There exists a need for interventions that are patient focused and characterized by ease of use, improved adverse-effect and safety profiles, and manageable overall costs.
Patient-controlled analgesia (PCA) is a widely used delivery system for intravenous (IV) administration of opioids during acute post-operative pain management. Various opioids have been used for IV PCA including morphine, meperidine, hydromorphone, and fentanyl. Morphine is by far the most commonly used opioid in this setting, yet the selection of morphine as the primary opioid is based largely on tradition. Meperidine should not be considered in the PCA armamentarium due to the associated risk of central nervous system toxicity from its metabolite normeperidine. The objective of this study is to compare the rate of opioid-induced adverse reactions among three IV PCA opioids, fentanyl, morphine, and hydromorphone, in acute post-operative pain management. Although morphine is the most frequently used opioid, the results from three US hospitals indicate that fentanyl IV PCA had a significantly lower rate of common opioid induce adverse reactions (nausea/vomiting, pruritus, urinary retention, or sedation), when compared to IV PCA morphine and hydromorphone in acute post-operative pain management. The median pain score on post-operative day-1 and -2 was significantly lower in fentanyl IV PCA group. The quantity of opioid in each group was not significantly different when converted to an analgesic equivalence. Morphine and hydromorphone IV PCA were no different in rates of adverse reactions in any area; although, the hydromorphone group trended toward a lower pruritus and urinary retention rate compared to morphine, but this was not statistically significant. The rate of respiratory depression was not significantly different between the three opioids. Fentanyl IV PCA is an under used opioid for post-operative acute-pain management and should be considered more often due to the lower adverse reaction profile.
Community Health Centers that provide diabetic care for underserved patients have unique challenges. This study describes how interprofessional care improves outcomes and results in cost savings. Interprofessional diabetes education and structured team building are discussed. The team consisted of a physician, nurse practitioner, clinical pharmacist, and a number of pre-medicinal, nursing, and pharmacy students. The outcomes were measured at one year intervals for a total of three years. During the two year period with the interprofessional care team, the diabetic patients in this study achieved a 10% improvement in HgA1c, and 9% improvement in systolic blood pressure, a 5% improvement in diastolic blood pressure, and a 62.6% reduction in triglycerides. These findings suggest that this interprofessional care model in a free clinic significantly improved the HgA1c, triglycerides, and blood pressure.
Assessment of pain intensity using a standard self-reported pain score is standard practice in most institutions. These instruments require the cognitive ability to process the pain intensity into a numeric or descriptive value. Many institutions are considering adopting an assessment tool for cognitive impairment. The purpose of this study is to evaluate a clinician-administered assessment tool, PAINAD, in patients with cognitive impairment. Opioid consumption and frequency of documented unknown pain were collected in 2 cognitive impaired groups. In the control group, a self-reporting pain intensity tool was used, and in a second group, the PAINAD was used. Opioid use was significantly higher (P = .003) and the rates of reported unknown pain were significantly lower (P< .01) in the group using the PAINAD instrument compared to the control group of patients with cognitive impairment. There were no noted differences in opioid-induced adverse reactions in either group.
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