Use of national early warning score for observation for increased risk for clinical deterioration during post-ICU care at a surgical ward

Publisher Copyright: © 2019 Klepstad et al.Purpose: Patients transferred from an intensive care unit (ICU) to a general ward are at risk for clinical deterioration. The aim of the study was to determine if an increase in National Early Warning Score (NEWS) value predicted worse outcomes in surgical ward patients previously treated in the ICU. Patients and methods: A retrospective observational study was conducted in a cohort of gastrointestinal surgery patients after transfer from an ICU/high dependency unit (HDU). NEWS values were collected throughout the ward admission. Clinical deterioration was defined by ICU readmission or death. The ability of NEWS to predict clinical deterioration was determined using a linear mixed effect model. Results: We included 124 patients, age 65.9±14.5, 60% males with an ICU Simplified Acute Physiology Score II 33.8±12.7. No patients died unexpectedly at the ward and 20 were readmitted to an ICU/HDU. The NEWS values increased by a mean of 0.15 points per hour (intercept 3.7, P<0.001) before ICU/HDU readmission according to the linear mixed effect model. NEWS at transfer from ICU was the only factor that predicted readmission (OR 1.32; 95% CI 1.01–1.72; P=0.04) at the time of admission to the ward. Conclusion: Clinical deterioration of surgical patients was preceded by an increase in NEWS.Peer reviewe

Can variability in the effect of opioids on refractory breathlessness be explained by genetic factors?

© 2015, BMJ Publishing Group. All rights reserved. Objectives: Opioids modulate the perception of breathlessness with a considerable variation in response, with poor correlation between the required opioid dose and symptom severity. The objective of this hypothesis-generating, secondary analysis was to identify candidate single nucleotide polymorphisms (SNP) from those associated with opioid receptors, signalling or pain modulation to identify any related to intensity of breathlessness while on opioids. This can help to inform prospective studies and potentially lead to better tailoring of opioid therapy for refractory breathlessness. Setting: 17 hospice/palliative care services (tertiary services) in 11 European countries. Participants: 2294 people over 18 years of age on regular opioids for pain related to cancer or its treatment. Primary outcome measures: The relationship between morphine dose, breathlessness intensity (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire; EORTCQLQC30 question 8) and 112 candidate SNPs from 25 genes (n=588). Secondary outcome measures: The same measures for people on oxycodone (n=402) or fentanyl (n=429). Results: SNPs not in Hardy-Weinberg equilibrium or with allele frequencies ( < 5%) were removed. Univariate associations between each SNP and breathlessness intensity were determined with Benjamini-Hochberg false discovery rate set at 20%. Multivariable ordinal logistic regression, clustering over country and adjusting for available confounders, was conducted with remaining SNPs. For univariate morphine associations, 1 variant on the 5-hydroxytryptamine type 3B (HTR3B) gene, and 4 on the β-2-arrestin gene (ARRB2) were associated with more intense breathlessness. 1 SNP remained significant in the multivariable model: people with rs7103572 SNP (HTR3B gene; present in 8.4% of the population) were three times more likely to have more intense breathlessness (OR 2.86; 95% CIs 1.46 to 5.62; p=0.002). No associations were seen with fentanyl nor with oxycodone. Conclusions: This large, exploratory study identified 1 biologically plausible SNP that warrants further study in the response of breathlessness to morphine therapy

