Volume 5, No. 9, October 2007
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Outcomes?
Background: To compare the postpartum pelvic floor function of women with sutured second-degree perineal lacerations, unsutured second-degree perineal lacerations, and intact perineums.
Methods: A prospective cohort of nurse-midwifery patients consented to mapping of genital trauma at birth and an assessment of postpartum pelvic floor outcomes. Women completed validated questionnaires for perineal pain and urinary and anal incontinence at 12 weeks postpartum and underwent physical examination to assess pelvic floor strength and anatomy at 6 weeks postpartum.
Results: One hundred seventy-two of 212 (80%) eligible women provided follow-up
assessment data at 6 or 12 weeks postpartum. Women with an intact perineum (n
= 89) used fewer analgesics (P < .002) and had lower pain scores at the time
of hospital discharge than women with second-degree lacerations (sutured, n =
46; unsutured, n = 37; intact, n = 89) (P 
.02).
The sutured group was more likely to use analgesics (52%) than the unsutured
(35%) or intact (23%) groups at time of hospital discharge (P < .002), although
pain scores were not different between sutured and unsutured groups. Postpartum
reports of urinary or anal incontinence, sexual inactivity, or sexual function
scores did not vary between groups. Weak pelvic floor exercise strength was more
common among the women with second-degree lacerations compared with women with
an intact perineum (53% vs. 28%; P = .03) but did not differ between sutured
(58%) and unsutured (47%) groups (P = not significant). Likewise, perineal body
or genital hiatus measurements did not vary between groups (P = not significant).
Conclusions: Women with sutured lacerations report increased analgesic use at the time of hospital discharge compared with women with intact perineums or unsutured lacerations. At 12 weeks postpartum, no differences were noted between groups regarding complaints of urinary or anal incontinence, sexual inactivity, or sexual function.
Leeman LM et al Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Functional Outcomes? The Journal of the American Board of Family Medicine 20 (5): 451-457 (2007) http://www.jabfm.org/cgi/content/abstract/20/5/451?etoc
Treating Gestational Diabetes May Reduce Childhood Obesity
The risk of childhood obesity in offspring of mothers with GDM by NDDG criteria (treated) was attenuated compared with the risks for the groups with lesser degrees of hyperglycemia (untreated).
CONCLUSIONS: Our results in a multiethnic U.S. population suggest that increasing hyperglycemia in pregnancy is associated with an increased risk of childhood obesity. More research is needed to determine whether treatment of GDM may be a modifiable risk factor for childhood obesity.
Hillier TA, et al Childhood obesity and metabolic imprinting: the ongoing effects of maternal hyperglycemia. Diabetes Care. 2007 Sep;30(9):2287-92.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17519427
Increased still birth among obese mothers
We found a 40% increased likelihood for stillbirth among obese compared with nonobese mothers. The authors found that
* About 9.5% of the women had a BMI greater than 30 (12.8% among blacks and 8.9% among whites).
* The likelihood of stillbirth was 40% greater for obese women, compared with normal-weight women. The likelihood of stillbirth for extremely obese women was more than 90% higher than the likelihood for normal-weight women.
* Of the total number of stillbirths among obese women (N=1,149), 320 or 28% (stillbirth rate 11.4 per 1,000) occurred among black obese women, while 829 or 72% (stillbirth rate 7.8 per 1,000) occurred among white obese women.
* In both racial groups, the risk for stillbirth increased progressively with increase in BMI in a dose-effect pattern. However, black-white disparity in obesity-related stillbirth remained persistent to the disadvantage of blacks, regardless of the obesity subtype.
It is recommended that future research examines the linkage between racial background and lethality of rising BMI on the fetus. Sstrategies to reduce black-white disparities in birth outcomes should consider targeting obese, black women.
