Naloxegol versus Methylnaltrexone for Opioid-Induced Constipation in Critically Ill Patients.

BACKGROUND: Constipation impacts 58% to 83% of critically ill patients and is associated with increased time on mechanical ventilation, delirium, and increased length of stay (LOS) in the intensive care unit (ICU). OBJECTIVE: The purpose of this study was to evaluate the efficacy of enteral naloxegol (NGL) versus subcutaneous methylnaltrexone (MNTX) for the management of opioid-induced constipation (OIC) in critically ill patients. METHODS: A retrospective analysis was conducted on adult patients admitted to the ICU who received a parenteral opioid infusion for at least 4 hours and experienced no bowel movement (BM) within the 48-hour period preceding the administration of NGL or MNTX. The primary outcome was time to first BM from the start of NGL or MNTX therapy. Secondary outcomes included number of BMs 72 hours following NGL or MNTX administration, ICU LOS, and cost-effectiveness. RESULTS: After exclusion criteria were applied, 110 and 51 patients were included in the NGL and MNTX groups, respectively. With a 10% noninferiority margin, NGL was noninferior to MNTX (Wald statistic = 1.67; P = 0.047). Median time to first BM was 23.7 hours for NGL and 18.3 hours for MNTX patients. Median LOS was 14 days (NGL) and 12 days (MNTX), and the average number of BMs in 72 hours was 3.9 for NGL and 3.8 for MNTX. Using wholesale acquisition cost (WAC), the cost per BM for NGL and MNTX was $21.74 and $170.00, respectively. CONCLUSION AND RELEVANCE: This study determined that NGL and MNTX had similar time to BM. NGL appears to be a safe and effective alternative with cost-saving potential in treating OIC in critically ill patients.

Relationships are the key to a successful publicly funded homebirth program, a qualitative study.

BACKGROUND: In Australia, publicly-funded homebirth is a relatively new option for women and their families. Two years after the inception of two publicly funded homebirth services in Victoria in 2009, a study found that midwives' experiences were more positive than doctors. There is no recent evidence on the perspectives of midwives and doctors of publicly-funded homebirth programs. AIM: To explore the experiences of midwives and doctors participating in or supporting one publicly-funded homebirth program in Australia. METHODS: An interpretive descriptive approach was used following individual in-depth interviews via 'Zoom'. Participants included midwives and doctors who provide or support the homebirth service at a large metropolitan health service in Melbourne's western suburbs. Data were thematically analysed. FINDINGS: Interviews were conducted with 16 homebirth midwives, six hospital-based midwives, and nine doctors. One central theme and three sub-themes demonstrate that effective relationships are critical to a successful publicly-funded homebirth program. Collaboration, teamwork, and mutual respect across professions were reported to be integral to success. The midwife-woman relationship was highly valued and especially important to provide continuity during transfers to the hospital where this occurred. DISCUSSION: Effective relationships underpin collaborative practice and are critical for safe healthcare. Shared common learning opportunities such as simulation training sessions and multi-professional forums to discuss cases were perceived to assist the development of these relationships. CONCLUSION: Effective relationships within and between midwives and doctors are key to collaborative practice, which underpins a successful publicly-funded homebirth service. Health services can support this by maintaining a respectful and supportive culture amongst staff.

Ten years of a publicly funded homebirth service in Victoria: Maternal and neonatal outcomes.

BACKGROUND: Rates of homebirth in Australia remain low, at less than 0.3% of all births. AIMS: To report maternal and neonatal outcomes of ten years of a publicly funded homebirth service, 2009-2019. METHOD: Retrospective analysis of clinical outcome data including neonatal outcomes of women who requested a homebirth at a large metropolitan health service in Victoria, Australia. The primary outcomes included: maternal outcomes (mortality, transfer to hospital, place and mode of birth, perineal status, type of third stage of labour, postpartum haemorrhage), and neonatal outcomes (mortality, Apgar score at five minutes, birthweight, breastfeeding initiation, significant morbidity, transfer to hospital). RESULTS: Referrals for 827 women were reviewed; 633 remained eligible at 36 weeks gestation, and 473 (57%) birthed at home. Compared to women who did not, women who had a homebirth were significantly more likely to be multiparous, have a normal vaginal birth and an intact perineum, less likely to require suturing and less likely to have blood loss of more than 500 mL. Compared to infants not born at home, infants born at home were significantly less likely to require resuscitation, more likely to be of normal birthweight and exclusively receive breastmilk on discharge. There were no maternal deaths and one neonatal death of a baby born at home before the arrival of a midwife. CONCLUSIONS: The outcomes for women accepted into the publicly funded homebirth program suggest appropriate triaging and case selection. A publicly funded homebirth program, with appropriate governance and clinical guidelines, appears to be a safe option for women experiencing low-risk pregnancies.