Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription

BackgroundAcross the world, 25–29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit–risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon.ObjectiveThis study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED.MethodsA 3-month prospective study with a case–control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher’s exact test or the chi-squared tests. Student’s t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression.ResultsA total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient’s epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient’s initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for “self-referral” [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32–12.18, p < 0.0001] and patients’ trajectories (Fisher’s exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, “junior physician grade” was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09–5.25, p = 0.03), but physician gender was not.ConclusionThis bedside case–control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of “NRS-only” IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways

Systemic perturbation of cytokine and chemokine networks in Erdheim-Chester disease: a single-center series of 37 patients

Immunopathogenesis of Erdheim-Chester disease (ECD), a rare non-Langerhan

Cytokine Profiles in Sepsis Have Limited Relevance for Stratifying Patients in the Emergency Department: A Prospective Observational Study

INTRODUCTION: Morbidity, mortality and social cost of sepsis are high. Previous studies have suggested that individual cytokines levels could be used as sepsis markers. Therefore, we assessed whether the multiplex technology could identify useful cytokine profiles in Emergency Department (ED) patients. METHODS: ED patients were included in a single tertiary-care center prospective study. Eligible patients were >18 years and met at least one of the following criteria: fever, suspected systemic infection, ≥ 2 systemic inflammatory response syndrome (SIRS) criteria, hypotension or shock. Multiplex cytokine measurements were performed on serum samples collected at inclusion. Associations between cytokine levels and sepsis were assessed using univariate and multivariate logistic regressions, principal component analysis (PCA) and agglomerative hierarchical clustering (AHC). RESULTS: Among the 126 patients (71 men, 55 women; median age: 54 years [19-96 years]) included, 102 had SIRS (81%), 55 (44%) had severe sepsis and 10 (8%) had septic shock. Univariate analysis revealed weak associations between cytokine levels and sepsis. Multivariate analysis revealed independent association between sIL-2R (p = 0.01) and severe sepsis, as well as between sIL-2R (p = 0.04), IL-1β (p = 0.046), IL-8 (p = 0.02) and septic shock. However, neither PCA nor AHC distinguished profiles characteristic of sepsis. CONCLUSIONS: Previous non-multiparametric studies might have reached inappropriate conclusions. Indeed, well-defined clinical conditions do not translate into particular cytokine profiles. Additional and larger trials are now required to validate the limited interest of expensive multiplex cytokine profiling for staging septic patients

Inhaled morphine titration in the emergency department : modernization of the severe pain management in adults

