Association of delirium screening on hospitalized adults and postacute care utilization: A retrospective cohort study.

BACKGROUND: Patients with delirium have increased hospital length of stay (LOS), morbidity and mortality. Impact of delirium on postacute care (PAC) utilization is not fully characterized. Impact of screening for delirium on general medicine patients is unknown. The objective of this study was to assess impact of screening for delirium on inpatient PAC utilization. METHODS: This was a single center, retrospective cohort study at an academic tertiary care center in Charleston, SC. Patients were selected from adults hospitalized from home and discharged alive between June 2014 and June 2018. The brief confusion assessment method (bCAM) screening was conducted and documented by nursing on admission and every shift thereafter. Outcome measure was the proportion of patients discharged to facility. RESULTS: Of 93,388 non-ICU adult admission between June 2014 and June 2018, 4.4% of those not screened for delirium were discharged to facility versus 15.0% in those screened and 41.4% in those screening positive. Multivariable regression analysis showed that patients screened for delirium were 2.3 times more likely to discharge to facility (95% CI (2.145, 2.429)) while those with a positive bCAM were 3.3 times more likely than those with a negative bCAM to discharge to facility (95% CI (2.949, 3.712)). CONCLUSIONS: After adjusting for demographics, medication orders and comorbidities there was an association between screening for delirium, positive delirium screen and discharge to facility. An appreciation of where and why patients are discharged is imperative to optimize both patient care and cost utilization.

Iatrogenic Oral Ketamine Overdose in Palliative Care.

Background: Optimal pain management in the palliative care setting often requires multiple pharmacological interventions including novel and off-label therapies. Ketamine is an anesthetic agent with increasing evidence supporting its use for pain. Through N-methyl-d-aspartate antagonism and activity at opioid receptors, it is an adjuvant to traditional analgesics with the benefit of being opioid sparing. Ketamine has a wide safety profile with limited reports of overdose. Little is published on supratherpeutic dosing in the pain setting. Objective: We report a case of a 41-year-old male with refractory nociceptive and neuropathic cancer-related pain. Conventional therapies were ineffective. Ketamine was initiated to reduce opioid burden and attenuate pain with good response. The patient received an iatrogenic overdose (10 times ordered dose) of the drug. Several self-limited physiologic and psychologic reactions were observed during subsequent monitoring. Design: This is a study and analysis of a patient with refractory nociceptive and neuropathic pain syndrome treated with ketamine who sustained an iatrogenic overdose of ketamine. Conclusions: Ketamine's use to treat pain is increasing along with its evidence of efficacy. Despite ketamine's wide safety profile, the medication is not without risk, especially in palliative care wherein patients are on multiple drugs with potentially severe interactions. Careful examination of the risks of overdose, especially of the various formulations of the drug, is needed.

Nebulized Fentanyl for Dyspnea: A Retrospective Chart Review.

Nebulized fentanyl is well established for analgesia but its use for dyspnea requires further investigation. The aim of our study was to determine the effectiveness of nebulized fentanyl in treating patients with dyspnea and to determine if there were harmful side effects described by patients or their providers. We used a convenience sample of patients from July 1 2014 to July 1 2018 and performed a retrospective chart review. We found that 360 doses of nebulized fentanyl were given to 73 patients during that time period. Of the 73 patients evaluated, 32 patients (43.8%) were female and forty-one were male (56.1%). The median age was 67 and the median length of stay was 9 days. There were no documented findings of bronchospasm, hypotension, or allergic reaction in any of the medical records reviewed. Patients treated with nebulized fentanyl for dyspnea showed a mean decreased respiratory rate of 4.3 breaths/min and a mean increased oxygen saturation of 2.3%. Also, 71% of patients with documented responses experienced an improvement in their dyspnea. Our preliminary data suggest that nebulized fentanyl has limited side effects and may have a role in the treatment of dyspnea. Further research is necessary to determine its efficacy.

Nebulized Vasopressin for the Control of Hematemesis and Hemoptysis in a Child With Recurrent, Refractory Stage III Burkitt Lymphoma.

BACKGROUND: Bleeding occurs with some regularity at the end of life. Patients often endure fatigue, weakness, pain, dyspnea and anxiety. These symptoms are magnified in visually apparent bleeds. Management can be particularly challenging as we attempt to balance therapies with goals of care. Children are at risk for such complications and symptoms; providers must ensure comfort for both the patient and family. CASE DESCRIPTION: A 7-year-old male with recurrent, refractory Burkitt lymphoma was frequently hospitalized for palliative chemotherapy and disease complications. On his final admission, he experienced gross hemoptysis and hematemesis: he was short of breath, fatigued and anxious due to his blood loss. His and his family's angst were heightened by "seeing" his bleed. Potential, especially invasive, treatments were limited by our goals to promote comfort, limit interventions, maintain alertness, poor intravenous access and a small bowel obstruction. Nebulized vasopressin, 10 units in 4ml of normal saline given over 10 minutes provided JC with needed relief. His bleeding remitted and he tolerated its administration. CONCLUSION: There are many treatments for hemorrhage; however, given the challenges of goals of care, administration, side-effects and tolerability, further investigation into nebulized vasopressin as a potential therapy for hemoptysis and hematemesis at the end-of-life is warranted.

Fosaprepitant for the Management of Refractory Pain in a Patient with Cancer-Related Dermatomyositis.

OBJECTIVE: Optimal pain management often requires multiple pharmacological interventions with the goal of disrupting the pain-signaling pathway and targeting the underlying pathophysiology. Off label use of nonpain medications may have a role in treating refractory pain syndromes. BACKGROUND: We report a case of a 60-year-old female with refractory nociceptive and neuropathic pain. Conventional therapies were either ineffective or fraught with side effects. Given the underlying inflammatory nature of her pain syndrome, and the role of substance P (SP) in pain transmission and modulation, we decided to use fosaprepitant, an SP and neurokinin-1 (NK1) receptor antagonist. The patient tolerated fosaprepitant and experienced acceptable analgesia without compromising her mental functioning. DESIGN: Study and analysis of a case of a patient with refractory mixed, nociceptive, and neuropathic pain syndrome treated with fosaprepitant. RESULTS AND DISCUSSION: Fosaprepitant is a potentially novel adjuvant therapy for the treatment of refractory inflammatory pain syndromes in palliative care.

Management of refractory status epilepticus in an actively dying patient.

No consensus guidelines exist for the treatment of refractory myoclonic status epilepticus or refractory myoclonus in the palliative care setting. Evidence-based guidelines for the general medical population are often neither practical nor applicable at the end of life. Many challenges, including medication availability, route of administration, monitoring, and work-up are all unique to the palliative care setting. Two patients with refractory myoclonus versus refractory myoclonic status epilepticus are described here, illustrating the challenges involved in treatment as well the need for further research for therapy in the palliative care setting.