The relationship of postoperative delirium with psychoactive medications

OBJECTIVE

To examine the role of medications with known psychoactive properties in the development of postoperative delirium.

DESIGN

Nested case-control study within a prospective cohort study.

SETTING

General surgery, orthopedic surgery, and gynecology services at Brigham and Women's Hospital, Boston, Mass.

PATIENTS

Cases (n = 91) were patients enrolled in a prospective cohort study who developed delirium during postoperative days 2 through 5. One or two controls (n = 154) were matched to each case by the calculated preoperative risk for delirium using a predictive model developed and validated in the prospective cohort study.

MAIN OUTCOME MEASURES

Medication exposures were ascertained from the medical record by a reviewer blinded to the study hypothesis. Exposures to narcotics, benzodiazepines, and anticholinergics were recorded for the 24-hour period before delirium developed in the 91 cases and for the same 24-hour postoperative period for the 154 matched controls.

RESULTS

Delirium was significantly associated with postoperative exposure to meperidine (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.3 to 5.5) and to benzodiazepines (OR, 3.0; 95% CI, 1.3 to 6.8). Meperidine had similar associations with delirium whether administered via epidural or patient-controlled routes, although only the epidural route reached significance (OR, 2.4; 95% CI, 1.3 to 4.4; OR, 2.1; 95% CI, 0.4 to 10.7, respectively). For benzodiazepines, long-acting agents had a trend toward stronger association with delirium than did short-acting agents (OR, 5.4; 95% CI, 1.0 to 29.2; vs 2.6; 1.1 to 6.5), and high-dose exposures had a trend toward slightly stronger association than low-dose exposures (OR, 3.3; 95% CI, 1.0 to 11.0; vs 2.6; 0.8 to 9.1). Neither narcotics (OR, 1.4; 95% CI, 0.5 to 4.3) nor anticholinergic drugs (OR, 1.5; 95% CI, 0.6 to 3.4) were significantly associated with delirium as a class, although statistical power was limited because of the high use of narcotics and the low use of anticholinergics in the study population.

CONCLUSIONS

Clinicians caring for patients at risk for delirium should carefully evaluate the need for meperidine and benzodiazepines in the postoperative period and consider alternative therapies whenever possible.

Ruling out acute myocardial infarction. A prospective multicenter validation of a 12-hour strategy for patients at low risk

BACKGROUND

Although previous investigations have suggested that 24 hours is required to exclude acute myocardial infarction in patients who are admitted to a coronary care unit for the evaluation of acute chest pain, we hypothesized that a 12-hour period might be adequate for patients with a low probability of infarction at the time of admission.

METHODS

Using a Bayesian model, we developed a strategy to identify candidates for a shorter period of observation from an analysis of a derivation set of 976 patients with acute chest pain who were admitted to three teaching and four community hospitals. In the derivation set, patients whose clinical characteristics in the emergency room predicted a low (less than or equal to 7 percent) probability of myocardial infarction had only a 0.4 percent risk of infarction if they had neither abnormal levels of cardiac enzymes nor recurrent ischemic pain during the first 12 hours of hospitalization. In an independent testing set of 2684 patients from the seven hospitals, 957 admitted patients (36 percent) were classified as candidates for this 12-hour period of observation according to a previously published multivariate algorithm. Few of these patients were actually transferred from a monitored setting at 12 hours.

RESULTS

Of the 771 candidates for a 12-hour period of observation who did not have enzyme abnormalities or recurrent pain during the first 12 hours, 4 (0.5 percent) were subsequently found to have acute myocardial infarction, and only 3 (0.4 percent) died after primary cardiac arrests, all of which occurred three to five days after admission. Rates of other major cardiovascular complications were low in the patients who might have been transferred from the coronary care unit after 12 hours with this strategy. In patients with a higher initial risk of infarction, the standard strategy of 24-hour observation identified all but 11 of 739 acute myocardial infarctions (1 percent).

CONCLUSIONS

Emergency room clinical data can be used to identify a large subgroup of patients for whom a 12-hour period of observation is normally sufficient to exclude acute myocardial infarction. Patient-specific evaluation and treatment can then proceed without the restrictions imposed by "rule-out" protocols for myocardial infarction.

