation to increase opioid prescribing regulations. Our study demonstrated a 39.5 percent decrease in overall morphine milligram equivalent (MME) prescribed the year after the laws took effect when compared with the year prior. It is clear that these laws have been effective in decreasing the number of opioids prescribed at discharge from Mercy Health Grand Rapids. INTRODUCTION: Opioid use disorder has become an epidemic with approximately 130 people dying every day in the United States due to prescription and illegal opioid overdoses. In December 2017, the Michigan legislature ratified a package of 10 acts to address a variety of problems through several layers of regulations including more restrictive prescribing rules, which took effect in June 2018. OBJECTIVE: To evaluate the impact of legislation on the opioid prescribing habits of providers who discharged patients from a community-based academic teaching hospital. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was performed using data from a community-based academic teaching hospital with 303 beds, a medical ICU, labor and delivery unit, and a 42-room emergency department. All patients discharged from in-patient or observation status in the 12 months before and after June 1, 2018 were included. MAIN OUTCOMES AND MEASURES: The primary outcome was MMEs of opioids prescribed at discharge before (June 1, 2017 to May 31, 2018) and after (June 1, 2018 to May 31, 2019) legislation. Medications included morphine, hydrocodone, oxycodone, fentanyl, methadone, hydromorphone, tramadol, codeine, and meperidine. RESULTS: There were 17,227 patients discharged during the first 12-month period and 15,855 patients discharged in the second 12-month period. There were 14,064 new opioid prescriptions in total during these time periods. Total MME prescribed during the study period showed a 39.5 percent decrease from pre- (2,268,460 MME) to post-legislation (1,372,424 MME), while average MMEs/discharge significantly decreased (135.1 ± 321.2 vs. 87.6 ± 187.4; p < 0.001). Total pill/patch count decreased by almost 40 percent. For patients who were prescribed opioids, average MME/discharge showed significant decline after legislation implementation (309.6 ± 427.1 vs. 212.2 ± 242.1; p < 0.001). Average daily MME/patient prescribed an opioid remained similar between the time periods (52.4 ± 37.0 vs. 51.6 ± 35.0; p = 0.21). Significant reductions (p < 0.05) were seen in MMEs for each individual medication with the exception of acetaminophen-codeine and methadone. CONCLUSIONS AND RELEVANCE: Our results indicate that the legislation implemented in Michigan to regulate opioid prescriptions was associated with a reduction in opioids prescribed to patients discharged from a community-based academic teaching hospital.


Assuntos
Analgésicos Opioides , Tramadol , Acetaminofen/uso terapêutico , Analgésicos Opioides/efeitos adversos , Codeína/uso terapêutico , Endrin/análogos & derivados , Fentanila/uso terapêutico , Humanos , Hidrocodona/uso terapêutico , Hidromorfona/uso terapêutico , Meperidina/uso terapêutico , Metadona/uso terapêutico , Michigan , Oxicodona/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Alta do Paciente , Padrões de Prática Médica , Estudos Retrospectivos , Tramadol/uso terapêutico , Estados Unidos
8.
Drug Des Devel Ther ; 16: 3401-3412, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36203818

RESUMO

Purpose: Postoperative pain after open hepatectomy is significant. Preoperative coagulopathy limits the use of epidural analgesia, the gold standard for pain control in open abdominal surgery. Erector spinae plane block (ESPB) is a novel regional anesthesia technique that has been shown to provide effective analgesia in abdominal surgery. In this study, we compared the analgesic efficacy of patient-controlled continuous ESPB (CESPB) with hydromorphone patient-controlled intravenous analgesia (PCIA) after right subcostal incision hepatectomies in hepatocellular carcinoma patients with preoperative coagulopathy. Patients and Methods: In this randomized, controlled, unblinded, and noninferiority trial, 120 patients were randomized to receive either CESPB or PCIA as primary postoperative analgesia together with parecoxib (40mg Q12 h IV) for 3 days after surgery. The primary outcome was the average cough-elicited pain numeric rating scales (NRS) recorded at the seven follow-up time points of 20:00 on the day of surgery and 9:00 and 15:00 on the postoperative day 1 to day 3 (POD1 to POD3). Results: The average cough-elicited pain NRS score was 2.402 in the CESPB group and 2.676 in the PCIA group. The mean difference (95% CI) was -0.274 (-0.620 to 0.072), which demonstrated the noninferiority of CESPB to PCIA. Patients in the CESPB group had less intraoperative opioid consumption, a lower incidence of moderate-to-severe pain and PONV at POD3, and early resumption of oral intake. Conclusion: CESPB provides analgesic efficacy noninferior to opioid PCIA in the context of multimodal analgesia after right subcostal incision open hepatectomy.