Notre objectif était d’optimiser la prise en charge de la douleur aiguë sévère en médecine d’urgence. La titration morphinique intraveineuse qui fait actuellement référence doit se moderniser pour répondre aux nouveaux enjeux de la pratique en même temps que l’on doit garantir une balance bénéfice risque inchangée dans la lutte contre l’oligoanalgésie. Le travail décrit dans cette thèse, constitue une première étape d’évaluation d’une alternative nébulisée à la titration morphinique, à travers 3 études cliniques (AEROMORPH1, CLIN-AEROMORPH, EPIMORPH) et l’étude de son contexte dans la littérature. Des travaux chez le volontaire sain ont permis d’établir un mode opératoire avec une technique aérosol simple et accessible, de courte durée (5 min), que l’on peut répéter en titration (toutes les 10 min). Sa faisabilité est en voie d’être confirmée à grande échelle dans une étude multicentrique clinique et sa non-infériorité en termes d’efficacité est en cours d’évaluation. Des données pharmacologiques chez le volontaire sain et chez les patients confirment une concentration sanguine en morphine proche des concentrations efficaces observées en intraveineux (1 à 120 ng/ml dans CLIN-AEROMORPH), ce qui est déjà un résultat positif démontré par nos travaux. Par ailleurs, sur le plan de son éligibilité, nos données observationnelles et de simulation de décision, associées aux données médico-économiques que nous avons analysées dans la littérature, suggèrent la nécessité de baser son indication autrement que sur la simple évaluation par EVA/EN à l’accueil. Dans ce travail nous montrons que la pratique des praticiens témoigne aujourd’hui de leur manque d’adhésion au déclenchement systématique de la prescription d’opiacés Iv titrés par l’autoévaluation de la douleur sévère (de 6 à 20% de respect des critères SFMU, 61% de réinterprétation des scores EVA/EN). Si la titration aérosol est uniquement proposée en starter de la titration morphinique sans moderniser les algorithmes de décision de prescription opiacée dans les protocoles d’urgences, il est probable que cette nouvelle proposition thérapeutique ne résoudra qu’une partie de la problématique actuellement posée. Une prise en charge pharmacologique la plus individualisée possible est plus que jamais pertinente, avec une prescription ciblée de la titration morphinique selon la typologie du patient, en plus d’une priorisation par typologie douloureuse. En développant un « modèle douleur » original chez le volontaire sain, nous avons d’ailleurs mis en lumière des profils de patients « hyperesthésiques » et « endurants », sur le plan neurophysiologique et biochimique, qui sont sûrement retrouvés en pratique clinique quotidienne. L’ensemble de ces éléments doivent donc être pris en compte pour améliorer la prise en charge de la douleur en médecine d’urgence, avec une vision plus systémique, et davantage d’études dédiées, utilisant des méthodes d’évaluation innovantes mêlant critères quantitatifs robustes et qualitatifs exhaustifs.Our goal was to optimize the management of severe acute pain in emergency medicine. Intravenous morphine titration, which is currently the referent method, must be modernised to meet the new challenges of practice while at the same time, we must keep guaranteeing an unchanged risk-benefit balance in the fight against oligoanalgesia. Our work, described in this thesis, has been a cornerstone for the evaluation of a nebulized alternative solution to emergencies through 3 clinical studies, (AEROMORPH1, CLIN-AEROMORPH, EPIMORPH), and study of its contextualisation in literature. Work in healthy volunteers allowed us to establish a simple and accessible procedure for aerosol, of short duration (5 min), which can be repeated in titration procedures (every 10 min). Its feasibility is likely to be confirmed on our multicentre clinical study at a large scale and its efficacy, by a non-inferiority design of study is being evaluated. Pharmacological data in healthy volunteers and in patients confirm a blood morphine concentration close to the effective blood concentrations observed by intravenous administration (CLIN-AEROMORPH: 1-20 ng/ml), which is already a positive result demonstrated by our work. Moreover, regarding eligibility, our observational study, combined to a experiment about decision mechanisms, combined with the analysis of medico-economic data in literature, suggest the need to base its indication on more than just the simple VAS/NRS assessment at triage. In this work we showed that emergency practitioners’ practice today underlines their lack of adherence to the systematic initiation of intravenous morphine titration by patient self-assessment of severe pain (compliance with SFMU criteria 6 to 20%, re-assessment of VAS/NRS scores 61%). If nebulized morphine titration is only proposed as a starter for morphine titration without modernising the algorithms for opiate prescription decision in emergency protocols, it is likely that this new therapeutic proposal will only solve part of the current problem. Targeted pharmacological management, as individualised as possible, is more relevant than ever, with prescription of morphine titration according to the patient's typology, in addition to prioritisation by pain typology. By developing an original pain model in healthy volunteers, we have also highlighted profiles of "pain sensitive" and "enduring" patients, according to neurophysiological and biochemical data, that are certainly represented in daily clinical practice. Therefore, all these components should be taken into account to improve pain management in emergency medicine, with a more systemic vision and more dedicated studies using innovative evaluation methods, combining robust quantitative criteria with comprehensive qualitative criteria

Titration morphinique inhalée aux Urgences : modernisation de la prise en charge des douleurs sévères de l'adulte

