Pharmacology

Haloperidol and Long Term ICU Outcome

This study examined the use of prophylactic Haloperidol in ICU patients at high risk of delirium. While it is often a treatment agent used when non-pharmacological approaches to delirium fail, this study confirms that prophylactic use exerts no beneficial effect on long-term quality of life in ICU survivors.

The REDUCE study previously showed that neither does it reduce the incidence or duration of delirium.

“The factors age, medical, and trauma admission, baseline quality of life, risk for delirium, and the number of sedation-induced coma days are associated with the decline in long-term outcome parameters.”

And a major message is “Every additional day of sedation-induced coma is associated with further decline of long-term physical and mental function”.

link

Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty

This large national cohort “identified various modifiable risk factors (including anesthesia type and pharmaceutical agents) for postoperative delirium, demonstrating possible prevention pathways.”

Benzodiazepines and gabapentinoids were associated with higher odds of delirium, whereas lower risk of delirium was associated with neuraxial vs. general anesthesia, use of NSAIDs and COX2 Inhibitors, and high vs low opioid use specifically in the over 65 year olds.

link

Reducing pain in infants, children, and adolescents

This Cochrane Special Collection highlights the evidence for reducing both chronic and acute pain in infants, children, and adolescents.

Some areas are still devoid of good evidence, but this review includes links to a large number of topics. Chronic pain topics include the use of antidepressants, anti-epileptics, NSAIDS, acetaminophen, and opioids in non-cancer pain. A list of reviews of different opioids for cancer pain is included. Various opioids as well as psychological interventions are surveyed in acute pain management.

The list is comprehensive and full text is available at:

Full text

Vitamin C, Steroids and Thiamine for Sepsis

One might be forgiven for assuming that this is a “revolutionary” and “astounding” treatment for sepsis – the cocktail of steroids, high dose vitamin C and Thiamine propounded almost by a single person, Dr. Paul Marik, based on tiny observational personal studies.

This is an important commentary on the state of wild claims not supported by a single randomized trial in Sepsis.

It is dubbed “science by press release” in this JAMA article. While everyone hopes for a new effective treatment for Sepsis, hype ahead of the evidence is not the way of science.

link

In utero exposure to antibiotics and risk of congenital malformations

This population based study compared 10 commonly prescribed antibiotics and compared first trimester exposure to a cohort exposed to either of four penicillins considered safe during pregnancy (ampicillin, pivampicillin, benzylpenicillin and phenoxymethylpenicillin.

No increased risk of congenital malformations was found between the two. Compared to non-exposed pregnancies, small increased risks for major malformations and cardiac malformations were apparent for pivmecillinam, sulfamethizole, and azithromycin.

The overall conclusions are somewhat reassuring.

link

Association of Opioid Overdose With Opioid Prescriptions to Family Members

It is known that opioid use often stems from family or friend prescriptions.

“In this analysis, opioid prescriptions to family members were associated with overdose among individuals who do not receive opioid prescriptions”.

“Prior opioid dispensing to family members was associated with 2.89-fold higher odds of individual overdose, which persisted in young children and increased with greater quantities of opioid medications dispensed to family members.”

Increased education as to the risks, safe storage of opioids, and availability of opioid antagonists is suggested.

link

Ketamine Infusions for Chronic Pain

A series of Ketamine infusion treatments for chronic pain have sprouted “Ketamine Clinics” globally but the longer outcome has not clearly been defined. Ketamine as an opioid-avoiding modality has often spurred the movement.

This review and meta-analysis summarizes the data, finding benefit in the short term (a few weeks) with less confidence on longer term pain relief, as well as higher incidences of nausea and psychotomimetic side effects:

“Evidence suggests that IV ketamine provides significant short-term analgesic benefit in patients with refractory chronic pain, with some evidence of a dose–response relationship. Larger, multicenter studies with longer follow-ups are needed to better select patients and determine the optimal treatment protocol.”

Full text

Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery

The risks from opioid and benzodiazepines may begin even earlier than the perioperative period. This retrospective analysis examined patients that received prescriptions for either in the year before surgery.

They found “opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption.”

It is suggested: “These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.”

link

Preadmission Statin Use and 90-day Mortality in the Critically Ill

The many advantages of statins has led to trials of their use in many conditions like ARDS, renal outcomes and in the ICU.

This study is retrospective and would require randomized studies to confirm but has interesting suggestions:

ICU Preadmission statin use was associated with a lower 90-day mortality. This association was more evident in the rosuvastatin group and with noncardiovascular 90-day mortality; no differences were seen according to daily dosage intensity.

link