Assuntos
Transtornos da Coagulação Sanguínea , Bloqueio Nervoso , Analgesia Controlada pelo Paciente/métodos , Analgésicos , Analgésicos Opioides/uso terapêutico , Transtornos da Coagulação Sanguínea/complicações , Tosse , Hepatectomia/efeitos adversos , Humanos , Hidromorfona , Fígado , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia
9.
JAMA ; 328(13): 1326-1335, 2022 10 04.
Artigo em Inglês | MEDLINE | ID: mdl-36194219

RESUMO

Importance: In arthroscopic knee and shoulder surgery, there is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients' pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. Objective: To evaluate the effect of a multimodal, opioid-sparing approach to postoperative pain management compared with the current standard of care in patients undergoing arthroscopic shoulder or knee surgery. Design, Setting, and Participants: This randomized clinical trial was performed at 3 clinical sites in Ontario, Canada, and enrolled 200 patients from March 2021 to March 2022 with final follow-up completed in April 2022. Adult patients undergoing outpatient arthroscopic shoulder or knee surgery were followed up for 6 weeks postoperatively. Interventions: The opioid-sparing group (100 participants randomized) received a prescription of naproxen, acetaminophen (paracetamol), and pantoprazole; a limited rescue prescription of hydromorphone; and a patient educational infographic. The control group (100 participants randomized) received the current standard of care determined by the treating surgeon, which consisted of an opioid analgesic. Main Outcomes and Measures: The primary outcome was postoperative oral morphine equivalent (OME) consumption at 6 weeks after surgery. There were 5 secondary outcomes, including pain, patient satisfaction, opioid refills, quantity of OMEs prescribed at the time of hospital discharge, and adverse events at 6 weeks all reported at 6 weeks after surgery. Results: Among the 200 patients who were randomized (mean age, 43 years; 73 women [38%]), 193 patients (97%) completed the trial; 98 of whom were randomized to receive standard care and 95 the opioid-sparing protocol. Patients in the opioid-sparing protocol consumed significantly fewer opioids (median, 0 mg; IQR, 0-8.0 mg) than patients in the control group (median, 40.0 mg; IQR, 7.5-105.0; z = -6.55; P < .001). Of the 5 prespecified secondary end points, 4 showed no significant difference. The mean amount of OMEs prescribed was 341.2 mg (95% CI, 310.2-372.2) in the standard care group and 40.4 mg (95% CI, 39.6-41.2) in the opioid-sparing group (mean difference, 300.8 mg; 95% CI, 269.4-332.3; P < .001). There was no significant difference in adverse events at 6 weeks (2 events [2.1%] in the standard care group vs 3 events [3.2%] in the opioid-sparing group), but more patients reported medication-related adverse effects in the standard care group (32% vs 19%, P = .048). Conclusions and Relevance: Among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared with standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks. Trial Registration: ClinicalTrials.gov Identifier: NCT04566250.


