The impact of mental state altering medications on preventable falls after total hip or total knee arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Joint replacement surgery of the lower extremities are common procedures in elderly persons who are at increased risk of postoperative falls. The use of mental state altering medications, such as opioids, antidepressants or benzodiazepines, can further contribute to impaired balance and risk of falls. The objective of the current systematic review was to evaluate the risk of the use of mental state altering medications on postoperative falls in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: A comprehensive search of Medline, Embase and Cochrane Controlled Trials Register was conducted from 1 October 1975 to 1 September 2021. The search was repeated in may 2023 and conducted from 1 October 1975 to 1 June 2023. Clinical trials that evaluated the risk of medication on postoperative THA and TKA falls were eligible for inclusion. Articles were evaluated independently by two researchers for risk of bias using the Newcastle-Ottawa Scale. A meta-analysis was performed to determine the potential effect of postoperative use of mental state altering medications on the risk of falls. Lastly, a qualitative synthesis was conducted for preoperative mental state altering medications use. RESULTS: Seven cohort studies were included, of which five studies focussed on the postoperative use of mental state altering medications and two investigated the preoperative use. Meta-analysis was performed for the postoperative mental state altering medications use. The postoperative use of mental state altering medications was associated with fall incidents (OR: 1.81; 95% CI: 1.04; 3.17) (p < 0.01) after THA and TKA. The preoperative use of opioids > 6 months was associated with a higher risk of fall incidents, whereas a preoperative opioid prescription up to 3 months before a major arthroplasty had a similar risk as opioid-naïve patients. CONCLUSIONS: The postoperative use of mental state altering medications increases the risk of postoperative falls after THA and TKA. Prior to surgery, orthopaedic surgeons and anaesthesiologists should be aware of the associated risks in order to prevent postoperative falls and associated injuries.

Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: A multicentre retrospective observational study.

AIMS: Knowledge about adverse drug events caused by drug-drug interactions (DDI-ADEs) is limited. We aimed to provide detailed insights about DDI-ADEs related to three frequent, high-risk potential DDIs (pDDIs) in the critical care setting: pDDIs with international normalized ratio increase (INR+ ) potential, pDDIs with acute kidney injury (AKI) potential, and pDDIs with QTc prolongation potential. METHODS: We extracted routinely collected retrospective data from electronic health records of intensive care units (ICUs) patients (≥18 years), admitted to ten hospitals in the Netherlands between January 2010 and September 2019. We used computerized triggers (e-triggers) to preselect patients with potential DDI-ADEs. Between September 2020 and October 2021, clinical experts conducted a retrospective manual patient chart review on a subset of preselected patients, and assessed causality, severity, preventability, and contribution to ICU length of stay of DDI-ADEs using internationally prevailing standards. RESULTS: In total 85 422 patients with ≥1 pDDI were included. Of these patients, 32 820 (38.4%) have been exposed to one of the three pDDIs. In the exposed group, 1141 (3.5%) patients were preselected using e-triggers. Of 237 patients (21%) assessed, 155 (65.4%) experienced an actual DDI-ADE; 52.9% had severity level of serious or higher, 75.5% were preventable, and 19.3% contributed to a longer ICU length of stay. The positive predictive value was the highest for DDI-INR+ e-trigger (0.76), followed by DDI-AKI e-trigger (0.57). CONCLUSION: The highly preventable nature and severity of DDI-ADEs, calls for action to optimize ICU patient safety. Use of e-triggers proved to be a promising preselection strategy.

ED90 of spinal 2-chloroprocaine 1% in ambulatory knee arthroscopy up to 45 min: a randomized biased-coin- up-and-down sequential allocation trial.