Salihu HM, Dunlop A-L, Hedayatzadeh M, et al. 2007. Extreme obesity and risk of stillbirth among black and white gravidas. Obstetrics and Gynecology 110(3):552-557.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766599
Neonatal sepsis increases linearly with membrane rupture up to 36 hours
METHODS: A registry study included 113,568 singleton infants born at term after a trial of labor (elective cesarean deliveries excluded). The incidence of a diagnosis of sepsis during the neonatal period was correlated to the interval between membrane rupture and delivery. Multiple logistic regression analysis was done with adjustments for maternal age, parity, infant gender, gestational age, birth weight, and duration of labor. Receiver operating characteristics curves were created to estimate the optimal cutoff of membrane rupture time associated with an increased risk of neonatal septicemia.
CONCLUSION: The risk of neonatal sepsis increases with duration of membrane rupture in a linear fashion during the first 36 hours, independently of labor duration. LEVEL OF EVIDENCE: II.
Herbst A, Källén K.Time between membrane rupture and delivery and septicemia in term neonates. Obstet Gynecol. 2007 Sep;110(3):612-8
Extraabdominal uterine repair at cesarean: Increased patient discomfort, nausea, vomiting
CONCLUSION: Exteriorization of the uterus for repair is associated with an increased incidence of nausea and vomiting and tachycardia during cesarean delivery under spinal anesthesia. Uterine repair should be done in situ where possible. LEVEL OF EVIDENCE: I.
Siddiqui, M et al Complications of Exteriorized Compared With In Situ Uterine Repair at Cesarean Delivery Under Spinal Anesthesia Obstet Gynecol. 2007 Sep;110(3):570-5.
Sonographic cervical length was not an effective predictor of successful labor induction
RESULTS: Cervical length predicted successful induction (likelihood ratio of positive test, 1.66; 95% confidence interval [CI], 1.20-2.31) and failed induction (likelihood ratio of negative test, 0.51; 95% CI, 0.39-0.67). Cervical length did not predict any specific outcome (eg, mode of delivery). The assessment of cervical wedging proved to be a useful diagnostic test, with a likelihood ratio of a positive test result of 2.64 and a likelihood ratio of a negative result of 0.64.
CONCLUSION: Sonographic cervical length was not an effective predictor of successful labor induction. Further evaluation of cervical wedging in the prediction of labor induction appears warranted.
Hatfield AS et al Sonographic cervical assessment to predict the success of labor induction: a systematic review with metaanalysis. Am J Obstet Gynecol. 2007; 197(2):186-92
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17689645
Daily intake of 100 mg of ascorbic acid played an important role in the reduction of UTIs
CONCLUSIONS: Daily intake of 100 mg of ascorbic acid played an important role in the reduction of urinary infections, improving the health level of the gestating women. We recommend additional vitamin C intake for pregnant women in populations which have a high incidence of bacteriuria and urinary infections.
Ochoa-Brust GJ et al Daily intake of 100 mg ascorbic acid as urinary tract infection prophylactic agent during pregnancy. Acta Obstet Gynecol Scand. 2007; 86(7):783-7
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17611821
Concurrent oxytocin with dinoprostone reduced the requirement for repeat dinoprostone
RESULTS: Concurrent oxytocin infusion with dinoprostone pessary did not significantly increase vaginal delivery rate within 24 hours (48.6 versus 35.9%; P = 0.07, relative risk [RR] 1.4 [95% CI 1.0-1.9]). It reduced the requirement for repeat dinoprostone (37.1 versus 61.2%; P = 0.001, RR 0.61 [95% CI 0.45-0.81]) and improved maternal satisfaction with the birth process (median score of 3 versus 5 on a 10-point visual analogue scale, P = 0.007). Caesarean rates were not different (41.9 versus 44.7%, P = 0.52). CONCLUSIONS: Labour induction with concurrent oxytocin infusion and vaginal dinoprostone could be considered for nulliparas with an unfavourable cervix. Larger studies are needed. Tan PC et al Concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction of nulliparas with an unfavourable cervix: a randomised placebo-controlled trial. BJOG. 2007; 114(7):824-32
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17506788
Little evidence of an association between depression during pregnancy and birth weight
There is conflicting evidence regarding the effect of depression during pregnancy on birth weight. We used data from the Avon Longitudinal Study of Parents and Children to investigate whether depressive symptoms during pregnancy in 10,967 women led to low birth weight at term in their offspring. Those with a high depressive symptom score during pregnancy were more likely to have babies of low birth weight (95% CI 1.16-2.40, P<0.01), but this attenuated after adjustment for confounders (OR=1.29,95% CI 0.87-1.91, P=0.210). Hence there is little evidence of an independent association between depressive symptoms during pregnancy and birth weight.