Assuntos
Analgésicos não Narcóticos , Analgésicos Opioides , Artroscopia , Articulação do Joelho , Dor Pós-Operatória , Articulação do Ombro , Acetaminofen/efeitos adversos , Acetaminofen/uso terapêutico , Adulto , Analgésicos não Narcóticos/efeitos adversos , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Antiulcerosos/efeitos adversos , Antiulcerosos/uso terapêutico , Protocolos Clínicos , Quimioterapia Combinada , Feminino , Humanos , Hidromorfona/efeitos adversos , Hidromorfona/uso terapêutico , Articulação do Joelho/cirurgia , Masculino , Naproxeno/efeitos adversos , Naproxeno/uso terapêutico , Ontário , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Pantoprazol/efeitos adversos , Pantoprazol/uso terapêutico , Educação de Pacientes como Assunto , Cuidados Pós-Operatórios , Articulação do Ombro/cirurgia
10.
Neuropharmacology ; 221: 109291, 2022 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-36241086

RESUMO

Cytochrome P450 2D (CYP2D) metabolises many centrally-acting substrates including opioids. Hydrocodone, an opioid and CYP2D substrate, is metabolised to hydromorphone, an active metabolite. CYP2D in the brain is active in vivo and can alter drug response however, it is unknown whether metabolism by CYP2D in the brain alters oral hydrocodone induced analgesia. Propranolol, a selective CYP2D mechanism-based inhibitor, or vehicle, was administered into the right cerebral ventricle of male rats, (HAN Wistars, Envigo), 24 h before testing for analgesia from oral hydrocodone (or hydromorphone, a non-CYP2D substrate). Hydrocodone and its CYP2D-mediated metabolites were simultaneously quantified using a novel LC-MS/MS assay. After propranolol vs vehicle pretreatment, there was significantly higher analgesia from oral hydrocodone, and a significantly lower brain CYP2D metabolic ratio (an in vivo phenotype of brain CYP2D activity that was derived from the molar sum of hydromorphone and its metabolites divided by hydrocodone). The brain CYP2D metabolic ratio correlated significantly with analgesia. There was no pretreatment effect on plasma hydrocodone concentrations, elimination rates, or metabolic ratio (an in vivo phenotype for hepatic CYP2D activity). The liver CYP2D metabolic ratio did not correlate with analgesia. Propranolol pretreatment had no impact on analgesia from oral hydromorphone. These data suggest that inhibited CYP2D activity in brain, causing reduced metabolism of brain hydrocodone, resulted in higher analgesia from oral hydrocodone, despite hydrocodone having a lower µ-opioid receptor affinity than hydromorphone. Thus, variation in CYP2D in the brain may be an important source of interindividual differences in response to CYP2D substrates, including oral hydrocodone.


Assuntos
Analgesia , Hidrocodona , Animais , Masculino , Ratos , Hidrocodona/metabolismo , Hidrocodona/farmacologia , Hidromorfona/metabolismo , Hidromorfona/farmacologia , Cromatografia Líquida , Propranolol/farmacologia , Ratos Wistar , Espectrometria de Massas em Tandem , Sistema Enzimático do Citocromo P-450/metabolismo , Sistema Enzimático do Citocromo P-450/farmacologia , Dor/metabolismo , Analgésicos Opioides , Encéfalo
11.
J Natl Compr Canc Netw ; 20(9): 1013-1021.e3, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-36075387

RESUMO

BACKGROUND: Optimal analgesic maintenance for severe cancer pain is unknown. This study evaluated the efficacy and safety of intravenous patient-controlled analgesia (IPCA) with continuous infusion plus rescue dose or bolus-only dose versus conventional oral extended-release morphine as a background dose with normal-release morphine as a rescue dose to maintain analgesia in patients with severe cancer pain after successful opioid titration. METHODS: Patients with persistent severe cancer pain (≥7 at rest on the 11-point numeric rating scale [NRS]) were randomly assigned to 1 of 3 treatment arms: (A1) IPCA hydromorphone with bolus-only dose where dosage was 10% to 20% of the total equianalgesic over the previous 24 hours (TEOP24H) administered as needed, (A2) IPCA hydromorphone with continuous infusion where dose per hour was the TEOP24H divided by 24 and bolus dosage for breakthrough pain was 10% to 20% of the TEOP24H, and (B) oral extended-release morphine based on TEOP24H/2 × 75% (because of incomplete cross-tolerance) every 12 hours plus normal-release morphine based on TEOP24H × 10% to 20% for breakthrough pain. After randomization, patients underwent IPCA hydromorphone titration for 24 hours to achieve pain control before beginning their assigned treatment. The primary endpoint was NRS over days 1 to 3. RESULTS: A total of 95 patients from 9 oncology study sites underwent randomization: 30 into arm A1, 32 into arm A2, and 33 into arm B. Arm B produced a significantly higher NRS over days 1 to 3 compared with arm A1 or A2 (P<.001). Daily NRS from day 1 to day 6 and patient satisfaction scores on day 3 and day 6 were worse in arm B. Median equivalent-morphine consumption increase was significantly lower in A1 (P=.024) among the 3 arms. No severe adverse event occurred in any arm. CONCLUSIONS: Compared with oral morphine maintenance, IPCA hydromorphone for analgesia maintenance improves control of severe cancer pain after successful titration. Furthermore, IPCA hydromorphone without continuous infusion may consume less opioid.


