Timing of sedation and patient-reported pain outcomes during cardiac catheterization: Results from the UNTAP-intervention study

BACKGROUND

Invasive cardiac catheterization (CC) temporarily increases pain, discomfort, and anxiety. Procedural sedation is deployed to mitigate these symptoms, though practice varies. Research evaluating peri-procedural patient-reported outcomes is lacking.

METHODS AND RESULTS

We randomized 175 patients undergoing CC to short interval ([SI] group, <6 min) or long interval ([LI] group, ≥6 min) time intervals between initial intravenous sedation and local anesthetic administration. Outcomes included: (1) total pain medication use, (2) patient-reported and behaviorally assessed pain and (3) patient satisfaction during outpatient CC. Generalized linear mixed effect models were used to evaluate the impact of treatment time interval on total medication utilization, pain, and satisfaction. Among enrollees the mean age was 62 (standard deviation [SD] = 13.4), a majority were male (66%), white (74%), and overweight (mean body mass index = 28.5 [SD = 5.6]). Total pain medication use did not vary between treatment groups (p = 0.257), with no difference in total fentanyl (p = 0.288) or midazolam (p = 0.292). Post-treatment pain levels and nurse-observed pain were not statistically significant between groups (p = 0.324 & p = 0.656, respectively. No significant differences with satisfaction with sedation were found between the groups (p = 0.95) Patient-reported pain, satisfaction and nurse-observed measures of pain did not differ, after adjustment for demographic and procedural factors. Analyses of treatment effect modification revealed that postprocedure self-reported pain levels varied systematically between individuals undergoing percutaneous coronary intervention (PCI) (SI = 2.2 [0.8, 3.6] vs. LI = 0.7 [-0.6, 2.0]) compared with participants not undergoing PCI (SI = 0.4 [-0.8, 1.7] vs. LI = 0.7 [-0.3, 1.6]) (p = 0.043 for interaction).

CONCLUSION

No consistent treatment differences were found for total medication dose, pain, or satisfaction regardless of timing between sedation and local anesthetic. Treatment moderations were seen for patients undergoing PCI. Further investigation of how procedural and individual factors impact the patient experience during CC is needed.

Understanding the patient experience of pain and discomfort during cardiac catheterization

OBJECTIVES

Patient centeredness is an essential component of high-quality care, yet little is known regarding the patient experience during procedures performed in the cardiac catheterization lab.

BACKGROUND

Available literature focuses on the safe delivery of sedation, but does not address patient-reported satisfaction or comfort. Further delineation of how procedural factors impact the patient experience is needed.

METHODS

We conducted a retrospective, exploratory analysis of adult cardiac catheterization outpatients (n = 375) receiving physician ordered, nurse administered procedural sedation (benzodiazepine and/or opioids) between April and June, 2017. Data were abstracted from the procedural database, Electronic Health Record, and Press Ganey^© surveys.

RESULTS

The mean age was 63 (SD 12.2), a majority were male (n = 226; 60%), white (n = 271; 73%), and overweight (mean body mass index = 29, SD 6.8). Patient-reported satisfaction with pain control and perceived staff concern for comfort were >75th percentile (Press Ganey^© survey), with no difference in preprocedure and postprocedure pain scores (p = .596). Intraprocedural medication dose range and mean frequency were highly variable: midazolam (0.25-5.5 mg; 1.48); fentanyl (12.5-200 mcg; 1.63); and hydromorphone (0.5-2.5 mg; 1.33). Median time interval between administration of initial sedation and local anesthetic was 6 min. Patients with longer intervals had less frequent dosing (p < .001) and less total procedural sedation (p < .001). Sensitivity analysis revealed that trainee/fellow involvement (p = .001), younger age (p = .002), and shorter time intervals (p < .001) were associated with increased frequency and larger total dose.

CONCLUSIONS

Waiting to gain vascular access following administration of procedural was associated with less frequent subsequent dosing, lower overall administration, and similar patient satisfaction. Optimizing processes for administering periprocedural sedation may allow for less medication without impacting patient experience.

Abstract 249: Understanding the Patient Experience of Pain and Discomfort During Cardiac Catheterization

Background: Patient centeredness is an essential component of high-quality care, yet little is published regarding the patient experience during procedures performed in the cardiac catheterization lab. Available literature focuses on the safe delivery of sedation, but does not address patient-reported satisfaction, comfort, or procedural experience. Further delineation of how procedural factors impact the patient experience is needed.

Methods and Results: We conducted a retrospective, exploratory analysis of adult cardiac catheterization outpatients receiving nurse-administered, physician-prescribed procedural sedation (benzodiazepine and/or opioids) between April-June, 2017. Data were abstracted from the procedural database, EHR and Press Ganey© surveys. Patients (n=375) had a mean age of 63, were male 60% (226/375), White 73% (271/375), and overweight / obese (mean BMI = 29). Procedural sedation was given in 93% (348/375) of cases. Press Ganey© results showed good satisfaction with pain control (>75 th percentile) and staff concern for comfort in all patients. There was no significant difference in pre- and post-procedural patient reported pain scores. The median patient received 1.63 doses of midazolam with either 1.48 doses of fentanyl or 1.33 doses of hydromorphone. Median time interval between administration of initial sedative dose and local anesthetic was 6.2 minutes. Patients with longer intervals had less frequent dosing (p<0.001) and less total procedural sedation (p<0.001). Adjusting for demographic and procedural characteristics, trainee involvement (p=0.001), older age (p=0.002) and longer time intervals (p=<0.001) between dosing and local anesthetic were associated with decreased frequency and total dose.