A REVIEW OF KETAMINE ABUSE AND DIVERSION

Ketamine was discovered in the 1960s and released for public use in 1970. Originally developed as a safer alternative to phencyclidine, ketamine is primarily used in clinical settings for analgesia and sedation. In recent years, other uses have been developed, including pain management and treatment of asthma and depression. Clinical use of ketamine causes dissociation and emergence delirium. These effects have led to recreational abuse. Although death from direct pharmacologic effects appears rare, the disinhibition and altered sensory perceptions caused by ketamine puts users at risk of environmental harm. Ketamine has also been implicated in nonconsensual sexual intercourse. Data continue to build that chronic ketamine use may lead to morbidity. Impairment of memory and persistent dissociative, depressive, and delusional thinking has also been reported with long-term use. Lower urinary tract symptoms, including cystitis have been described. Gastric and hepatic pathology have also been noted, including abnormal liver function tests, choledochal cysts and dilations of the common bile duct. S-ketamine, an enantiomer in racemic ketamine, has been shown to be hepatotoxic in vitro. Abstinence from ketamine may reduce the adverse effects of chronic use and is considered the mainstay of treatment. Specialized urine drug testing may be required to detect use, as not all point of care urine drug screens include ketamine.

Influence of culture on cancer pain management in Hispanic patients

PURPOSE

The purpose of this pilot study was to describe the influence of culture on cancer pain management in Hispanic (Mexican and Central American) patients.

DESCRIPTION OF STUDY

This qualitative study is guided by the conceptual framework of the Pain and Quality of Life model and the Biocultural Model of Pain. It was developed as a companion study to a National Cancer Institute (NCI)-funded project to disseminate a pain education program for adult patients with cancer and their family care givers in community home-care agencies. After completing the NCI study, Hispanic subjects were invited to participate in the qualitative companion study. A total of 17 subjects, the majority of whom were women, were interviewed. The Hispanic Pain Experience Questionnaire (HPEQ) was used to elicit answers to open-ended questions regarding the perception and management of cancer pain.

RESULTS

Themes that emerged from the questionnaire were Influence of Culture, Expressions of Pain, Managing Pain/Medications, and Use of Nondrug Interventions. Responses suggest that culture, family beliefs, and religion contribute significantly to management and expression of pain by the patient and care giver. In addition, this group showed that pain may be approached with stoicism; therefore, lack of verbal or behavioral expression of pain does not indicate a lack of pain itself. These patients also demonstrated a reliance on folk beliefs and nondrug interventions. The most common reason cited for noncompliance with pharmacologic treatment was an inability to understand instructions.

CLINICAL IMPLICATIONS

When providing care to Hispanic patients, it is imperative to be nonjudgmental, sensitive, and respectful. To improve compliance, the multidisciplinary cancer team should 1) incorporate the patients' folk healthcare practices and beliefs into the plan of care when possible; 2) involve family members and friends in the patient's care, identifying one key family contact; and 3) ensure that instructions for medications are available in Spanish and understood by the patient and care giver. When patients' overall beliefs and values are respected, compliance with pharmacological and other interventions may increase accordingly.

Family caregiving in cancer pain management

The experience of cancer pain is known to greatly affect family caregivers as well as patients. There are many demands placed on caregivers of cancer patients with pain at home as a result of the shifting of care from the acute setting to the home. These complex demands significantly affect caregiver quality of life. The purpose of this study was to describe the experience of pain management from the perspective of family caregivers of patients with cancer amidst the current healthcare environment. This quasi-experimental study involved 231 family caregivers of patients with cancer pain receiving home care. Family caregivers were assessed in conjunction with a pain education program that provided patient and. family education regarding pain assessment, drug and nondrug interventions. Assessment measures used were the Quality of Life (QOL)-Family Caregiver Tool, Knowledge and Attitudes about Pain (K&A) Tool, and Caregiver Finances Tool. Study findings reveal disruption to family caregiver quality of life in the areas of physical, psychological, social, and spiritual well-being. There is also a continued need for education regarding cancer pain management. Comparison between patients and family caregivers demonstrates that pain impacts both the patient experiencing it and their caregivers.

Surgical palliation at a cancer center: incidence and outcomes

HYPOTHESIS

Surgical intervention in palliative care is common; however, the indications, risks, and outcomes are not well described.

DESIGN

Retrospective review of surgical cases during a 1-year period with a minimum 1-year survival update.

SETTING

A National Cancer Institute-designated comprehensive cancer center.

PATIENTS

Patients with a cancer diagnosis undergoing operative procedures.

MAIN OUTCOME MEASURES

Number of palliative surgeries and analysis of length of stay, morbidity, and mortality.

RESULTS

Palliative surgeries comprised 240 (12.5%) of 1915 surgical procedures. There were 170 major and 70 minor procedures. Neurosurgical (46.0%), orthopedic (31.3%), and thoracic (21.5%) surgical procedures were frequently palliative. The most common primary diagnoses were lung, colorectal, breast, and prostate cancers. Length of hospital stay was 12.4 days (range, 0-99 days), with 21.3% of procedures performed on an outpatient basis. The 30-day mortality was 12.2%, with 5 patients dying within 5 days of their procedure. The overall mortality was 23.3% (56/240). Mortality for surgical procedures classified as major was 21.9% (44/170) and 10.0% (7/70) for those classified as minor (Fisher exact test, P<.01).