Assuntos
Dor Irruptiva , Dor do Câncer , Neoplasias , Analgesia Controlada pelo Paciente , Analgésicos Opioides , Dor Irruptiva/tratamento farmacológico , Dor do Câncer/tratamento farmacológico , Dor do Câncer/etiologia , Humanos , Hidromorfona/efeitos adversos , Morfina/efeitos adversos , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Medição da Dor
12.
Am J Emerg Med ; 61: 234.e1-234.e3, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-35961832

RESUMO

BACKGROUND: Phlegmasia cerulea dolens (PCD) is a rare condition characterized by a severely swollen, cyanotic, blue extremity due to a large proximal (iliofemoral) deep venous thrombosis extending into the collateral veins. Mortality in PCD ranges 20-40%. Due to severely compromised venous drainage, compartment pressures can rapidly increase 16-fold within 6 h, but rarely result in arterial compromise. CASE REPORT: We present a case of a middle-aged woman with no prior history of deep venous thrombosis, with a blue swollen left leg in intractable severe pain unresponsive to 3 doses of hydromorphone. Her pain was successfully alleviated with IV Lidocaine. Patient was found to have phlegmasia cerulea dolens resulting in compartment syndrome of her left leg. Although the patient initially had no motor function, after catheter-directed thrombolysis and emergent thrombectomy, she regained her motor function and made a full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Phlegmasia cerulea dolens complicated by severe compartment syndrome is a rare entity. Prompt recognition and treatment are necessary to prevent irreversible limb ischemia and associated morbidity and mortality. IV Lidocaine may be considered as an option for analgesia for such patients.


Assuntos
Síndromes Compartimentais , Tromboflebite , Trombose Venosa , Humanos , Pessoa de Meia-Idade , Feminino , Hidromorfona/uso terapêutico , Trombose Venosa/complicações , Trombose Venosa/tratamento farmacológico , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/etiologia , Síndromes Compartimentais/cirurgia , Edema , Dor/etiologia , Lidocaína/uso terapêutico , Tromboflebite/complicações
13.
JAMA Netw Open ; 5(8): e2228588, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-36001312

