Fentanyl transdermal patch: The silent new killer?

Background: Transdermal fentanyl patches represent an excellent alternative for the treatment of chronic and cancer-related pain, but can lead to death due to their incorrect use or increasing abuse. Purpose: Present an overview of literature regarding fentanyl patch related fatalities. Methods: Literature research into PubMed database for all types of publications. Search terms were "fentanyl", "patch" and "death". Additional publications by manual examination of references of the PubMed results were included. Results and conclusions: To date 29 publications about transdermal fentanyl patch related deaths are available on PubMed and their time span is of 26 years. A total of 674 deaths related to fentanyl were found, 658 associated with transdermal fentanyl patch. Use of patches was more frequently in males (68 %) than in females (32 %) and in the 31–40 and 41–50 decades. The most frequent route of administration was the transdermal route, followed by oral and intravenous route. Cause of death was in 63.5 % of cases drug abuse, followed by accidental death (16.2 %), death unrelated to fentanyl (13.3 %) and suicide (2.8 %). The use of concomitant drugs was reported in 19 of the 29 publications and antidepressant followed by benzodiazepines and ethanol were the most frequent discovered drugs. In conclusion, fentanyl transdermal patch misuse and abuse is a major problem and still need to be completely addressed

Safety and efficacy of new oral anticoagulants and low-molecular-weight heparins compared with aspirin in patients undergoing total knee and hip replacements

Item does not contain fulltextBACKGROUND: There has been much debate recently on the best type of thromboprophylaxis following elective total joint replacement surgery. OBJECTIVE: This study aims to compare rates of venous thromboembolism (VTE), gastro-intestinal (GI) bleeding and mortality events, with use of new oral anticoagulants (NOAC) or low-molecular-weight heparins (LMWHs) compared with aspirin in patients undergoing total joint replacement. METHODS: A population-based retrospective cohort study was performed using the Clinical Practice Research Datalink. Patients >/=18 years of age who had undergone total knee (n = 3261) or hip replacement (THR (n = 4016)) between 2008 and 2012 were included. Within this population, three cohorts were selected, based on their first prescription within the 35-day period after surgery: use of NOACs only, LMWHs only and aspirin only. Incidence rates were calculated, and Cox proportional hazard models were fitted to estimate the risk of VTE, GI bleeding and all-cause mortality with the use of NOACs and LMWHs compared with aspirin use after total knee replacement and THR. We statistically adjusted our analyses for lifestyle factors, comorbidities and concomitant drug use. RESULTS: Total knee replacement and THR patients currently on LMWHs had higher risk of VTE (HR = 17.2 (6.9-43.0) and HR = 39.5 (18.0-87.0), respectively), GI bleeding (HR = 20.9 (1.9-232.3) and HR = 2.0 (0.2-17.2), respectively) and all-cause mortality (HR = 4.3 (1.7-12.4) and HR = 4.0 (2.4-6.7), respectively). NOAC use was associated with an increased risk of GI bleeding in patients undergoing THR surgery. CONCLUSIONS: In contrast to previous studies, we found an increased risk of VTE, GI bleeding and all-cause mortality with the use of LMWHs compared with aspirin. Risk of GI bleeding was increased with the use of NOACs compared with aspirin use after THR surgery. Copyright (c) 2016 John Wiley & Sons, Ltd

Improved patient outcomes using the enhanced recovery pathway in breast microsurgical reconstruction: a UK experience

Summary: Introduction: The enhanced recovery after surgery (ERAS) pathway is a protocol aimed at optimizing patient care by reducing the physiological alterations caused by surgery, thus reducing recovery time, surgical morbidities and length of stay. This study assessed the impact of ERAS on patients undergoing microsurgical breast reconstruction. Methods: Patients undergoing microsurgical breast reconstruction over an eight-month period were retrospectively examined. LOS, complication rates and perioperative outcomes were analysed. Results were compared between patients admitted on the traditional recovery after surgery (TRAS) and the ERAS pathways. Results: One hundred and thirty-eight patients were included. Seventy-two patients were admitted on the TRAS pathway and 66 patients on the ERAS pathway. There was no difference in median LOS (4 days) between the two groups, p = 0.48. We noted a significant reduction in the total number of major complications (ERAS 11%, TRAS 24% p = 0.04) as well as significant differences in time to catheter removal, time to independent mobilisation, total opioid usage and time to removal of PCA, all in favour of the ERAS group. There was a non-significant reduction in return to theatre and readmission rate in the ERAS group (11% versus 21% p = 0.1 and 6% versus 11% p = 0.29 respectively). Obesity and complications were predictors of a prolonged LOS. Conclusion: The ERAS pathway reduced overall and major complication rates in a tertiary centre using an already streamlined service. Adoption of ERAS pathways to reduce surgical morbidities and improve patient care is encouraged. Further work is required to optimise enhanced recovery in breast microsurgical reconstruction. Keywords: Enhanced recovery, ERAS, Autologous breast reconstruction, Microsurgery, DIEP flap, TUG fla