Revue de Presse

Annals of Emergency Medicine..

Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department

Herbert C. Duber, MD, MPH, et al.

 

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing—specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment—interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

 

Burden of Hyperkalemia and Treatment Patterns in the Emergency Department Setting: Results from the REVEAL-ED Study

W.F. Peacock, J. Miller, D. Char, C.L. Clark, A.J. Singer, Z. Rafique, H. Rasmussen, S. Turner, M. Kosiborod

Baylor College of Medicine, Houston, TX. Henry Ford Hospital, Detroit, MI Washington University, St. Louis, MO. Beaumont Hospital-Royal Oak, Royal Oak, MI Stony Brook University Hospital, Stony Brook, NY

Objectives

Although hyperkalemia (HK) is frequently encountered in the emergency department (ED) and is potentially life-threatening, standard of care (SOC) for HK treatment is poorly described. The key objectives of the REVEAL-ED study are to define the burden of HK in the ED, describe variability of treatment patterns, and characterize the effectiveness and safety of ED SOC therapies.

Jump to SectionStudy ObjectivesMethodsResultsConclusion

Methods

REVEAL-ED is a multicenter, prospective, observational study evaluating the management of ED patients with HK. ED patients ≥18 years of age with a serum potassium (K+) ≥5.5 mEq/L (limit of 50 patients with a K+ ≥5.5 to <6.0 mEq/L) were eligible for study participation. Target enrollment was approximately 200 patients. After signing and informed consent, patients received SOC treatment at the discretion of the clinical team caring for the patient. Serum K+, blinded to the treating team, was measured at 0.5, 1, 2, 4, 8, 12, and 24 hours post-treatment or until discharge, whichever was sooner. The primary endpoint was the absolute change in K+ over 4 hours starting at initial HK treatment.

Jump to SectionStudy ObjectivesMethodsResultsConclusion

Results

Overall, 203 patients with HK were enrolled at 14 U.S. sites from October 25, 2015 to March 30, 2016. Mean (SD) age was XX (XX) years, XX% were male, XX% White, XX% African American, and XX% Hispanic. The most common presenting symptoms included XX (XX%), XX (XX%), and XX (XX%). The most common possible causes of HK were XX (XX%), XX (XX%), and XX (XX%). XX (XX%) of patients received no treatment; XX (XX%) with a baseline K+ ≥5.5 mEq/L but <6.0 mEq/L received no treatment. HK treatment was initiated at a median (IQR) of XX hours (XX, XX) after ED admission. Mean (IQR) K+ decreased from XX mEq/L (XX, XX) at baseline to XX mEq/L (XX, XX) 4 hours after treatment. The most common initial treatments included: insulin/glucose XX (XX%), albuterol XX (XX%), bicarbonate XX (XX%), calcium XX (XX%), sodium polystyrene sulfonate XX (XX%), intravenous diuretics XX (XX%), and hemodialysis XX (XX%). Patients with K+ ≥6.0 mEq/L were more likely to have ECG changes, receive intravenous calcium, and be treated with dialysis, than those with K+ <6.0 mEq/L (XX (XX%) vs XX (XX%), p=XX; XX (XX%) vs XX (XX%), p=XX; and XX (XX%) vs XX (XX%), p=XX, respectively). XX (XX%) of patients received multiple therapies. Recordable outcomes were reported in XX (XX%) of patients; the most commonly reported outcomes were XX (XX%), XX (XX%) and XX (XX%). Cardiac arrest, endotracheal intubation, or defibrillation occurred in XX (XX%), XX (XX%), and XX (XX%), respectively. Of the cohort with a K+ ≥5.5 to <6.0, ≥6-6.5, >6.5-7.0 and >7.0, XX (XX%), XX (XX%), XX (XX%), XX (XX%), respectively, experienced a cardiac event. The rate of those with a K+ ≥5.5 to <6.0, ≥6-6.5, >6.5-7.0 and >7.0 who had a cardiac event, and who had HK-related ECG changes (peaked T waves or prolonged QRS), was XX (XX%), XX (XX%), XX (XX%), XX (XX%). XX (XX%) patients were hospitalized, XX (XX%) to the ICU. Mean (IQR) ED and hospital length of stay was XX hours (XX, XX) and XX days (XX, XX), respectively. Overall, XX (XX%) died in-hospital.

Jump to SectionStudy ObjectivesMethodsResultsConclusion

Conclusion

REVEAL-ED found that hyperkalemia is common, adverse events are not rare, and that current practice patterns for its treatment vary considerably across U.S. sites.

 

 

 

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