RESUMO

Importance: Prescription opioids are often used during pregnancy even though they are associated with neonatal opioid withdrawal syndrome (NOWS). Most studies of adverse outcomes of opioid use for pain have assessed only the class-wide outcome despite the pharmacodynamic and pharmacokinetic heterogeneity across opioid medications. Objective: To compare the risk of NOWS across common types of opioids when prescribed as monotherapy during the last 3 months of pregnancy. Design, Setting, and Participants: This cohort study analyzed administrative claims data of Medicaid-insured mothers and newborns in 46 states and Washington DC from January 1, 2000, through December 31, 2014. Participants were mothers with 2 or more dispensed opioid prescriptions within 90 days before delivery and their eligible live-born neonates. Data were analyzed from February 2020 to March 2021. Exposure: Different types of opioid medications were compared by agonist strength (strong vs weak) and half-life (medium vs short and long vs short) of the opioid active ingredient. Main Outcomes and Measures: The primary outcome was NOWS, which was identified using an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code in the 30 days after delivery. Relative risks (RRs) were adjusted for an exposure propensity score, including demographic characteristics, comorbidities, other medication use, and opioid treatment characteristics (including morphine milligram equivalents), using fine stratification. Results: The cohort comprised 48 202 opioid-exposed pregnancies with live newborns. A total of 1069 neonates (2.2%) had NOWS and 559 (1.2%) had severe NOWS. Opioid exposure during pregnancy included 16 202 pregnancies exposed to codeine, 4540 to oxycodone, 1244 to tramadol, 260 to methadone (dispensed for pain), 90 to hydromorphone, and 63 to morphine compared with 25 710 exposed to hydrocodone. Demographic characteristics varied across opioids, with tramadol, oxycodone, methadone, hydromorphone, and morphine being more commonly dispensed at older maternal age (≥35 years). Compared with hydrocodone, codeine had a lower adjusted RR of NOWS (0.57; 95% CI, 0.46-0.70), with a similar adjusted RR for tramadol (RR, 1.06; 95% CI, 0.73-1.56), and 2- to 3-fold higher adjusted RRs for oxycodone (1.87; 95% CI, 1.66-2.11), morphine (2.84; 95% CI, 1.30-6.22), methadone (3.02; 95% CI, 2.45-3.73), and hydromorphone (2.03; 95% CI, 1.09-3.78). Strong agonists were associated with a higher risk of NOWS than weak agonists (RR, 1.97; 95% CI, 1.78-2.17), and long half-life opioids were associated with an increased risk compared with short half-life products (RR, 1.33; 95% CI, 1.12-1.56). Findings were consistent across sensitivity and subgroup analyses. Conclusions and Relevance: Results of this study show higher risk of NOWS and severe NOWS among neonates with in utero exposure to strong agonists and long half-life prescription opioids. Information on the opioid-specific risk of NOWS may help prescribers select opioids for pain management in late stages of pregnancy.


Assuntos
Doenças do Recém-Nascido , Síndrome de Abstinência Neonatal , Síndrome de Abstinência a Substâncias , Tramadol , Adulto , Analgésicos Opioides/efeitos adversos , Codeína , Estudos de Coortes , Feminino , Humanos , Hidrocodona , Hidromorfona , Recém-Nascido , Doenças do Recém-Nascido/induzido quimicamente , Metadona/uso terapêutico , Morfina , Síndrome de Abstinência Neonatal/tratamento farmacológico , Síndrome de Abstinência Neonatal/epidemiologia , Síndrome de Abstinência Neonatal/etiologia , Oxicodona/efeitos adversos , Dor/tratamento farmacológico , Gravidez , Prescrições , Síndrome de Abstinência a Substâncias/complicações , Estados Unidos/epidemiologia
14.
Anal Bioanal Chem ; 414(24): 7211-7221, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-35986104

RESUMO

Opioids, such as morphine and hydromorphone, are common pain management drugs with a high risk for addiction and adverse effects when delivered in large doses or administered too frequently. Point-of-care (POC) tools provide a solution to combat these negative outcomes through active monitoring of opioid concentrations in clinical settings. We demonstrate that giant magnetoresistive (GMR) nanosensors offer a quantitative, sensitive, and rapid solution for low-cost, sample-to-answer opioid detection at the POC. We show the robust nature of GMR nanosensors by developing a competitive morphine assay and characterizing it in saliva, blood, and plasma. We then implemented the assay on a fully automated POC GMR platform and demonstrated its duality to detect either morphine or hydromorphone using only 180 µL of direct saliva without the need for pre-processing. In 35 min from sample addition to result, the automated platform was controlled via smartphone and had seamless transmission of results via Bluetooth. The fully automated POC assay had a limit of detection of 3.43 ng/mL for morphine and 3.49 ng/mL for hydromorphone. The low-cost, 80-plex GMR nanosensor array coupled with the automated POC platform enables future development of multiplexed drug screening tools that can be deployed in clinical settings using a wide variety of non-invasive matrices.