BACKGROUND: A short acting spinal anesthetic facilitates smooth flow since quick recovery of motor function will facilitate unassisted ambulation. The aim of this study was to estimate the effective dose (ED90) of intrathecal 2-chloroprocaine 1% in outpatient knee arthroscopy. METHODS: Two cohorts were included in two different hospitals. In cohort I, a randomized biased-coin up-and-down design with 40 patients was used to find the ED90. Four dose-levels of plain 2-chloroprocaine 1% were used: 25, 30, 35 and 40 mg. The identified primary outcome, the ED90, was validated in 50 patients in cohort II with an open label design. Secondary outcomes included time to complete recovery from motor and sensory block with spinal injection as time zero, peak sensory block level, urine retention and time until hospital discharge. RESULTS: Forty patients were included in the final analysis in cohort I. The ED90 was estimated at 27.8 mg, successful spinal anesthesia was obtained in 38 patients (95%). Fifty patients were included in the final analysis in cohort II, 49 patients had successful anesthesia with a fixed round dose of 28 mg. In this Cohort, peak sensory block was T10/T11 (range: (L4-T4)). The median time to full recovery of the motor block was 60 min (45-60) and 90 min (75-105) for the sensory block. The mean time to hospital discharge was 2.9 hours (0.7). CONCLUSION: The ED90 of 2-chloroprocaine 1% in knee arthroscopy was estimated to be 27.8 mg. In an external population, the ED90 resulted in successful anesthesia in 98% of the patients (95% CI 89% to 100%). TRIAL REGISTRATION NUMBER: Netherlands Trial Registry (NL6769).

The Effect of Medication Reconciliation via a Patient Portal on Medication Discrepancies: A Randomized Noninferiority Study.

BACKGROUND: Medication reconciliation has become standard care to prevent medication transfer errors. However, this process is time-consuming but could be more efficient when patients are engaged in medication reconciliation via a patient portal. OBJECTIVES: To explore whether medication reconciliation by the patient via a patient portal is noninferior to medication reconciliation by a pharmacy technician. DESIGN (INCLUDING INTERVENTION): Open randomized controlled noninferiority trial. Patients were randomized between medication reconciliation via a patient portal (intervention) or medication reconciliation by a pharmacy technician at the preoperative screening (usual care). SETTING AND PARTICIPANTS: Patients scheduled for elective surgery using at least 1 chronic medication were included. MEASURES: The primary endpoint was the number of medication discrepancies compared to the electronic nationwide medication record system (NMRS). For the secondary endpoint, time investment of the pharmacy technician for the medication reconciliation interview and patient satisfaction were studied. Noninferiority was analyzed with an independent t test, and the margin was set at 20%. RESULTS: A total of 499 patients were included. The patient portal group contained 241 patients; the usual care group contained 258 patients. The number of medication discrepancies was 2.6 ± 2.5 in the patient portal group and 2.8 ± 2.7 in the usual care group. This was not statistically different and within the predefined noninferiority margin. Patients were satisfied with the use of the patient portal tool. Also, the use of the portal can save on average 6.8 minutes per patient compared with usual care. CONCLUSIONS AND IMPLICATIONS: Medication reconciliation using a patient portal is noninferior to medication reconciliation by a pharmacy technician with respect to medication discrepancies, and saves time in the medication reconciliation process. Future studies should focus on identifying patient characteristics for successful implementation of patient portal medication reconciliation.

Chloroprocaine versus prilocaine for spinal anesthesia in ambulatory knee arthroscopy: a double-blind randomized trial.