Our goal was to optimize the management of severe acute pain in emergency medicine. Intravenous morphine titration, which is currently the referent method, must be modernised to meet the new challenges of practice while at the same time, we must keep guaranteeing an unchanged risk-benefit balance in the fight against oligoanalgesia. Our work, described in this thesis, has been a cornerstone for the evaluation of a nebulized alternative solution to emergencies through 3 clinical studies, (AEROMORPH1, CLIN-AEROMORPH, EPIMORPH), and study of its contextualisation in literature. Work in healthy volunteers allowed us to establish a simple and accessible procedure for aerosol, of short duration (5 min), which can be repeated in titration procedures (every 10 min). Its feasibility is likely to be confirmed on our multicentre clinical study at a large scale and its efficacy, by a non-inferiority design of study is being evaluated. Pharmacological data in healthy volunteers and in patients confirm a blood morphine concentration close to the effective blood concentrations observed by intravenous administration (CLIN-AEROMORPH: 1-20 ng/ml), which is already a positive result demonstrated by our work. Moreover, regarding eligibility, our observational study, combined to a experiment about decision mechanisms, combined with the analysis of medico-economic data in literature, suggest the need to base its indication on more than just the simple VAS/NRS assessment at triage. In this work we showed that emergency practitioners’ practice today underlines their lack of adherence to the systematic initiation of intravenous morphine titration by patient self-assessment of severe pain (compliance with SFMU criteria 6 to 20%, re-assessment of VAS/NRS scores 61%). If nebulized morphine titration is only proposed as a starter for morphine titration without modernising the algorithms for opiate prescription decision in emergency protocols, it is likely that this new therapeutic proposal will only solve part of the current problem. Targeted pharmacological management, as individualised as possible, is more relevant than ever, with prescription of morphine titration according to the patient's typology, in addition to prioritisation by pain typology. By developing an original pain model in healthy volunteers, we have also highlighted profiles of "pain sensitive" and "enduring" patients, according to neurophysiological and biochemical data, that are certainly represented in daily clinical practice. Therefore, all these components should be taken into account to improve pain management in emergency medicine, with a more systemic vision and more dedicated studies using innovative evaluation methods, combining robust quantitative criteria with comprehensive qualitative criteria.Notre objectif était d’optimiser la prise en charge de la douleur aiguë sévère en médecine d’urgence. La titration morphinique intraveineuse qui fait actuellement référence doit se moderniser pour répondre aux nouveaux enjeux de la pratique en même temps que l’on doit garantir une balance bénéfice risque inchangée dans la lutte contre l’oligoanalgésie. Le travail décrit dans cette thèse, constitue une première étape d’évaluation d’une alternative nébulisée à la titration morphinique, à travers 3 études cliniques (AEROMORPH1, CLIN-AEROMORPH, EPIMORPH) et l’étude de son contexte dans la littérature. Des travaux chez le volontaire sain ont permis d’établir un mode opératoire avec une technique aérosol simple et accessible, de courte durée (5 min), que l’on peut répéter en titration (toutes les 10 min). Sa faisabilité est en voie d’être confirmée à grande échelle dans une étude multicentrique clinique et sa non-infériorité en termes d’efficacité est en cours d’évaluation. Des données pharmacologiques chez le volontaire sain et chez les patients confirment une concentration sanguine en morphine proche des concentrations efficaces observées en intraveineux (1 à 120 ng/ml dans CLIN-AEROMORPH), ce qui est déjà un résultat positif démontré par nos travaux. Par ailleurs, sur le plan de son éligibilité, nos données observationnelles et de simulation de décision, associées aux données médico-économiques que nous avons analysées dans la littérature, suggèrent la nécessité de baser son indication autrement que sur la simple évaluation par EVA/EN à l’accueil. Dans ce travail nous montrons que la pratique des praticiens témoigne aujourd’hui de leur manque d’adhésion au déclenchement systématique de la prescription d’opiacés Iv titrés par l’autoévaluation de la douleur sévère (de 6 à 20% de respect des critères SFMU, 61% de réinterprétation des scores EVA/EN). Si la titration aérosol est uniquement proposée en starter de la titration morphinique sans moderniser les algorithmes de décision de prescription opiacée dans les protocoles d’urgences, il est probable que cette nouvelle proposition thérapeutique ne résoudra qu’une partie de la problématique actuellement posée. Une prise en charge pharmacologique la plus individualisée possible est plus que jamais pertinente, avec une prescription ciblée de la titration morphinique selon la typologie du patient, en plus d’une priorisation par typologie douloureuse. En développant un « modèle douleur » original chez le volontaire sain, nous avons d’ailleurs mis en lumière des profils de patients « hyperesthésiques » et « endurants », sur le plan neurophysiologique et biochimique, qui sont sûrement retrouvés en pratique clinique quotidienne. L’ensemble de ces éléments doivent donc être pris en compte pour améliorer la prise en charge de la douleur en médecine d’urgence, avec une vision plus systémique, et davantage d’études dédiées, utilisant des méthodes d’évaluation innovantes mêlant critères quantitatifs robustes et qualitatifs exhaustifs

