Alpha Alert: Utilization of Transdermal Clonidine for Refractory Agitation.

Alpha-2 agonists are under-recognized for their class effects yet offer potential benefit in specialty palliative care via decreasing sympathetic output, inducing sedation, and modulating pain. Especially in clinical contexts where agitation predominates and patients are intolerant of oral medication route, transdermal medication delivery is advantageous. We report a case of agitated behaviors in setting of mixed Alzheimer/vascular-type dementia limiting hospital discharge to nursing facility that were ameliorated with transdermal clonidine. We suggest palliative clinicians routinely conceptualize the seemingly disparate alpha-2 agonists as a class for effective symptom palliation especially as new clinical evidence becomes available.

Observations from Optimizing an Electronic Order Set for Withdrawal of Life-Sustaining Treatment.

Background: Withdrawal of life-sustaining treatment (WLST) is a process with unique pressure for all involved. The use of an electronic order set can facilitate best care. Objective: To assess utilization of a WLST order set and time to inpatient death before and after optimization. Design: A retrospective chart review for 12-month periods before and after enhancements to a WLST order set. Setting/Subjects: Multicenter study within an American, not-for-profit health care system of inpatient decedents July 2017-June 2018 and April 2021-March 2022 with orders placed via WLST order set. Measurements: Co-primary outcomes included order set utilization and time from activation of orders to patient death. Descriptive post hoc analyses featured demographics, palliative consultation, ordering clinician type/specialty, and COVID-19. Results: A total of 1949 patients had orders placed via the WLST order set and died in-hospital. Compared with the 2017-2018 period, use increased 35.8% in 2021-2022. Time to death after release of orders was significantly longer for the 2021-2022 group (4.4 vs. 3.7 hours). Demographic details included nurse practitioners (39%) as most frequent WLST order set utilizer and palliative consultation in 46% of terminal hospitalizations. Among decedents with consultation, palliative clinicians were the WLST order set utilizer for 47% of cases (i.e., 21% of all WLST order set utilizations). The median time to death was significantly longer when orders were placed by a palliative clinician (4.5 hours) compared with nonpalliative specialists (3.9 hours). COVID-19 was a hospital diagnosis for 29% of decedents in the 2021-2022 group. Conclusions: In the emotionally and cognitively intense process that is WLST, an order set provides a modifiable panel of defaults. Our experience highlights the power in guiding primary palliative care for WLST in the hospital setting and suggests that advanced practice providers and nonpalliative clinicians, as primary utilizers, be integral in the design of a WLST order set.

Survey of Buprenorphine Low-dose Regimens Used by Healthcare Institutions.

BACKGROUND: Buprenorphine microdosing ("low-dosing") allows for initiation of buprenorphine without requiring patients to endure withdrawal. Case studies suggest its favorable utility as an alternative to conventional buprenorphine induction. However, published regimens vary in duration, dosage forms used, and timing of full opioid agonist discontinuation. METHODS: This cross-sectional survey study sought to determine how buprenorphine low-dosing is approached by medical institutions across the United States. The primary end point was characterization of inpatient buprenorphine low-dosing regimens. Situations and types of patients in which low-dosing is used and obstacles to institutional protocol development were also collected. An online survey was disseminated through professional pharmacy organizations and personal contacts. Responses were collected over 4 weeks. RESULTS: Twenty-three unique protocols were collected from 25 institutions. Most protocols used buccal (8 protocols) or transdermal (8 protocols) buprenorphine as first doses before transitioning to sublingual buprenorphine. The most common starting doses were buprenorphine 20 µg/h transdermal, 150 µg buccal, and 0.5 mg sublingual. Patients unable to tolerate conventional buprenorphine induction or those who potentially used fentanyl nonmedically were most likely to be prescribed low-dosing. The most common obstacle to developing an internal low-dosing protocol was lack of existing consensus guidelines. CONCLUSIONS: Similar to published regimens, internal protocols are variable. Buccal first doses may be used more commonly in practice based on survey results, while transdermal first doses are more commonly reported in publications. More research is needed to determine whether differences in starting formulations impact safety and efficacy of buprenorphine low-dosing in the inpatient setting.

Acute Pain Management Pearls: A Focused Review for the Hospital Clinician.

Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.