37 research outputs found
Opioid use and effectiveness of its prescription at discharge in an acute pain relief and palliative care unit
The aim of this study was to present how opioids
are used in an acute pain relief and palliative care unit
(APRPCU), where many patients with difficult pain conditions
are admitted from GPs, home palliative care programs,
oncology departments, other hospitals or emergency units,
and other regional places. From a consecutive sample of
cancer patients admitted to an APRPCU for a period of
6 months, patients who had been administered opioids were
included in this survey. Basic information was collected as
well as opioid therapy prescribed at admission and, subsequently,
during admission and at time of discharge. Patients
were discharged once stabilization of pain and symptoms
were obtained and the treatment was considered to be optimized.
One week after being discharged, patients or relatives
were contacted by phone to gather information about
the availability of opioids at dosages prescribed at time of
discharge. One hundred eighty six of 231 patients were
specifically admitted for uncontrolled pain, with a mean
pain intensity of 6.8 (SD 2.5). The mean dose of oral
morphine equivalents in patients receiving opioids before
admission was 45 mg/day (range 10–500 mg). One hundred
seventy five patients (75.7 %) were prescribed around the
clock opioids at admission. About one third of patients
changed treatment (opioid or route). Forty two of 175
(24 %), 27/58 (46.5 %), 10/22 (45.4 %), and 2/4 (50 %)
patients were receiving more than 200 mg of oral morphine
equivalents, as maximum dose of the first, second, third, and
fourth opioid prescriptions, respectively. The pattern of
opioids changed, with the highest doses administered with
subsequent line options. The mean final dose of opioids,
expressed as oral morphine equivalents, for all patients was
318 mg/day (SD 798), that is more than six times the doses
of pre-admission opioid doses. One hundred eighty six
patients (80.5 %) were prescribed a breakthrough cancer
pain (BTcP) medication at admission. Sixty five patients
changed their BTcP prescription, and further 27 patients
changed again. Finally, eight patients were prescribed a
fourth BTcP medication. Of 46 patients available for interview,
the majority of them (n=39, 84 %) did not have
problems with their GPs, who facilitated prescription and
availability of opioids at the dosages prescribed at discharge.
For patients with severe distress, APRPCUs may
guarantee a high-level support to optimize pain and symptom
intensities providing intensive approach and resolving
highly distressing situations in a short time by optimizing
the use of opioids
Incidence and outcome of invasive candidiasis in intensive care units (ICUs) in Europe: results of the EUCANDICU project
BACKGROUND: The objective of this study was to assess the cumulative incidence of invasive candidiasis (IC) in intensive care units (ICUs) in Europe. METHODS: A multinational, multicenter, retrospective study was conducted in 23 ICUs in 9 European countries, representing the first phase of the candidemia/intra-abdominal candidiasis in European ICU project (EUCANDICU). RESULTS: During the study period, 570 episodes of ICU-acquired IC were observed, with a cumulative incidence of 7.07 episodes per 1000 ICU admissions, with important between-center variability. Separated, non-mutually exclusive cumulative incidences of candidemia and IAC were 5.52 and 1.84 episodes per 1000 ICU admissions, respectively. Crude 30-day mortality was 42%. Age (odds ratio [OR] 1.04 per year, 95% CI 1.02-1.06, p < 0.001), severe hepatic failure (OR 3.25, 95% 1.31-8.08, p 0.011), SOFA score at the onset of IC (OR 1.11 per point, 95% CI 1.04-1.17, p 0.001), and septic shock (OR 2.12, 95% CI 1.24-3.63, p 0.006) were associated with increased 30-day mortality in a secondary, exploratory analysis. CONCLUSIONS: The cumulative incidence of IC in 23 European ICUs was 7.07 episodes per 1000 ICU admissions. Future in-depth analyses will allow explaining part of the observed between-center variability, with the ultimate aim of helping to improve local infection control and antifungal stewardship projects and interventions
Do ventilatory parameters influence outcome in patients with severe acute respiratory infection? Secondary analysis of an international, multicentre14-day inception cohort study
Purpose
To investigate the possible association between ventilatory settings on the first day of invasive mechanical ventilation (IMV) and mortality in patients admitted to the intensive care unit (ICU) with severe acute respiratory infection (SARI).
Materials and methods
In this pre-planned sub-study of a prospective, multicentre observational study, 441 patients with SARI who received controlled IMV during the ICU stay were included in the analysis.
Results
ICU and hospital mortality rates were 23.1 and 28.1%, respectively. In multivariable analysis, tidal volume and respiratory rate on the first day of IMV were not associated with an increased risk of death; however, higher driving pressure (DP: odds ratio (OR) 1.05; 95% confidence interval (CI): 1.01–1.1, p = 0.011), plateau pressure (Pplat) (OR 1.08; 95% CI: 1.04–1.13, p < 0.001) and positive end-expiratory pressure (PEEP) (OR 1.13; 95% CI: 1.03–1.24, p = 0.006) were independently associated with in-hospital mortality. In subgroup analysis, in hypoxemic patients and in patients with acute respiratory distress syndrome (ARDS), higher DP, Pplat, and PEEP were associated with increased risk of in-hospital death.
Conclusions
In patients with SARI receiving IMV, higher DP, Pplat and PEEP, and not tidal volume, were associated with a higher risk of in-hospital death, especially in those with hypoxemia or ARDS
Intraoperative positive end-expiratory pressure and postoperative pulmonary complications: a patient-level meta-analysis of three randomised clinical trials
Background: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery.Methods: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Prespecified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed.Results: Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17).Conclusions: High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications