Brian L Erstad

PMID: 20978218;Abstract:

OBJECTIVE: To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy. DATA SOURCES: Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department. STUDY SELECTION AND DATA EXTRACTION: The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED. DATA SYNTHESIS: At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction. CONCLUSIONS: Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.

PMID: 7848020;Abstract:

Objective: To develop contemporary, comprehensive guidelines for the appropriate and efficient use of albumin, nonprotein colloid, and crystalloid solutions. Design: A systematic, literature-based, consensus exercise employing a modified Delphi method. Participants: Thirty-one medical and allied health professionals from 26 University Hospital Consortium (Oak Brook, Ill) member institutions were initially chosen to participate. Participants were selected on the basis of their recognized research in the use of albumin, nonprotein colloid, and crystalloid solutions, and/or experience in the review of appropriateness of such use. A total of 24 participants completed the exercise. Main Outcome Measures: Group responses were statistically analyzed in an iterative consensus development process. Five separate questionnaire rounds were designed to establish criteria for the appropriate use of albumin, nonprotein colloid, and crystalloid solutions. Results: Consensus guidelines were developed outlining the appropriate use of these products for 12 clinical indications, including hemorrhagic shock, nonhemorrhagic (maldistributive) shock, hepatic resection, thermal injury, cerebral ischemia, nutritional intervention, cardiac surgery, hyperbilirubinemia of the newborn, cirrhosis and paracentesis, nephrotic syndrome, organ transplantation, and plasmapheresis. Conclusions: The Delphi method, a systematic, literature-based consensus process, was shown to be useful in the development of complex clinical practice guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. It is anticipated that the guidelines will assist health care providers to develop local institutional policies and procedures for the appropriate and efficient use of albumin and albumin alternatives. Institutions reviewing and updating existing local guidelines may use the University Hospital Consortium guidelines as a model for comparison.

Under consideration - Revisions submitted 10/2016

PMID: 19792995;Abstract:

Compilations of key articles and guidelines in a particular clinical practice area are useful not only to clinicians who practice in that area, but also to all clinicians. We compiled pertinent articles and guidelines pertaining to drug therapy in the intensive care setting from the perspective of experienced critical care pharmacists. A broad assembly of practitioners with expertise in various areas of intensive care unit pharmacology were involved in the compilation of this update.