Conclusions: Extended duration of sedation intervals was associated with lower overall sedation administration with similar patient satisfaction. Optimizing processes for administering peri-procedural sedation may allow for less total medication without impacting patient experience.

(2,3)-alpha-Methylenepenams: synthesis and in vitro activity

A series of alpha-methylene penicillins was synthesized and SAR were studied. The alpha-isomers were found to be chemically reactive and biologically active in contrast to the beta-isomers. In addition, the alpha-isomers have broader spectrum of in vitro activity than the corresponding penicillins. Generally, the alpha-isomers are more active against gram-negative bacteria than the corresponding penicillins, but slightly weaker in potency towards gram-positive organisms.

In vitro and in vivo activity of carbamate-linked dual-action antibacterial Ro 24-4383

Ro 24-4383 contains desacetylcefotaxime linked by a carbamate bond at the 3' position to ciprofloxacin. Ro 24-4383 was active against 99% of the 363 gram-positive and gram-negative aerobes tested in vitro, while the comparative agents cefotaxime and ciprofloxacin were active against 77 and 97%, respectively. The activities (ED50: mg/kg s.c.) of Ro 24-4383, cefotaxime and ciprofloxacin in systemic murine infections were: Escherichia coli 257, 1.4, less than 0.5, less than 0.2; Klebsiella pneumoniae A, 11, 30, 0.7; Enterobacter cloacae 5699, 3.2, 35, less than 0.2; Citrobacter freundii BS16, 3, 41, less than 0.5; Serratia marcescens SM, 35, greater than 100, 1.6; Pseudomonas aeruginosa 5712, 67, 100, 10; P. aeruginosa 8780, 33, 193, 3; Staphylococcus aureus Smith (oxacillin-susceptible), 12, 3.7, 1; S. aureus 753 (oxacillin-resistant), 28, greater than 100, 2; Streptococcus pneumoniae 6301, 10, 15, greater than 50, and S. pyogenes 4, 3.3, 1.6, 54. Ro 24-4383, although inactive against the S.-pneumoniae-induced pneumonia following one administration of the agent, was highly active (ED50 = 1.5) when three treatments were given following infection. Ro 24-4383 was active against the K.-pneumoniae-induced pneumonia (ED50 = 37), as well as the meningitis induced by S. pneumoniae (ED50 = 158) or K. pneumoniae (ED50 = 100). The protective effect of Ro 24-4383 was demonstrated when administered 8 h before infection with E. coli (ED50 = 37) and 4 h before infection with S. pyogenes (ED50 = 199).

Comparison of speed of sound and ultrasound attenuation in the os calcis to bone density of the radius, femur and lumbar spine

Broadband ultrasonic attenuation (BUA) between 0.1 and 0.6 MHz and speed of sound (SOS) were measured on the os calcis in normal women (n = 40), and women who had mild osteoporosis (n = 36). Comparisons were made between the ultrasonic properties and bone mineral densities (BMD) obtained using photon absorptiometry on the lumbar spine, proximal femur and radius shaft. In the osteoporotic women, whose spine BMD was significantly reduced, BUA and SOS were lower, to about the same degree of significance as radius BMD; ROC analysis demonstrated that for discrimination of spinal osteopenia, the area under the ROC curve was similar for radius BMD, SOS, and BUA. There was a modest correlation (r about 0.65) between either SOS or BUA on the os calcis and BMDs of the spine and radius. Correlations of the SOS and BUA with femoral neck BMD were lower (r about 0.4 to 0.5). The standard error of estimate for both spine and femoral neck BMD was too high (about 0.14 g cm-2) for os calcis measurements to be substituted clinically for densitometry at these fracture sites.

Interaction of (2,3)-methylenepenams with penicillin-binding proteins

A series of (2,3)-methylenepenams were examined with respect to binding to essential penicillin-binding proteins (PBPs) in Escherichia coli and Staphylococcus aureus. The compounds were also examined with respect to their interaction with Streptomyces strain R61 DD-carboxypeptidase. The alpha isomer of (2,3)-methylene penicillin G bound to PBP 3 of E. coli and other enterobacteria at 0.1 to 10 micrograms/ml. The beta isomer bound to PBP 3 at 100 micrograms/ml. Either isomer bound to PBPs 1b and 2 of E. coli only at 100 micrograms/ml. The alpha, but not the beta, isomer also bound to PBP 2 of S. aureus at 0.1 micrograms/ml. Binding studies with radiolabeled compounds indicated the binding to be covalent and revealed no additional binding proteins. (2,3)-Methylenepenams active against E. coli bound to PBP 3 and induced filamentation. The compounds also inhibited Streptomyces strain R61 DD-carboxypeptidase with apparent 50% inhibitory concentrations as low as 10(-7) M. The two (2,3)-methylene penicillin G isomers bound to the enzyme covalently, most likely at the same site as penicillin G since partial proteolysis after binding radiolabeled compounds produced similar peptide patterns. The bound beta isomer was released with a half-time similar to that of penicillin G (70 min at 30 degrees C), while the alpha isomer was released with a longer half-time (13 h at 30 degrees C). With either isomer, the major release product was phenylacetylglycine, suggesting C-5-C-6 cleavage.