Evans J et al Depressive symptoms during pregnancy and low birth weight at term: longitudinal study. Br J Psychiatry. 2007; 191:84-5
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=ShowDetailView&TermToSearch=17602131
Gynecology
Cervical cancer differences disappear in rural women after controling for poverty and race
CONCLUSION: Rural women in the United States have higher cervical cancer incidence rates. Among older women (aged 45-80 years) in whom half of cervical cancers occur, geographic differences largely disappear after controlling for poverty and race. LEVEL OF EVIDENCE: III.
Benard VB, et al Cervical cancer incidence in the United States by area of residence, 1998 2001. Obstet Gynecol. 2007 Sep;110(3):681-6
Cochrane Update: Improvements in outcome with subtotal hysterectomy not confirmed
AUTHORS' CONCLUSIONS: This review has not confirmed the perception that subtotal hysterectomy offers improved outcomes for sexual, urinary, or bowel function when compared with total abdominal hysterectomy. Surgery is shorter and intraoperative blood loss and fever are reduced, but women are more likely to experience ongoing cyclical bleeding up to a year after surgery with subtotal hysterectomy compared with total hysterectomy.
Neilson JP. Total versus subtotal hysterectomy for benign gynaecological conditions Obstet Gynecol. 2007 Sep;110(3):705-6.
Cost effectiveness of home based population screening for Chlamydia trachomatis
CONCLUSIONS: Proactive register based screening for chlamydia is not cost effective if the uptake of screening and incidence of complications are based on contemporary empirical studies, which show lower rates than commonly assumed. These data are relevant to discussions about the cost effectiveness of the opportunistic model of chlamydia screening being introduced in England
Roberts TE et al Cost effectiveness of home based population screening for Chlamydia trachomatis in the UK: economic evaluation of chlamydia screening studies (ClaSS) project. BMJ. 2007; 335(7614):291
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17656504
Child Health
How to improve psychosocial problems at well child care visits?
This study demonstrates the feasibility and effectiveness of addressing multiple family psychosocial problems during WCC [well child care] visits for low-income children.
The authors found that
* The mean number of family psychosocial topics discussed at the WCC visit was significantly higher for parents in the intervention group vs.
the control group (2.9 vs. 1.8).
* Parents in the intervention group had fewer unmet desires to discuss family psychosocial topics, compared with parents in the control group
(0.46 vs. 1.41).
* Fifty-one percent of parents in the intervention group reported receiving at least one referral from their child's provider, compared with 11.6% in the control group. Parents in the intervention group had significantly higher odds of receiving referrals for graduate degree programs, job training, food resources, and smoking-cessation classes than parents in the control group.
* At 1 month, 20.0% of the parents in the intervention group reported contacting a referred community resource, compared with 2.2% in the control group.
* Twenty-two (91.6%) of the 24 residents in the intervention group completed the post-study questionnaire. Seventy-seven percent of the residents who completed the post-study questionnaire reported that the survey did not slow down the visit; 54.5% reported that the survey added less than 2 minutes to the visit.
We believe that the WE CARE intervention can serve as a model for addressing family psychosocial problems for medical homes that care for low-income children. Additional research will be needed to assess the long-term impact of family psychosocial screening interventions on parental outcomes and child health, behavioral, and developmental outcomes.
Garg A, Butz AM, Dworkin P, et al. 2007. Improving the management of family psychosocial problems at low-income children's well-child care
visits: The WE CARE project. Pediatrics 120(3):547-588. Abstract available at http://pediatrics.aappublications.org/cgi/content/abstract/120/3/547
Is Ibuprofen Appropriate for Pain Control in Children?