Assuntos
Hidromorfona , Morfina , Analgésicos Opioides , Hidromorfona/efeitos adversos , Sistemas Automatizados de Assistência Junto ao Leito , Smartphone
15.
Cell Mol Biol (Noisy-le-grand) ; 68(3): 213-220, 2022 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-35988186

RESUMO

Nano-carbon is often used as a tracer in thyroidectomy, to improve the accuracy of the operation. Remifentanil is the most commonly used anesthetic during thyroidectomy, but the use of remifentanil can sometimes cause patients with anesthesia hyperalgesia. Therefore, auxiliary anesthetics are often used in surgery to prevent remifentanil from causing anesthesia hyperalgesia. The purpose of this article is to explore the specific application effect of the fusion agent of hydromorphone and parecoxib sodium after thyroidectomy based on nano-carbon in the prevention of remifentanil-induced anesthesia hyperalgesia. Taking 60 patients who underwent thyroidectomy based on carbon nanotechnology in our hospital as the research object, the patients were divided into the parecoxib sodium group, hydromorphone control group and hydromorphone and parecoxib sodium fusion agent group. All patients were injected with remifentanil before surgery for general paralysis. Ten minutes before the end of the operation, the parecoxib sodium group was injected with quantitative parecoxib sodium, and the hydromorphone control group was injected with quantitative hydromorphone, hydromorphone and the parecoxib sodium fusion medicament group was injected with a quantitative combination of parecoxib sodium and hydromorphone. The patient's comfort, calmness, pain, adverse reactions and recovery time of consciousness were counted. The results of the study showed that the sedation score of the hydromorphone and parecoxib sodium fusion drug group was (15.8±1.5), the pain degree score was (1.9±0.5), lower than the other two groups, and the postoperative recovery time was (38±5.0) )min, lower than the other two groups. It can be seen that the use of a fusion agent of hydromorphone and parecoxib sodium after thyroidectomy based on nano-carbon is effective in preventing and reducing remifentanil-induced anesthesia hyperalgesia.


Assuntos
Anestesia , Hiperalgesia , Analgésicos Opioides/efeitos adversos , Humanos , Hidromorfona/uso terapêutico , Hiperalgesia/induzido quimicamente , Hiperalgesia/tratamento farmacológico , Hiperalgesia/prevenção & controle , Isoxazóis , Dor/induzido quimicamente , Piperidinas/uso terapêutico , Remifentanil/efeitos adversos , Tireoidectomia/efeitos adversos
16.
Ann Emerg Med ; 80(5): 432-439, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-35965162

RESUMO

STUDY OBJECTIVE: We conducted a randomized study to compare the efficacy and adverse event profile of 1,000 mg of intravenous acetaminophen to that of 0.5 mg of intravenous hydromorphone among patients aged 65 years or more with acute pain of severity that was sufficient enough to warrant intravenous opioids. METHODS: This randomized comparative effectiveness study with 162 participants was conducted in 2 urban emergency departments (EDs). The primary outcome was an improvement in a 0 to 10 pain scale from baseline to 60 minutes later. Secondary outcomes included the need for additional analgesic medication and adverse events that were attributable to the investigational medication. The minimum clinically important difference was an improvement of 1.3 on the 0 to 10 pain scale. RESULTS: The median baseline pain score was 10 (interquartile range 8 to 10) in both the groups. By 60 minutes, patients taking acetaminophen improved by 3.6 (standard deviation 2.9) on the 0 to 10 pain scale, whereas patients taking hydromorphone improved by 4.6 (standard deviation 3.3) (95% confidence interval [CI] for the difference of 1.0 was 0.1 to 2.0). Additional analgesic medications were required for 37 (46%) of 81 patients taking acetaminophen and 31 (38%) of 81 patients taking hydromorphone (95% CI for the rounded difference of 7% was -8% to 23%). Adverse events were reported by 6 (7%) of 81 patients taking acetaminophen and 10 (12%) of 81 patients taking hydromorphone (95% CI for the difference of 5% was -4% to 14%) and included dizziness, drowsiness, headache, and nausea. CONCLUSION: Although 0.5 mg of the intravenously administered hydromorphone was statistically superior to 1,000 mg of intravenous acetaminophen administered in older patients with acute severe pain in the ED, this difference was not clinically significant. Regardless of the medication received, many participants experienced minimal or incomplete pain relief.