CONCLUSIONS

Significant numbers of palliative procedures are performed at our cancer center. Overall morbidity and mortality were high; however, a significant number of patients had short hospital stays and low morbidity. Palliative surgery should remain an important part of end-of-life care. Patients and their families must be aware of the high risks and understand the clear objectives of these procedures.

Salmonella arizona infections in Latinos associated with rattlesnake folk medicine

In 1987 two Los Angeles County (California) hospitals reported four Latino patients with serious Salmonella arizona (Salmonella subgroup 3) infections who gave a medical history of taking rattlesnake capsules prior to illness. Capsules supplied by the patients or household members grew Salmonella arizona. We reviewed surveillance data for this Salmonella species and conducted a case-control study to determine the magnitude of this public health problem. Eighteen (82 percent) of the 22 Latino cases in 1986 and 1987 who were questioned reported ingesting snake capsules compared to two (8 percent) of 24 matched Latino controls with non-subgroup 3 salmonellosis or shigellosis (matched pair odds ratio = 18.0, CI = 4.2, 76.3). An average of 18 cases per year of Salmonella arizona were reported in the county between 1980 and 1987. In this investigation the majority of S. arizona cases reporting snake capsule ingestion had underlying illnesses such as acquired immunodeficiency syndrome (AIDS), diabetes, arthritis, cancer. The capsules were obtained primarily from Tijuana, Mexico and from Los Angeles, California pharmacies in Latino neighborhoods. Despite publicity and attempts to remove the capsules from sale in California, Salmonella arizona cases associated with snake-capsule ingestion continue to occur.

Perceptions of quality of life in Hispanic patients with cancer

PURPOSE

The purpose of this study was to describe perceptions of quality of life (QOL) of Hispanic patients with cancer pain.

DESCRIPTION OF STUDY

This qualitative pilot study is guided by the conceptual framework of pain and QOL. From interviews with 17 Hispanic patients with cancer pain, data on perceptions of QOL were analyzed and are reported here.

RESULTS

The study demonstrated the influence of culture on perceptions of QOL and the impact of pain on QOL. Several themes were identified for each domain of QOL, including physical, psychological, social, and spiritual well-being. The role of the family and faith in God were important components of QOL for all patients.

CLINICAL IMPLICATIONS

It is important for clinicians to devote greater attention to cultural assessment and to include cultural beliefs in cancer care to improve QOL for Hispanic patients. The role of the family and religious beliefs should be included in the planning and evaluation of each patient's care.

Cultural considerations in education for cancer pain management

BACKGROUND

Ethnicity is an important factor not only in the incidence of cancer but also in relation to symptom management. Inadequate pain management at home has been demonstrated to result in associated physical symptoms as well as great distress to patients and family.

METHODS

The study purpose was to evaluate a structure program to educate patients about cancer pain management. The City of Hope quality-of-life (QOL) tool was used to measure patient outcomes in the QOL domains of physical, psychological, social, and spiritual well-being. The Patient Pain Questionnaire was used to assess knowledge and beliefs about pain.

RESULTS

A total of 369 patients were enrolled in the study. The three largest groups, Caucasians, Hispanics, and African Americans, were compared. There were several significant differences between groups; overall; Hispanics had the worst pain and QOL outcomes.

CONCLUSIONS

The findings demonstrate significant differences among the three ethnic groups, which indicates a continued need for cultural considerations in patient education.

Axial band scaling for bidisperse mixtures in granular tumblers

Axial banding in rotating tumblers has been experimentally observed, but the dependence of band formation on the relative concentration of the bidisperse particles has not been thoroughly examined. We consider axial band formation and coarsening for dry and liquid granular systems of bidisperse mixtures of glass beads where the small particle volume fraction ranges from 10% to 90% in half-filled tumblers for several rotation rates. Single bands form for small particle volume fractions as low as 10% and as high as 90%, usually near the end walls. Band formation along the entire length of the tumbler is less likely at very low or very high volume fractions. After many rotations the segregation pattern coarsens, and for small particle volume fractions of 50% and greater, the coarsening is logarithmic. For very low or very high small particle volume fractions, the rate of coarsening is either not logarithmic or coarsening does not occur within the duration of the experiment (600 rotations). When bands form, the width of the band for either the small or large particles scales with the tumbler diameter.