Genetics and opioids: new data gives insight into opioid analgesia

Dawki opioidów niezbędne do złagodzenia bólu różnią się u poszczególnych osób. Ta indywidualna zmienność dotycząca skuteczności opioidów sugeruje, że na reakcje pacjentów na tę grupę leków wpływa ich genetycznie uwarunkowana podatność. Ze względu na złożony obraz farmakologii morfiny różnice mogą być wynikiem działania wielu genów, do których należą geny związane z farmakokinetyką morfiny, receptorami opioidowymi &#956; oraz z transportem morfiny poprzez barierę krew-mózg za pośrednictwem transporterów oporności wielolekowej. Skuteczność morfiny mogą zmieniać także geny związane z działaniem biologicznych systemów modyfikujących analgezję opioidową. W niniejszej pracy krótko przedstawiono wyniki wybranych badań dotyczących związku między farmakologią opioidów a genetyką, ze szczególnym uwzględnieniem prób obejmujących ochotników lub pacjentów otrzymujących morfinę. Dotychczasowe rezultaty zdecydowanie wskazują, że skuteczność opioidów częściowo zależy od cech wrodzonych, u podłoża których leży zmienność genetyczna związana z metabolizmem opioidów, funkcją receptorów opioidowych oraz transporterów tej grupy leków.The doses of opioids needed for pain relief vary between individuals. This individual variability of opioid efficacy suggests that the patient&#8217;s genetic disposition influences the response to opioids. Given the complexity of morphine pharmacology, variability may be caused by several genes. Candidate genes are those related to morphine pharmacokinetics, to mu-opioid receptors and to the BBB transport of morphine through multidrug resistance transporters. Genes related to biological systems modifying opioid analgesia may also alter the efficacy of morphine. This short review presents results from some selected studies which investigate the relationship between opioid pharmacology and genetics with the emphasis on studies in volunteers or patients receiving morphine. The results obtained so far strongly argue that opioid efficacy is partly related to inborn properties caused by genetic variability related to opioid metabolism, opioid receptors and opioid transporters

Confiabilidad inter-observador del Nursing Activities Score entre profesionales de la salud en una Unidad de Cuidado Intensivo

Objetivo : Analizar la confiabilidad inter-observador del NAS entre administradores y enfermeras clínicas en la UCI. Método : Estudio metodológico desarrollado en una UCI general en Noruega. En una muestra seleccionada el NAS fue aplicado en 101 pacientes críticos por tres clases de evaluadores: Enfermeras asistenciales, médicos intensivistas y enfermeras gestoras. La confiabilidad inter-observador fue analizada mediante el test de Kappa. Resultados : Los promedios del NAS fueron 88,4(DE=16,2) y 88,7(DE=24,5) respectivamente para las enfermeras asistenciales y gestoras. Los médicos obtuvieron un promedio NAS inferior 83,7;DE=21,1). Las 18 intervenciones médicas tuvierón mayor concordancia entre las enfermeras asistenciales y los médicos (85,6), en comparación con las enfermeras asistenciales y gestoras (78,7). En las cinco actividades de enfermería, los coeficientes Kappa fueron bajos entodas las actividades y entre todos los grupos. Conclusión : El estudio mostró confiabilidad inter-observador satisfactorias para el NAS entre las enfermeras asistenciales y gestoras.Objetivo Analisar a confiabilidade interobservadores do NAS entre enfermeiros intensivistas e administradores em UTI. Método Estudo metodológico desenvolvido em UTI geral, de adultos, na Noruega. Em uma amostra selecionada, o NAS foi aplicado em 101 pacientes por três avaliadores: enfermeira assistencial, médico intensivista e enfermeira gestora. A confiabilidade interobservadores foi analisada por meio do teste Kappa. Resultados As médias NAS foram 88,4(SD=16,2) e 88,7(SD=24,5) respectivamente para enfermeiros assistenciais e gestores. Os médicos obtiveram média NAS inferior (83,7; SD=21,1). As 18 intervenções médicas tiveram maior concordância entre enfermeiros assistenciais e médicos (85,6), comparativamente aos enfermeiros assistenciais e gestores (78,7). Nas cinco atividades de enfermagem, os coeficientes Kappa foram baixos em todas as atividades e entre todos os grupos. Conclusão O estudo mostrou confiabilidade interobservadores satisfatória para o NAS entre enfermeiros assistenciais e gestores.Objective To analyze the interrater reliability of NAS among critical care nurses and managers in an ICU. Method This was a methodological study performed in an adult, general ICU in Norway. In a random selection of patients, the NAS was scored on 101 patients by three raters: a critical care nurse, an ICU physician and a nurse manager. Interrater reliability was analyzed by agreement between groups and kappa statistics. Results The mean NAS were 88.4 (SD=16.2) and 88.7 (SD=24.5) respectively for the critical care nurses and nurse managers. A lower mean of 83.7 (SD=21.1) was found for physicians. The 18 medical interventions showed higher agreement between critical care nurses and physicians (85.6%), than between critical care nurses and nurse managers (78.7). In the five nursing activities the Kappa-coefficients were low for all activities in all compared groups. Conclusion The study indicated a satisfactory agreement of nursing workload between critical care nurses and managers