A Systemic Approach to Complete the Multimodal Assessment Model of Pain

International audienc

“Please lower your mask”: A hard diagnosis in COVID‐19 times

International audienc

Particularités de la prise en charge des patients douloureux chronique aux urgences

À peu près 30 % des patients admis aux urgences ont une douloureux chronique (DC). Parmi ceux-ci, 20 à 30 % ont pour motif d’admission une douleur en rapport avec leur douleur habituelle, soit 10 % des patients des urgences. L’objectif du présent article est de mettre en avant cette pathologie peu connue des urgentistes bien que fréquente et de proposer des modalités de prise en charge. Celle-ci admet 2 limites principales dans ce contexte. La première est le faible niveau de connaissance de ces pathologies par les urgentistes, le second est le temps limité pour s’en occuper. La DC est maintenant reconnue comme maladie à part entière et comprend 1 sous-groupe de DC primaires et 6, de DC secondaires, dont les douleurs cancéreuses. Elle est présente dans la CIM-11depuis 2018. Lors de la prise en charge, s’il s’agit d’une DC non cancéreuse, la stratégie est basée sur la recherche d’éléments de décompensation d’ordre thérapeutique, psychologique, de perte de contrôle de la gestion de la douleur. S’il s’agit d’une DC cancéreuse, il faut éliminer une urgence carcinologique puis rechercher des accès paroxystiques douloureux ou une augmentation des besoins en antalgique. En conclusion, la douleur chronique est une pathologie fréquente aux urgences et 10 % des patients des urgences vient pour leur douleur habituelle. Étant donné le volume de patients admis chaque année aux urgences cela représente un nombre absolu non négligeable. On se doit d’être attentif aux causes possibles d’une aggravation de la douleur chronique notamment chez les patients cancéreux. Globalement il est clair que les médecins urgentistes ne sont pas encore bien familiarisés avec ces pathologies.Around 30% of patients admitted in Emergency departments have chronic pain (CP). Among these last, 20 to 30% comes to ED for a pain in relation with their usual pain, i.e. 10% of patients in ED. The aim of this article is to highlight this disease that is not well known by emergency physicians although it is frequent and to propose management modalities. This last is limited by 2 factors in this context. First, emergency physicians have a weak knowledge of these diseases, second, time to take care of these patients is limited in ED. CP is now recognized as a disease in its own right and includes 1 subgroup of primary CP and 6, secondary CPs, including cancer pain. It has been present in the ICD-11since 2018. During management, if it is a non-cancerous CP, the strategy is based on the search for elements of decompensation of a therapeutic or psychological nature, or loss of control over pain management. In the case of cancerous CP, a carcinologic emergency must be ruled out and then a search must be made for breakthrough pain or an increase of pain killers need. In conclusion, patient with chronic pain are frequent in ED and 10% of ED patients comes for their usual pain. Given the volume of patients admitted to the emergency room each year, this represents a significant absolute number. Beware of possible causes of worsening chronic pain, especially in cancer patients. Overall it is clear that emergency physicians are not yet familiar with these diseases

Medico-economic study of pain in an emergency department: a targeted literature review

International audienceBackground: Pain management in emergency departments is a complex objective. The absence of a care pathway or a high level of activity complicates diagnostic or analgesic therapeutic strategies. Medical innovation can impact both individual practices and the functioning of an emergency department.Objective: We then wanted to understand how medico-economic studies on pain were carried out in an emergency department.Study design: We reviewed the literature of the last 20 years (between 1998 and 2018).Setting: Of 846 titles screened, a total of 268 abstracts qualified for further screening, and 578 titles were excluded. A total of 14 studies qualified for inclusion in the review. Studies on medico-economics in an emergency department are very diverse. None of the methods used are identical; the studies differ in their very nature (prospective, retrospective, cost-effectiveness, etc.) and the determination of emergency room costs differs according to the part of the world studied. In addition, organizational impact is rarely measured, although it is an essential dimension for choosing or not a medical innovation