Assuntos
Dor Aguda , Hidromorfona , Humanos , Idoso , Hidromorfona/uso terapêutico , Acetaminofen/uso terapêutico , Dor Aguda/tratamento farmacológico , Resultado do Tratamento , Analgésicos Opioides
17.
Am J Vet Res ; 83(10)2022 Aug 18.
Artigo em Inglês | MEDLINE | ID: mdl-35973002

RESUMO

OBJECTIVE: To evaluate the sedative and cardiopulmonary effects of various combinations of acepromazine, dexmedetomidine, hydromorphone, and glycopyrrolate, followed by anesthetic induction with propofol and maintenance with isoflurane in healthy dogs. ANIMALS: 6 healthy adult female Beagles. PROCEDURES: Dogs were instrumented for hemodynamic measurements while anesthetized with isoflurane. Two hours after recovery, dogs received 1 of 4 IM combinations in a crossover design with 1 week between treatments: hydromorphone (0.1 mg/kg) and acepromazine (0.005 mg/kg; HA); hydromorphone and dexmedetomidine (0.0025 mg/kg; HD); hydromorphone, acepromazine, and dexmedetomidine (HAD); and hydromorphone, acepromazine, dexmedetomidine, and glycopyrrolate (0.02 mg/kg; HADG). Sedation was scored after 30 minutes. Physiologic variables and cardiac index were measured after sedation, after anesthetic induction with propofol, and every 15 minutes during maintenance of anesthesia with isoflurane for 60 minutes (target expired concentration at 760 mm Hg, 1.3%). RESULTS: Sedation scores were not significantly different among treatments. Mean ± SD cardiac index was significantly higher for the HA (202 ± 45 mL/min/kg) and HADG (185 ± 59 mL/min/kg) treatments than for the HD (88 ± 31 mL/min/kg) and HAD (103 ± 25 mL/min/kg) treatments after sedation and through the first 15 minutes of isoflurane anesthesia. No ventricular arrhythmias were noted with any treatment. CLINICAL RELEVANCE: In healthy dogs, IM administration of HADG before propofol and isoflurane anesthesia provided acceptable cardiopulmonary function with no adverse effects. This combination should be considered for routine anesthetic premedication in healthy dogs.


Assuntos
Anestesia , Anestésicos , Dexmedetomidina , Isoflurano , Propofol , Acepromazina/farmacologia , Anestesia/veterinária , Anestésicos/farmacologia , Animais , Estudos Cross-Over , Dexmedetomidina/farmacologia , Cães , Feminino , Glicopirrolato/farmacologia , Frequência Cardíaca , Hidromorfona/farmacologia , Hipnóticos e Sedativos/farmacologia , Isoflurano/farmacologia , Propofol/farmacologia
18.
BMC Anesthesiol ; 22(1): 253, 2022 08 08.
Artigo em Inglês | MEDLINE | ID: mdl-35941536