A Web-Based Communication Tool for Postoperative Follow-up and Pain Assessment at Home After Primary Knee Arthroplasty: Feasibility and Usability Study

Background: We report the use of an electronic tool, Eir (Eir Solutions AS, Norway), for symptom registration at home after knee arthroplasty. This electronic tool was used in a randomized controlled trial (RCT) comparing 3 different analgesic regimens with respect to postoperative pain and side effects. Objective: The aim of this substudy was to investigate this electronic tool for symptom registrations at home with respect to usability (ie, how easy it was to use) and feasibility (ie, how well the tool served its purpose). Methods: To assess the tool's usability, all participants were invited to fill out the 10-item System Usability Scale (SUS) after using the tool for 8 days. To assess feasibility, data regarding the participants' ability to use the tool with or without assistance or reminders were collected qualitatively on a daily basis during the study period. Results: A total of 134 patients completed the RCT. Data concerning feasibility of the web-based tool were collected from all 134 patients. The SUS was completed by 119 of the 134 patients; 70.2% (94/134) of the patients managed to use the tool at home without any technical support. All technical challenges were related to the login procedure or internet access. The mean SUS score was 89.6 (median 92.5; range 22.5-100). Conclusions: This study showed high feasibility and high usability of the Eir web tool. The received reports gave the necessary information needed for both research data and clinical follow-up.publishedVersio

Day-to-day variations during clinical drug monitoring of morphine, morphine-3-glucuronide and morphine-6-glucuronide serum concentrations in cancer patients. A prospective observational study

BACKGROUND: The feasibility of drug monitoring of serum concentrations of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) during chronic morphine therapy is not established. One important factor relevant to drug monitoring is to what extent morphine, M6G and M3G serum concentrations fluctuate during stable morphine treatment. METHODS: We included twenty-nine patients admitted to a palliative care unit receiving oral morphine (n = 19) or continuous subcutaneous (sc) morphine infusions (n = 10). Serum concentrations of morphine, M6G and M3G were obtained at the same time on four consecutive days. If readmitted, the patients were followed for another trial period. Day-to-day variations in serum concentrations and ratios were determined by estimating the percent coefficient of variation (CV = (mean/SD) ×100). RESULTS: The patients' median morphine doses were 90 (range; 20–1460) mg/24 h and 135 (range; 30–440) mg/24 h during oral and sc administration, respectively. Intraindividual fluctuations of serum concentrations estimated by median coefficients of day-to-day variation were in the oral group for morphine 46%, for M6G 25% and for M3G 18%. The median coefficients of variation were lower in patients receiving continuous sc morphine infusions (morphine 10%, M6G 13%, M3G 9%). CONCLUSION: These findings indicate that serum concentrations of morphine and morphine metabolites fluctuate. The fluctuations found in our study are not explained by changes in morphine doses, administration of other drugs or by time for collection of blood samples. As expected the day-to-day variation was lower in patients receiving continuous sc morphine infusions compared with patients receiving oral morphine

Genetic variation and cognitive dysfunction in opioid-treated patients with cancer

Background and purpose The effects of single‐nucleotide polymorphisms (SNP s) on the cognitive function of opioid‐treated patients with cancer until now have not been explored, but they could potentially be related to poor functioning. This study aimed at identifying associations between SNP s of candidate genes, high opioid dose, and cognitive dysfunction. Methods Cross‐sectional multicenter study (European Pharmacogenetic Opioid Study, 2005–2008); 1586 patients; 113 SNP s from 41 genes. Inclusion criteria: cancer, age ≥18 year, opioid treatment, and available genetic data. Cognitive assessment by Mini‐Mental State Examination (MMSE ). Analyses: SNP s were rejected if violation of Hardy–Weinberg equilibrium (P < 0.0005), or minor allele frequency <5%; patients were randomly divided into discovery sample (2/3 for screening) and validation sample (1/3 for confirmatory test); false discovery rate of 10% for determining associations (Benjamini–Hochberg method). Co‐dominant, dominant, and recessive models were analyzed by Kruskal–Wallis and Mann–Whitney tests. Results In the co‐dominant model significant associations (P < 0.05) between MMSE scores and SNP s in the HTR 3E , TACR 1 , and IL 6 were observed in the discovery sample, but the replication in the validation sample did not confirm it. Associations between MMSE scores among patients receiving ≥400 mg morphine equivalent dose/day and SNP s in TNFRSF 1B , TLR 5 , HTR 2A , and ADRA 2A were observed, but they could not be confirmed in the validation sample. After correction for multiple testing, no SNP s were significant in the discovery sample. Dominant and recessive models also did not confirm significant associations. Conclusions The findings did not support influence of those SNP s analyzed to explain cognitive dysfunction in opioid‐treated patients with cancer