Conclusion: Ibuprofen provided superior pain relief compared with codeine and acetaminophen, especially in children with fracture-related pain, but only 52 percent of the children received adequate pain relief. Additional measures, such as ice or distraction, should be sought to help alleviate acute musculoskeletal pain. When used alone, ibuprofen is not an adequate analgesic in all children with musculoskeletal injuries.
Clark E, et al. A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics March 2007;119:460-7.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17332198
School based intervention to lower incidence of disordered weight control behavior
The present study adds novel empirical evidence in support of the viability of integrating obesity and eating disorders prevention initiatives, The authors found that
* After 2 school years, 3.6% of girls in control schools, compared with 1.2% of girls in intervention schools, reported new disordered weight-control behaviors.
* The odds of adopting a disordered weight-control behavior were reduced by two-thirds in girls in intervention schools compared with girls in control schools.
* In models that also controlled for grade, race and ethnicity, and overweight, the magnitude of the effect estimate associated with the intervention for girls remained stable, changing less than 10%, but the confidence interval widened to include the null value of 1.0.
* No protective effects of the intervention were observed for boys.
New research efforts will need to identify protective strategies for early adolescent boys also and to understand the mechanism of Planet Health and other strategies in school settings that integrate obesity and eating disorders prevention.
Austin SB, Kim J, Wiecha J, et al. 2007. School-based overweight preventive intervention lowers incidence of disordered weight-control behaviors in early adolescent girls. Archives of Pediatric and Adolescent Medicine 161(9):865-869.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17768286
Management of Type 2 Diabetes in Youth: An Update (also see Patient Education)
Although type 1 diabetes historically has been more common in patients eight to 19 years of age, type 2 diabetes is emerging as an important disease in this group. Type 2 diabetes accounts for 8 to 45 percent of new childhood diabetes. This article is an update from the National Diabetes Education Program on the management of type 2 diabetes in youth. High-risk youths older than 10 years have a body mass index greater than the 85th percentile for age and sex plus two additional risk factors (i.e., family history, high-risk ethnicity, acanthosis nigricans, polycystic ovary syndrome, hypertension, or dyslipidemia). Reducing overweight and impaired glucose tolerance with increased physical activity and healthier eating habits may help prevent or delay the development of type 2 diabetes in high-risk youths. The American Academy of Pediatrics does not recommend population-based screening of high-risk youths; however, physicians should closely monitor these patients because early diagnosis may be beneficial. The American Diabetes Association recommends screening high-risk youths every two years with a fasting plasma glucose test. Patients diagnosed with diabetes should receive self-management education, behavior interventions to promote healthy eating and physical activity, appropriate therapy for hyperglycemia (usually metformin and insulin), and treatment of comorbidities. Am Fam Physician 2007;76:658-64, 665-6 http://www.aafp.org/afp/20070901/658.html
Are babies born to short, primiparous, or thin mothers "normally" or "abnormally" small?
CONCLUSIONS: Slower fetal growth due to maternal short stature or low prepregnancy body mass index appears to be physiologic, whereas the slower growth of fetuses born to primiparous women is associated with higher risks of perinatal death.
Zhang X et al Are babies born to short, primiparous, or thin mothers "normally" or "abnormally" small? J Pediatr. 2007; 150(6):603-7, 607.e1-3
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17517243
Chronic Disease and Illness
Why Hasn't This Patient Been Screened for Colon Cancer?
Results : Reasons patients were not up to date fell into 2 major categories: (1) no discussion by physician (50%) and (2) patient refusal (43%). Reasons for no discussion included lack of opportunity, assessment that cost would be prohibitive, distraction by other life issues/health problems, physician forgetfulness, and expected patient refusal. Patients declined because of cost, lack of interest, autonomy, other life issues, fear of screening, and lack of symptoms. Patients who were up to date received (1) diagnostic testing (for previous colon pathology or symptoms; 56%) or (2) asymptomatic screening (44%). Physicians who were more adamant about screening had higher screening rates (P < .05; Wilcoxon rank sum). Physicians framed their recommendations differently ("I recommend" vs "They recommend"), with lower screening rates among physicians who used "they recommend" (P = .05; Wilcoxon rank sum).