RESUMO

BACKGROUND: Opioids remain the mainstream therapy for post-surgical pain. The choice of opioids administered by patient-controlled intravenous analgesia (PCIA) for thoracoscopic lung surgery is unclear. This study compared 3 opioid analgesics for achieving satisfactory analgesia with minimal emesis (SAME). METHODS: This randomized clinical trial enrolled patients scheduled for thoracoscopic lung surgery randomized to receive 1 of 3 opioids for PCIA: oxycodone (group O), hydromorphone (group H), and sufentanil (group S). The primary outcome was the proportion of subjects achieving SAME, i.e., no-to-mild pain (pain score < 4/10) with minimal nausea/vomiting (PONV score < 2/4) when coughing during the pulmonary rehabilitation exercise in the first 3 postoperative days. RESULTS: Of 555 enrolled patients, 184 patients in group O, 186 in group H and 184 in group S were included in the final analysis. The primary outcome of SAME was significantly different among group O, H and S (41.3% vs 40.3% vs 29.9%, P = 0.043), but no difference was observed between pairwise group comparisons. Patients in groups O and H had lower pain scores when coughing on the second day after surgery than those in group S, both with mean differences of 1 (3(3,4) and 3(3,4) vs 4(3,4), P = 0.009 and 0.039, respectively). The PONV scores were comparable between three groups (P > 0.05). There were no differences in other opioid-related side effects, patient satisfaction score, and QoR-15 score among three groups. CONCLUSIONS: Given clinically relevant benefits detected, PCIA with oxycodone or hydromorphone is superior to sufentanil for achieving SAME as a supplement to multimodal analgesia in patients undergoing thoracoscopic lung surgery. TRIAL REGISTRATION: This study was registered at ( ChiCTR2100045614 , 19/04/2021).


Assuntos
Analgésicos Opioides , Sufentanil , Analgesia Controlada pelo Paciente , Humanos , Hidromorfona , Pulmão/cirurgia , Oxicodona , Dor Pós-Operatória/tratamento farmacológico , Náusea e Vômito Pós-Operatórios/induzido quimicamente
19.
J Palliat Med ; 25(10): 1557-1562, 2022 10.
Artigo em Inglês | MEDLINE | ID: mdl-35930252

RESUMO

Background: The opioid rotation ratios (ORRs) and conversion ratios (CRs) used worldwide among palliative care (PC) professionals to perform opioid rotations (ORs) and route conversions may have a wide variation. Methods: We surveyed PC professionals on opioid ratios used through email to the Multinational Association of Supportive Care in Cancer's PC study group and Twitter and Facebook posts between September and November 2020. Results: We received 370 responses from respondents from 53 countries: 276 (76%) were physicians, 46 (13%) advanced practice providers, 39 (11%) pharmacists, and 9 respondents did not report their profession. There were statistically significant variations in median CR from intravenous (IV) to oral morphine (2-3), IV to oral hydromorphone (2-4.5), ORR from IV hydromorphone to oral morphine (10-20), and ORR from transdermal fentanyl mcg/hour to oral morphine (2-3.5) across various groups. Conclusion: This survey highlights the wide variation in ORRs and CRs among PC clinicians worldwide and the need for further research to standardize practice.


Assuntos
Analgésicos Opioides , Neoplasias , Analgésicos Opioides/uso terapêutico , Fentanila , Humanos , Hidromorfona , Morfina , Cuidados Paliativos , Inquéritos e Questionários
20.
Pain Manag ; 12(7): 821-827, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-36017724

RESUMO

Aim: At our institution, reductions to hydromorphone and fentanyl unit dose quantities provided us with a unique opportunity to study opioid utilization. Materials & methods: A retrospective study examining effects of changes in opioid unit dose on intra-operative and postoperative opioid utilization in patients who underwent laparoscopic cholecystectomy. The study included three arms: the predosage change (n = 254), fentanyl only change group (n = 102) and the postdosage change arm (n = 254). Results: Decreasing opioid unit dosing decreased intraoperative opioid administration and total perioperative utilization. Decreased postanesthesia care unit morphine milligram equivalent (MME) requirements were observed in all, but one group comparison. Conclusion: Our data suggests that opioid unit dosing and administration are directly proportional and that decreased intraoperative MME utilization leads to decreased total perioperative MME use.


This study suggests that by supplying anesthesia providers with smaller quantities of opioid pain medication for use during surgery less pain medication is used both during and after surgery without a resultant increase in a patient's pain score or the amount of time they need to stay in the postoperative recovery area. As a result, some of the negative side effects associated with opioid pain medications may be diminished.


Assuntos
Analgésicos Opioides , Colecistectomia Laparoscópica , Analgésicos Opioides/uso terapêutico , Endrin/análogos & derivados , Fentanila , Humanos , Hidromorfona , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Estudos Retrospectivos
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