Enteral Sedation in Patients Requiring Mechanical Ventilation During an Intravenous Analgesic and Sedative Shortage

Background: There is a paucity of data evaluating the use of enteral sedation in mechanical ventilation. A sedative shortage resulted in the use of this approach. Purpose: To evaluate the feasibility of using enteral sedatives to decrease intravenous (IV) analgesia and sedative requirements. Materials/Methods: This single-center, retrospective, observational study compared two groups of patients admitted to the ICU who were mechanically ventilated. One group received a combination of enteral and IV sedatives and the second group received IV monotherapy. Linear mixed model (LMM) analyses were performed to assess the impact of enteral sedatives on IV fentanyl equivalents, IV midazolam equivalents, and propofol. Mann-Whitney U tests were performed on percent of days at goal for Richmond Agitation and Sedation Scale (RASS) and critical care pain observation tool (CPOT) scores. Results: One hundred and four patients were included. The average cohort age was 62 years and 58.7% were male. The median length of mechanical ventilation was 7.1 days and the median length of stay was 11.9 days. The LMM estimated that enteral sedatives reduced IV fentanyl equivalents received per patient by an average of 305.6 mcg/day (P = .04), although did not significantly decrease midazolam equivalents or propofol. There was no statistically significant difference in CPOT scores (P = .57 and P = .46 respectively), however RASS scores in the enteral sedation group were more often at goal (P = .03); oversedation occurred more in the non-enteral sedation group (P = .018). Conclusion: Enteral sedation may be a possible way to decrease IV analgesia requirements during periods of shortage.

Defining Over-Sedation: Literature Review and National Survey of Dental Hospitals Within the United Kingdom

AIMS

To review the literature, to investigate whether there was aconsensus on what encompasses over-sedation, and to determine the guidance employed for the administration of flumazenil.

METHODS

A literature search was performed following which a self-designed questionnaire was emailed to 14 sedation leads within UK Dental Hospitals.

RESULTS

10 documents in the literature review met the inclusion criteria. In their definitions of over-sedation, loss of consciousness and respiratory depression were the main terms used; but a variety of terms were also seen, indicating a lack of agreement. Fourteen dental institutes were contacted of which nine (64%) responded. Thirty-seven per cent of sedation leads who responded stated they were unaware of a definition for over-sedation. Seventy-seven percent stated that when flumazenil was used this was recorded in a drugs book, with a broad range of justifications given.

CONCLUSION

This study shows that there is a lack of uniformity both from clinicians and the literature, in what encompasses over-sedation. This makes formulating an accepted definition of over-sedation difficult. In order to ensure accurate reporting, monitoring and auditing of such events, a clear definition for over-sedation is required and can be used to provide clarity when flumazenil is to be administered.

Clinical and economic impact of substituting dexmedetomidine for propofol due to a US drug shortage: examination of coronary artery bypass graft patients at an urban medical centre

BACKGROUND

Propofol has reduced healthcare costs in coronary artery bypass graft (CABG) surgery patients by decreasing post-operative duration of mechanical ventilation. However, the US shortage of propofol necessitated the use of alternative agents.

OBJECTIVE

This study sought to evaluate clinical and economic implications of substituting dexmedetomidine for propofol in patients undergoing CABG surgery.

METHODS

This was a retrospective cohort study. Patients undergoing isolated, elective CABG surgery and sedated with either propofol or dexmedetomidine during the study period were included. The cohorts were matched 1:1 based on important characteristics. The primary outcome was the number of patients achieving a post-operative duration of mechanical ventilation ≤6 h. Secondary outcomes were post-operative intensive care unit (ICU) length of stay (LOS) ≤48 h, total post-operative LOS ≤5 days, the need for adjunctive opioid therapy and associated cost savings. Variables recorded included patient demographics, co-morbid medical conditions, health risks, sedation drug doses, post-operative medical complications and sedation-related adverse events. Univariate and multivariate analyses were completed to examine the relationship between these covariates and post-operative LOS. The cost analysis consisted of examination of the net financial benefit (or cost) of choosing dexmedetomidine versus propofol in the study population, with utilisation observed in the study converted to costs using institutional data from the Premier database.

RESULTS

Eighty-four patients were included, with 42 patients per cohort. Mechanical ventilation duration ≤6 h was achieved in 24 (57.1 %) versus 7 (16.7 %) in the dexmedetomidine and propofol cohorts, respectively (p < 0.001). More patients treated with dexmedetomidine achieved ICU LOS ≤48 h (p < 0.05) and total hospital LOS ≤5 days (p < 0.05), as compared with the propofol group. Multivariate analysis revealed that having one or more post-operative medical complication was the most significant predictor of increased post-operative LOS, whereas choosing dexmedetomidine was also significant in terms of reduced post-operative LOS. The estimated net financial benefit of choosing dexmedetomidine versus propofol was US$2,613 per patient (year 2012 value).

CONCLUSIONS

Findings suggest that use of dexmedetomidine as an alternative to propofol for sedation of CABG patients post-operatively contributes to reduced mechanical ventilation time, ICU LOS and post-operative LOS. Higher drug costs resulting from the propofol shortage were offset by savings in post-operative room and board costs. Additional savings may be possible by preventing medical complications to the extent possible.