Conclusions: Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2) patient refusal; and (3) the focus on diagnostic testing. Strategies to improve screening might include patient and physician education about the rationale for screening, universal coverage for health maintenance exams, and development of effective tracking and reminder systems. The words physicians choose to frame their recommendations are important and should be explored further.
Levy BT et alWhy Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study The Journal of the American Board of Family Medicine 20 (5): 458-468 (2007)
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17823463
Migraine With Aura Increases Risk for Ischemic Stroke
CONCLUSIONS: Probable migraine with visual aura (PMVA) was associated with an increased risk of stroke, particularly among women without other medical conditions associated with stroke. Behavioral risk factors, specifically smoking and oral contraceptive use, markedly increased the risk of PMVA, as did recent onset of PMVA.
MacClellan LR, et al Probable migraine with visual aura and risk of ischemic stroke: the stroke prevention in young women study Stroke. 2007 Sep;38(9):2438-45
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17690308
US Dietary Guidelines Effectively Limit Insulin Resistance in Women
CONCLUSIONS: Consumption of a diet consistent with the 2005 DGA may be an effective means to limit insulin resistance in women.
Fogli-Cawley JJ, et al The 2005 Dietary Guidelines for Americans and insulin resistance in the Framingham Offspring Cohort. Diabetes Care. 2007 Apr;30(4):817-22.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17259479
The Choice of a Metabolic Syndrome Generation: Soft Drink Consumption Associated With Increased Metabolic Risk
CONCLUSIONS: In middle-aged adults, soft drink consumption is associated with a higher prevalence and incidence of multiple metabolic risk factors.
Dhingra R, et al Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation. 2007 Jul 31;116(5):480-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17646581
ACIP Recommends the Use of Tdap in Adults
In 2005, a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap; Adacel) was approved in the United States for use in adults and adolescents. The Advisory Committee on Immunization Practices (ACIP) now recommends the routine use of Tdap among adults 19 to 64 years of age who have not already received a dose of Tdap. The ACIP recommendations are intended to decrease pertussis-related morbidity among adults, to maintain the standard of care for tetanus and diphtheria prevention, and to reduce transmission of pertussis to infants and in health care settings.
Routine Vaccination
Patients 19 to 64 years of age who received their most recent dose of tetanus and diphtheria toxoid (Td) at least 10 years earlier should be given a single dose of Tdap for active booster vaccination against tetanus, diphtheria, and pertussis. If less than 10 years has passed since the previous dose of Td was administered, a single dose of Tdap is appropriate to protect patients against pertussis. This is especially true in patients at increased risk of pertussis or its complications; the benefit of a single dose of Tdap at an interval of less than 10 years will likely outweigh the risk of adverse reactions to the vaccine. In addition, an interval as short as two years between Td and Tdap is considered safe.
In patients who have not previously received Tdap and who need a vaccine containing tetanus toxoid as part of wound management care, Tdap is preferred to Td.
Adults in contact with infants
Compared with adults, infants younger than 12 months are at a higher risk of hospitalization from pertussis-related complications, and they have a higher risk of death. Therefore, vaccinating adults who come into contact with these infants may reduce the risk of transmitting pertussis
To protect against pertussis, adults who have not previously received Tdap and who are in contact or anticipate contact with infants younger than 12 months should receive a single dose of Tdap at an interval of less than 10 years since their most recent Td vaccination. These adults should receive the Tdap vaccine at least two weeks before coming into contact with an infant. An interval as short as two years from the previous dose of Td is recommended to reduce the risk of systemic and local reactions after the vaccination, but shorter intervals may be used, if appropriate.
Women who are pregnant or may become pregnant
Ideally, women should be vaccinated with Tdap before becoming pregnant. If this is not possible, they should receive a single dose of Tdap in the immediate postpartum period. It should be administered before the patient is discharged from the hospital or birthing center.
Morbidity and Mortality Weekly Report, December 15, 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm
Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy
Background: Colonoscopy visualizes more of the colon than flexible sigmoidoscopy. This study compares the outcomes of an unsedated modified colon endoscopy (MCE) with flexible sigmoidoscopy (FS) in family medicine practice.
