Christopher J. Edwards

A Guide to Pain Assessment and Management in the Neonate

Abstract Newborn infants experience acute pain with various medical procedures. Evidence demonstrates that controlling pain in the newborn period is beneficial, improving physiologic, behavioral, and hormonal outcomes. Multiple validated scoring systems exist to assess pain in a neonate; however, there is no standardized or universal approach for pain management. Healthcare facilities should establish a neonatal pain control program. The first step is to minimize the total number of painful iatrogenic events when possible. If a procedure cannot be avoided, a tiered approach to manage pain using environmental, non-pharmacologic, and pharmacologic modalities is recommended. This systematic approach should decrease acute neonatal pain, poor outcomes, and provider and parent dissatisfaction.

Induction dose of propofol for pediatric patients undergoing procedural sedation in the emergency department.

Objective This study aimed to determine if patient age is an independent predictor of the propofol dose required for the induction of sedation in pediatric patients for procedures performed in the emergency department (ED). Methods This is a retrospective study conducted in an academic, tertiary ED between May 2005 and October 2009. Medical records of patients younger than 18 years who received propofol for procedural sedation were evaluated. Data collected included patient demographics, procedure type, propofol doses administered, time to sedation induction, pain scores before procedure, opioid administration, and adverse effects. Factors predictive of propofol induction dose were analyzed using linear regression analyses. Results Eighty-eight patients were included in the final analyses. The mean age was 11 years (range, 1–17 years), and 75% were male. The mean induction dose required was 2.1 ± 1.3 mg/kg using a median of 3 boluses (interquartile range, 2–4). The mean time to induction was 3.9 ± 4.2 minutes. In the linear regression analyses (R2 = 0.07), patient age was inversely predictive of the induction dose (in milligram per kilogram) of propofol (coefficient = −0.074; P = 0.013). Sex, race, procedure type, pain score before procedure, and opioid administration were not predictive of induction dose. Transient respiratory depression occurred in 13.6% and hypotension occurred in 8% of patients, without further complications. Conclusions In pediatric patients undergoing procedural sedation in the ED, age is an independent predictor of the dose of propofol required for induction of sedation. Therefore, younger patients may require higher doses by body weight (in milligram per kilogram).

The Role of the Emergency Pharmacist in Trauma Resuscitation

The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient’s care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.

Medication Palatability Affects Physician Prescribing Preferences for Common Pediatric Conditions

OBJECTIVES The objective of this study was to determine if physicians would alter their prescribing preferences after sampling liquid formulations of medications for common pediatric diagnoses. METHODS This was a prospective interventional before/after study conducted at an academic medical center in the United States. The participants of interest included emergency, family medicine, and pediatric physicians. Participants initially completed a brief survey for their primary oral liquid medication of choice for the treatment of selected disease states. These included otitis media, sinusitis, cellulitis, asthma, colitis, and pneumonia. Participants were asked to choose one of the medication options for each disease and then were given all medications to sample for a taste test. The prescribing preference survey was then repeated. The primary outcome was change in prescribing. McNemars test was used to evaluate change in proportion of medications chosen before and after taste testing. RESULTS There were 101 physicians who participated in the study. There were three conditions for which participants changed their prescribing preferences significantly. These were otitis media (change from amoxicillin to cefdinir, difference = 13.2%, 95% confidence interval [CI] = 5.5% to 21.0%), asthma exacerbation (change from dexamethasone or prednisone to prednisolone, 28%, 95% CI = 15.9% to 40.1%), and pneumonia (change from azithromycin to amoxicillin, 16.0%, 95% CI = 6.4% to 25.6%). There was no significant change with respect to the other scenarios. CONCLUSIONS Physicians showed preferences for certain pediatric medications based on taste and showed significant changes in prescribing preferences for some common pediatric diagnoses after tasting different medications for these conditions.

Comparison of lower-dose versus higher-dose intravenous naloxone on time to recurrence of opioid toxicity in the emergency department

Abstract Introduction: The initial dose of naloxone administered to patients who present to the emergency department (ED) with opioid overdose is highly variable. The objective of this study was to determine if the initial dose of intravenous (IV) naloxone given to these patients was associated with the time to recurrence of opioid toxicity. Methods: This was a multicenter retrospective cohort study, conducted at two academic EDs in the United States. Consecutive adults who had a positive response to naloxone for opioid overdose in the ED were included. Patients were categorized into two groups based on initial IV naloxone dose administered: 0.4 mg (lower-dose) or 1–2 mg (higher-dose). The main outcome measure was the time to recurrence of opioid toxicity requiring a second dose of naloxone. Secondary outcomes included the need for naloxone continuous infusion and adverse events. Results: The study included 84 patients with 42 patients receiving lower-dose and 42 patients receiving higher-dose naloxone. Median time to re-dose of naloxone was similar between the lower-dose (72 [IQR 46–139] minutes) and higher-dose (70 [IQR 44–126] minutes) groups (p=.810). There were 12 patients (29%) in the lower-dose group and 17 patients (41%) in the higher-dose group who subsequently required continuous infusions (p=.359). The proportion of patients with adverse events was similar between lower-dose and higher-dose groups (31% versus 41%, p=.495). There was no difference in the incidence of specific withdrawal related adverse effects. Conclusions: The initial dose of naloxone given to patients in the ED does not influence the time to recurrence of opioid toxicity.

Comparison of blood product use and costs with use of 3-factor versus 4-factor prothrombin complex concentrate for off-label indications

Purpose. Results of a comparison of blood product use and cost outcomes with use of 3‐factor versus 4‐factor prothrombin complex concentrate (PCC) for indications other than warfarin reversal are presented. Methods. Consecutive patients who received 3‐factor PPC (PCC3) or 4‐factor PCC (PCC4) for non–warfarin‐related indications at 2 U.S. hospitals during a 19‐month period were identified. The primary outcome was in‐hospital blood product use, with a focus on plasma use. Total hemostasis costs, intensive care unit (ICU) and hospital lengths of stay, and other outcomes were evaluated. Results. Indications for PCC3 use (n = 118) or PCC4 use (n = 64) included intraoperative bleeding, nonintraoperative bleeding, coagulopathy of liver disease, and reversal of direct‐acting oral anticoagulant effects. The proportion of patients who received plasma was 56.8% with PCC3 use versus 53.1% with PCC4 use (p = 0.643); the corresponding median volumes of plasma received were 638 mL (interquartile range [IQR], 550–1,355 mL) and 656 mL (IQR, 532–1,136 mL), respectively. The median total hemostasis costs were

Analgosedative interventions after rapid sequence intubation with rocuronium in the emergency department

5,559 (IQR,

Age-related Differences in Propofol Dosing for Procedural Sedation in the Emergency Department

3,922–

Should morphine dosing be weight based for analgesia in the emergency department

8,159) with PCC3 use and

Comparison of 3-Factor Versus 4-Factor Prothrombin Complex Concentrate With Regard to Warfarin Reversal, Blood Product Use, and Costs

7,771 (IQR,