Sources of prescription drugs for illicit use

OBJECTIVES

This exploratory study investigated the sources of four classes of abusable prescription medications (sleeping, sedative/anxiety, stimulant, and pain medications) that were used illicitly by undergraduate students in the past year. The relationship between these sources and other substance use was examined.

METHODS

In the spring of 2003, a random sample of 9,161 undergraduate students attending a large public Midwestern research university was selected to self-administer a Web-based survey.

RESULTS

The respondents identified 18 sources of prescription drugs that were classified into three broad categories: peer, family, and other sources. The majority of respondents who were illicit users obtained their prescription drugs from peer sources. Undergraduate students who obtained prescription medication from peer sources reported significantly higher rates of alcohol and other drug use than students who did not use prescription drugs illicitly or students who obtained prescription medication from family sources.

CONCLUSIONS

The findings of the present study offer strong evidence that undergraduate students obtain abusable prescription drugs from their peers. Greater prevention efforts are needed to reduce the illicit use and diversion of prescription medication.

Prevalence of alcohol and drug use in a highly educated workforce

This study examined alcohol and licit and illicit drug use in a highly educated workforce. A comprehensive health survey of a 10% random sample of a workforce (n = 8,567) yielded a 60% response rate (n = 504) after accounting for 15 undeliverable surveys. Many respondents reported past-year use of alcohol (87%). Thirteen percent of respondents consumed three or more drinks daily; 15% were binge drinkers. Twelve percent of the workforce was assessed as having a high likelihood of lifetime alcohol dependence; 5% of respondents met criteria for current problem drinking. Overall, 42% reported using mood-altering prescription drugs (analgesics, antidepressants, sedatives, or tranquilizers). Eleven percent reported using illicit drugs (cocaine, hallucinogens, heroin, or marijuana) in the past year. Significant relationships were found between gender, age, ethnicity, and occupation with some measures of alcohol consumption and use of mood-altering drugs. These results indicate prevention and early intervention programs need to address use of mood-altering substances (including alcohol) in highly educated workforces.

Computerized controlled-substance surveillance: application involving automated storage and distribution cabinets

A secondary data-reporting system used to scan the archives of a hospital's automated storage and distribution cabinets (ASDCs) for indications of controlled-substance diversion is described. ASDCs, which allow access to multiple doses of the same medication at one time, use drug count verification to ensure complete audits and disposition tracking. Because an ASDC may interpret inappropriate removal of a medication as a normal transaction, users of ASDCs should have a comprehensive plan for detecting and investigating controlled-substance diversion. Monitoring for and detecting diversion can be difficult and time-consuming, given the limited report-generating features of many ASDCs. Managers at an 800-bed hospital used report-writing software to address these problems. This application interfaces with the hospital's computer system and generates customized reports. The monthly activity recapitulation report lists each user of the ASDCs and gives a summary of all the controlled-substance transactions for those users for the time period specified. The monthly summary report provides the backbone of the surveillance system and identifies situations that require further audit and review. This report provides a summary of each user's activity for a specific medication for the time period specified. The detailed summary report allows for efficient review of specific transactions before there is a decision to conduct a chart review. This report identifies all ASDC controlled-substance transactions associated with a user. A computerized report-generating system identifies instances of inappropriate removal of controlled substances from a hospital's ASDCs.

[Epidemiology of the use of anxiolytic and hypnotic drugs in France and in the world]

A higher anxiolytic and hypnotic consumption has been evidenced in France by recent international and national surveys. In an effort to counteract this pattern French Health authorities have enforced limitation to the prescription of these drugs. Understanding the causes of this overuse needs a careful analysis of the pattern of use of this medicine but also of the associated morbidity factors. In the last ten years several studies have attempted to address these issues. In the general population there were 25 to 30% of occasional or regular users with between 5 and 7% chronic users making french anxiolytic users two to three time superior to most industrialised countries. This high level of consumption is not the privilege of anxiolytic since the same pattern of use is observed for all medicine. Studies in primary care, in medical inpatients and psychiatric inpatients show as expected that anxiolytic use increase with the psychiatric morbidity and also with somatic disorder. The main risk factors for anxiolytic use are female sex, old age and psychic and somatic morbidity. Age seems to play a major role in subjects over 65: 17% are chronic users. Multiple factors might play a role in benzodiazepine use as medical care system, physician type of practice, cultural specific aspects but no proper simple explanation is available to explain the mechanism of the french high anxiolytic use. Given the poor global recognition of mental disorder observed in most countries it is suggested to privilege primary care physician training in psychiatry to optimize psychotropic drug use.

Cohort analysis of suicide rates in Australia

Age-specific cohort analysis of Australian suicide rates confirmed recent Canadian and American reports of a substantial increase in suicide rate among young age groups. However, it was unable to replicate fully the previous findings that not only did successive birth cohorts have higher suicide rates, but that at each successive five-year period they had higher suicide rates than preceding cohorts had at that age. The major differences could be explained on the basis of the introduction of legislation that restricted the prescription of sedatives. This suggests that although there may be early and lasting effects on successive birth cohorts contributing to a general increase in cohort-specific suicide rates in the countries examined, such rates also can be influenced by changing environmental factors more immediately related to the suicide itself.