Results: No significant differences were found between MCE and FS regarding completion rates (83.3% vs 75%, respectively). Expected statistically significant differences were found between the 2 procedures in the anatomic site visualized (P < .01) and depth reached (P < .01). Clinical pathologies were identified in 58% of MCE patients and 37% of FS patients. Four adenocarcinomas were identified in the MCE group in the proximal region of the colon that could not have been detected by FS.
Completion Rates
The completion rate for MCE at the 3 practice sites was 83.3%, which is not significantly
different from the completion rate (75%) obtained for FS. The main reason cited
for failure to complete both procedures was patient discomfort: 8.3% of MCE patients
and 11.4% of FS patients did not complete the procedure because of discomfort.
In MCE, poor preparation was also cited as a reason for noncompletion in 3 cases
(6.3%).
Depth Reached and Site Visualized
The cecum was visualized but not intubated in 72.9% of the MCE patients. In 6.3%
of MCE procedures there was a successful cecal intubation. Because of the limited
length of FS equipment, none of these sites could be visualized. Thus, as expected,
statistically significant differences were found between the 2 procedures in
anatomic site visualized (P < .01). Similarly, when analyzed by depth readings
on the endoscopes, MCE reached significantly further into the colon (mean, 130.1
cm; SD, 30.1 cm) than the FS (mean, 50.6 cm; SD, 10.0 cm); again showing an expected
and statistically significant difference (P < .01). A summary of findings
is provided in
Conclusions: Findings from this study suggest that MCE can be an acceptable alternative to FS in office settings for colorectal cancer screening.
Knox L et al A Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy in the Family Medicine Setting: An LA Net Study The Journal of the American Board of Family Medicine 20 (5): 444-450 (2007)
http://www.jabfm.org/cgi/content/abstract/20/5/444?etoc
Preventing Patient Deaths from Fentanyl Patches
A recent report from the Institute for Safe Medication Practices warns about the dangers of misprescribing fentanyl transdermal patches, such as Duragesic. ISMP reminds practitioners that these patches are intended only for patients who are opioid-tolerant, and should not be used for acute pain.
ISMP also pointed out other prescribing errors. In some cases, deaths occurred in patients who were prescribed multiple fentanyl patches, resulting in overdose. In other cases the fentanyl was prescribed in addition to other pain medications, such as oxycodone, or it was prescribed for patients with pre-existing respiratory compromise. ISMP points out that sometimes pharmacists have dispensed these prescriptions without questioning them, and nurses have applied the patches without recognizing the prescribing error.
Here are some of ISMP's recommendations to help avoid these
tragic and preventable errors:
• Prescribe fentanyl patches only for patients who are opioid tolerant,
and who have chronic pain that is not well-controlled with shorter-acting analgesics.
These patches should not be used for postoperative pain, or for pain that's short-term
or intermittent. Pharmacists should ensure that the patient is opioid-tolerant
and suffering from chronic pain before dispensing the drug, and should question
the prescriber if this is not the case.
• Set dosing limits. For example, pharmacy computer systems could be set
to flash an alert if more than 25 mcg per hour has been prescribed as a first-time
dose. Also, in evaluating whether the dose is appropriate, take into account
other opiates or analgesics that may have been prescribed.
• Educate practitioners and patients to know the signs of overdose, which
include respiratory distress, shallow breathing, fatigue, sleepiness, confusion,
dizziness and fainting.
• Prescribing errors are not the only cause of deaths and injuries from
fentanyl patches. They also occur when patients mis-use the patches. Sometimes
patients and family members do not understand that heat can increase absorption
of the drug to dangerous levels. So patients should be told to avoid heating
pads, electric blankets or hot baths while the patch is in place, and let their
doctors know if they develop a temperature above 102 degrees.
• There have also been cases where children found used patches in the trash
and applied them to their own bodies, and died as a result. And so patients should
be warned to dispose of the patches by folding them in half and flushing them
down the toilet.
Additional Information:
ISMP Medication Safety Alert! Ongoing, Preventable Fatal Events with Fentanyl Transdermal Patches Are Alarming http://www.ismp.org/Newsletters/acutecare/articles/20070628.asp
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