Family and caregiver involvement in pain management

Pain management is a common concern of elderly patients with chronic cancer pain as well as many nonmalignant chronic illnesses. Family caregivers are central to pain management efforts, particularly in the home-care environment. Pain management is cited as an aspect of caregiving with both physical and emotional demands. Comfort for elderly patients in pain is enhanced by support from family caregivers. Education is necessary to dispel common misconceptions regarding pain and use of analgesics, and also to address the emotional aspects of relieving pain. This family education must be preceded by the education of professionals in geriatric care and to the extension of recent advances in pain management into the geriatric population. These advances can provide comfort to elderly patients as well as to the family members who care for them.

Use of routine and breakthrough analgesia in home care

PURPOSE/OBJECTIVES

To describe current use of routine analgesics in home care and the treatment of breakthrough pain.

DESIGN

Descriptive, companion study.

SETTING

Homecare agencies in southern California.

SAMPLE

Convenience sample of 369 patients with cancer participating in a pain-education study.

METHODS

Data regarding breakthrough pain were derived from the homecare medical records and patient interviews.

MAIN RESEARCH VARIABLES

Analgesic medications prescribed and used for treatment of routine and breakthrough cancer pain.

FINDINGS

Results demonstrate discrepancy between recommended pain management in clinical practice guidelines and the actual practice of pain management at home. Deficiencies were found in medications prescribed as well as in actual use by patients.

CONCLUSIONS

Optimum relief of cancer pain is contingent on adequate treatment of routine and breakthrough pain, including greater use of recommended analgesics in adequate doses and clinical care consistent with clinical practice guidelines.

IMPLICATIONS FOR NURSING PRACTICE

Breakthrough pain is a common problem affecting the quality of life of patients with cancer. Improved management of breakthrough pain is contingent on accurate pain assessment, optimum use of analgesics, and patient education. Nurses should address the important topic of breakthrough pain as new analgesic drugs and methods of delivery become available.

Analysis of palliative care content in nursing textbooks

Overall, this study demonstrates significant deficiencies in end-of-life care content in nursing textbooks. Defining palliative care, quality of life at the end of life, and issues of policy, ethics, and law are the foundation of end-of-life care. Analysis of these topics revealed a need to clarify concepts and to apply them within the context of end-of-life care. The analysis also demonstrated a need to transfer findings from palliative care research and concepts from hospice into basic education. In March 1999 the investigators convened a conference in New York in collaboration with a group of medical investigators analyzing EOL content in medical textbooks. The conference was also attended by publishers, editors, and authors of textbooks. The investigators were very encouraged by their interest in and commitment to correcting any weaknesses in their books. The investigators provided them with specific recommendations for improvement and resources for locating both appropriate content and authors with palliative care expertise. These resources are also made available on the City of Hope Pain Resource Center Web site (http:@mayday.coh.org). Achieving the overall project goal of strengthened nursing education in end-of-life care will be reached through a variety of measures. Improving textbooks is but one important step. The various disciplines involved in palliative care can contribute to this project by working in collaboration with textbook publishers.

Resource utilization by palliative surgery patients: results of the decision and outcomes in palliative surgery (DOPS) trial

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Background: The number of cancer patients is increasing. Though many cancer treatments are successful at improving survival, most tumors recur and become incurable. A spectrum of symptoms then manifest, many requiring operations. As this happens and the focus becomes symptom management, health system resources used often differ from other scenarios. This study seeks to define the type and breadth of perioperative resource utilization after palliative operations. Methods: Prospectively, patients with advanced malignancies getting palliative operations were followed 3 months postoperatively. In addition to demographics, all encounters with any medical personnel and healthcare resources used were captured by a thorough chart audit and entered into a database. Results: Of the 106 patients entering the study, 67 remained after 3 months. Patients suffered from a mean of 2 symptoms, pain being most common. Patients had a mean of 25.4 encounters (range 1–94). Most commonly, the encounters were with the departments of surgery, medical oncology, and radiation oncology. Half of the encounters were with physicians while 47% were with physician extenders and 3% with supportive staff. Eighty-seven percent of encounters were scheduled. Half occurred in the clinics, 21% in urgent care, and 29% by phone. Fifteen patients were readmitted, most often for symptom management (52%). The 54 patients receiving supportive care referrals had a mean of 2 different referrals per patient and were primarily social work, nutrition, and rehabilitation. Two pain management referrals were initiated. Conclusions: Patients undergoing palliative operations use no more resources than those having curative procedures. Because of disease persistence, the types of resources used differ. Defining these differences is important as health systems plan for the increase in aged with incurable cancers. Early referral to supportive care specialists, vital as symptoms worsen, remains underutilized. Without inclusion of these professions, patient quality of life and distress are not being helped as much as possible. Medical and surgical oncologists should aggressively assess and manage symptoms and consult colleagues to comprehensive symptom management.

No significant financial relationships to disclose.