Long-term survival and quality of life after intensive care for patients 80 years of age or older

Background: Comparison of survival and quality of life in a mixed ICU population of patients 80 years of age or older with a matched segment of the general population. Methods: We retrospectively analyzed survival of ICU patients ≥80 years admitted to the Haukeland University Hospital in 2000–2012. We prospectively used the EuroQol-5D to compare the health-related quality of life (HRQOL) between survivors at follow-up and an age- and gender-matched general population. Follow-up was 1–13.8 years. Results: The included 395 patients (mean age 83.8 years, 61.0 % males) showed an overall survival of 75.9 (ICU), 59.5 (hospital), and 42.0 % 1 year after the ICU. High ICU mortality was predicted by age, mechanical ventilator support, SAPS II, maximum SOFA, and multitrauma with head injury. High hospital mortality was predicted by an unplanned surgical admission. One-year mortality was predicted by respiratory failure and isolated head injury. We found no differences in HRQOL at follow-up between survivors (n = 58) and control subjects (n = 179) or between admission categories. Of the ICU non-survivors, 63.2 % died within 2 days after ICU admission (n = 60), and 68.3 % of these had life-sustaining treatment (LST) limitations. LST limitations were applied for 71.3 % (n = 114) of the hospital non-survivors (ICU 70.5 % (n = 67); post-ICU 72.3 % (n = 47)). Conclusions: Overall 1-year survival was 42.0 %. Survival rates beyond that were comparable to those of the general octogenarian population. Among survivors at follow-up, HRQOL was comparable to that of the age- and sex-matched general population. Patients admitted for planned surgery had better short- and long-term survival rates than those admitted for medical reasons or unplanned surgery for 3 years after ICU admittance. The majority of the ICU non-survivors died within 2 days, and most of these had LST limitation decisions

Can variability in the effect of opioids on refractory breathlessness be explained by genetic factors?

© 2015, BMJ Publishing Group. All rights reserved. Objectives: Opioids modulate the perception of breathlessness with a considerable variation in response, with poor correlation between the required opioid dose and symptom severity. The objective of this hypothesis-generating, secondary analysis was to identify candidate single nucleotide polymorphisms (SNP) from those associated with opioid receptors, signalling or pain modulation to identify any related to intensity of breathlessness while on opioids. This can help to inform prospective studies and potentially lead to better tailoring of opioid therapy for refractory breathlessness. Setting: 17 hospice/palliative care services (tertiary services) in 11 European countries. Participants: 2294 people over 18 years of age on regular opioids for pain related to cancer or its treatment. Primary outcome measures: The relationship between morphine dose, breathlessness intensity (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire; EORTCQLQC30 question 8) and 112 candidate SNPs from 25 genes (n=588). Secondary outcome measures: The same measures for people on oxycodone (n=402) or fentanyl (n=429). Results: SNPs not in Hardy-Weinberg equilibrium or with allele frequencies (<5%) were removed. Univariate associations between each SNP and breathlessness intensity were determined with Benjamini-Hochberg false discovery rate set at 20%. Multivariable ordinal logistic regression, clustering over country and adjusting for available confounders, was conducted with remaining SNPs. For univariate morphine associations, 1 variant on the 5-hydroxytryptamine type 3B (HTR3B) gene, and 4 on the β-2-arrestin gene (ARRB2) were associated with more intense breathlessness. 1 SNP remained significant in the multivariable model: people with rs7103572 SNP (HTR3B gene; present in 8.4% of the population) were three times more likely to have more intense breathlessness (OR 2.86; 95% CIs 1.46 to 5.62; p=0.002). No associations were seen with fentanyl nor with oxycodone. Conclusions: This large, exploratory study identified 1 biologically plausible SNP that warrants further study in the response of breathlessness to morphine therapy