BACKGROUND: In ambulatory lower limb surgery, spinal anesthesia with rapid onset and a short duration of block is preferable. We hypothesized that the use of 2-chloroprocaine would be associated with a faster motor block recovery compared with prilocaine in knee arthroscopy. A difference of 15 min was considered clinically relevant. METHODS: 150 patients were randomly allocated to receive intrathecally either 40 mg of 2-chloroprocaine or 40 mg of prilocaine. The primary outcome was the time to complete recovery from motor blockade. Secondary outcomes included time to full regression of sensory block, peak sensory block level, urine retention needing catheterization, time until hospital discharge, incidence of transient neurologic symptoms and patient satisfaction. RESULTS: Time to complete recovery from motor blockade was 15 min shorter for 2-chloroprocaine (median: 60 min; IQR: 60-82.5) than for prilocaine (median: 75 min; IQR: 60-90; p=0.004). 2-Chloroprocaine also resulted in faster full regression of sensory block (median: 120 min; IQR: 90-135 compared with median: 165 min; IQR: 135-190, p<0.001) and faster time to hospital discharge (mean difference: 57 min; 95% CI 38 to 77, p<0.001). Peak sensory block was higher in the 2-chloroprocaine group (median: T9; IQR: T6-T12 compared with median: T10; IQR: T8-T12, p<0.008). Patient satisfaction and urine retention needing catheterization were equal in both groups. CONCLUSIONS: In knee arthroscopy, spinal anesthesia with 2-chloroprocaine results in a faster recovery of motor and sensory block, leading to quicker hospital discharge compared with prilocaine. TRIAL REGISTRATION NUMBER: NTR6796.

Prospective Validation of a Risk Prediction Model to Identify High-Risk Patients for Medication Errors at Hospital Admission.

BACKGROUND: Pharmacy-led medication reconciliation in elective surgery patients is often performed at the preoperative screening (POS). Because of the time lag between POS and admission, changes in medication may lead to medication errors at admission (MEAs). In a previous study, a risk prediction model for MEA was developed. OBJECTIVE: To validate this risk prediction model to identify patients at risk for MEAs in a university hospital setting. METHODS: The risk prediction model was derived from a cohort of a Dutch general hospital and validated within a comparable cohort from a Dutch University Medical Centre. MEAs were assessed by comparing the POS medication list with the reconciled medication list at hospital admission. This was considered the gold standard. For every patient, a risk score using the risk prediction model was calculated and compared with the gold standard. The risk prediction model was assessed with receiver operating characteristic (ROC) analysis. RESULTS: Of 368 included patients, 167 (45.4%) had at least 1 MEA. ROC analysis revealed significant differences in the area under the curve of 0.535 ( P = 0.26; validation cohort) versus 0.752 ( P < 0.0001; derivation cohort). The sensitivity in this validating cohort was 66%, with a specificity of 40%. Conclusion and Relevance: The risk prediction model developed in a general hospital population is not suitable to identify patients at risk for MEA in a university hospital population. However, number of medications is a common risk factor in both patient populations and should, thus, form the basis of an adapted risk prediction model.

Risk factors for medication errors at admission in preoperatively screened patients.

BACKGROUND: Preoperative screening (POS) may help to reduce medication errors at admission (MEA). However, due to the time window between POS and hospital admission, unintentional medication discrepancies may still occur and thus a second medication reconciliation at hospital admission can be necessary. Insight into potential risk factors associated with these discrepancies would be helpful to focus the second medication reconciliation on high-risk patients. OBJECTIVE: To determine the proportion of POS patients with MEA and to identify risk factors for MEA. METHODS: This single-centre observational cross-sectional study included elective surgical patients between October 26 and December 18, 2015. Main exclusion criteria were age younger than 18 years and daycare admissions. Medication reconciliation took place at the POS and was repeated within 30 hours of admission. Unintended discrepancies between the first and second medication reconciliation were defined as MEA. The primary outcome was the proportion of patients with one or more MEA. The association of this outcome with potential risk factors was analysed using multivariate logistic regression analysis. RESULTS: Of the 183 included patients, 60 (32.8%) patients had at least one MEA. In a multivariate model, the number of medications at POS (adjusted odds ratio 1.16 [95% confidence interval, 1.04-1.30]) and respiratory disease (4.25 [1.52-11.83]) were significantly associated with MEA. CONCLUSION: In one-third of preoperatively screened patients, an MEA was found. The number of medications and respiratory comorbidities are risk factors for MEA in preoperatively screened patients.