Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands.

BACKGROUND: Emergency physicians have been successful in implementing procedural sedation and analgesia (PSA) to treat emergency department (ED) patients who need to undergo painful procedures. However, 25% of the EDs in the Netherlands are not staffed by emergency physicians. The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians. METHODS: We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands. Data were gathered using a standardized questionnaire. RESULTS: The response rate was 34.3% (148/432). Of the respondents, 84/148 (56.8%) provided adult PSA and 30/148 (20.3%) provided paediatric PSA. Main reasons for not providing PSA were insufficient numbers of trained staff to support PSA in the ED and insufficient training and exposure. The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients. CONCLUSION: The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both qualified in PSA and available in the ED.

Clinical validation of dried blood spot sampling in therapeutic drug monitoring of ciclosporin A in allogeneic stem cell transplant recipients: direct comparison between capillary and venous sampling.

BACKGROUND: The immunosuppressive drug ciclosporin A has a narrow therapeutic window and a large inter- and intraindividual pharmacokinetic variability. Therapeutic drug monitoring of ciclosporin is usually performed in ethylenediaminetetraacetic acid blood, obtained by venous sampling. Dried blood spot sampling (DBS) could be a useful alternative sampling method, which also easily allows multiple sampling, for example, for obtaining area under the curve. With DBS, capillary blood is obtained from a finger prick with an automatic lancet by the patients themselves, and the drop of blood is applied to sampling paper. This may limit the number and duration of hospital visits for these patients. METHODS: We describe a validation study in which venous and finger prick blood samples were collected at the same time. Venous sampling was performed by venipuncture, and the ethylenediaminetetraacetic acid blood samples were collected and stored at 4°C until analysis. Finger prick blood samples were collected using an automatic lancing device. The volume of the blood drops of patients was approximately 30 µL, and blood spots of about 10-mm diameter were produced. Paper disks with a diameter of 8 mm were punched out with an electromagnetic-driven hole puncher. DBS was compared with the routine assay in venous blood. The study population consisted of adult patients (18 years or older) who were treated with ciclosporin A and routinely monitored for adequate blood concentrations. RESULTS: Thirty-eight duplicate dried blood spots and venous samples were studied. Using weighted Deming regression, the slope was 1.01 with a standard error of 0.03 associated with an intercept of -9.0 (standard error = 5.9). These results indicate that there is no significant difference between the 2 sampling methods. For the medical decision level of 300 mcg/L, the bias was -4.7 mcg/L with a 95% confidence interval of -19.2 to 9.8 mcg/L. The Altman-Bland plot showed no difference between the 2 sampling methods. CONCLUSIONS: Our results demonstrate that DBS is a valid alternative for conventional venous sampling in allogeneic stem cell transplant recipients.