Nebulized Fentanyl for Dyspnea: A Retrospective Chart Review.

Nebulized fentanyl is well established for analgesia but its use for dyspnea requires further investigation. The aim of our study was to determine the effectiveness of nebulized fentanyl in treating patients with dyspnea and to determine if there were harmful side effects described by patients or their providers. We used a convenience sample of patients from July 1 2014 to July 1 2018 and performed a retrospective chart review. We found that 360 doses of nebulized fentanyl were given to 73 patients during that time period. Of the 73 patients evaluated, 32 patients (43.8%) were female and forty-one were male (56.1%). The median age was 67 and the median length of stay was 9 days. There were no documented findings of bronchospasm, hypotension, or allergic reaction in any of the medical records reviewed. Patients treated with nebulized fentanyl for dyspnea showed a mean decreased respiratory rate of 4.3 breaths/min and a mean increased oxygen saturation of 2.3%. Also, 71% of patients with documented responses experienced an improvement in their dyspnea. Our preliminary data suggest that nebulized fentanyl has limited side effects and may have a role in the treatment of dyspnea. Further research is necessary to determine its efficacy.

Drug-Induced Liver Injury Caused by Kratom Use as an Alternative Pain Treatment Amid an Ongoing Opioid Epidemic.

Kratom ( Mitragyna speciosa) is a prevalent medicinal plant used mainly for the stimulant and analgesic properties provided through multiple alkaloid compounds. Over the past decade, use of kratom has increased despite the limited knowledge of toxicities and adverse side effects. With the current opioid epidemic, both patients and providers are seeking alternative methods to treat both addiction and pain control, and kratom as an alternative means of treatment has increasingly entered the mainstream. In this article, we present the clinical course of a 47-year-old male who developed fatigue, pruritus, and abnormal liver tests (with a mixed hepatocellular/cholestatic pattern) approximately 21 days after beginning kratom. After extensive evaluation including a negligible alcohol history, negative hepatitis serologies, and inconclusive imaging, the patient was diagnosed with drug-induced liver injury (DILI) caused by kratom. Nine months after his liver tests returned to normal, he took kratom again, and after a latency of 2 days, he developed fatigue, pruritus, and loss of appetite along with abnormal liver tests (with the same biochemical profile as previously), consistent with a positive rechallenge. We believe, through the use of the Roussel-Uclaf Causality Assessment Method and expert opinion, that this is a highly likely or definite example of kratom-induced DILI. With the gaining popularity of this drug, it appears that DILI may be an important complication of kratom for providers to recognize.