Lidocaine Infusions Relieve Pain in Chronic Migraine
Patients with a particularly refractory form of chronic migraine who received a multiday continuous lidocaine infusion as part of aggressive inpatient treatment reported significant improvement in pain immediately following the infusion, and almost half of those who responded reported sustained relief at 1 month. This retrospective cohort study, published in Regional Anesthesia and Pain Medicine, analyzed medical records of patients with chronic migraine (at least 15 headache days/month for at least 3 months, in which at least 8 days meet criteria for migraine) refractory to outpatient treatment. These patients are treated in hospital with infusions of NSAIDs, corticosteroids, and neuroleptics, hoping to break the cycle of pain.
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Researchers examined the medical records of 609 hospital admissions from April 2017 to April 2020 at the Jefferson Inpatient Headache Unit in Philadelphia. This comprised 537 unique patients; 72 admissions were repeat admissions. Mean number of days between hospitalization for repeat admissions was 215.2 days. The mean age of the patients was 46, and 81% were female; all met criteria for refractory chronic migraine. The patients received continuous lidocaine infusions, starting at 1 mg/min and titrated to a maximum of 4 mg/min based on daily plasma levels, pain response, and tolerability. The infusions were planned for 5 to 7 days, although length differed based on clinical factors; for example, hospitalization and the infusion could be extended if the patient reported that the pain was slowly but steadily improving. The patients were otherwise be discharged from the hospital if they reported being pain-free for from 12 to 24 hours, or had a pain level that the patient felt allowed improved function, or if they experienced minimal response to treatment by hospital day 5. Mean duration of treatment was 5.2 days.
Patients recorded pain intensity using a self-report Numerical Rating Scale, from 0 (pain-free) to 10 (worst pain imaginable); researchers measured change in that self-reported headache pain from baseline to discharge. At baseline and at postdischarge office visits (25 to 65 days after discharge), patients were also asked the number of headache days they had experienced during the previous 28 days, as well as current worst daily pain and average daily pain.
A decline in median pain ratings was seen with lidocaine infusion: from 7.0 at baseline to 1.0 at discharge. Nearly 88% of patients showed a reduction in pain ratings by at least 2 points during the hospitalization period. These patients were labeled acute responders; of the 535 acute responders with available postdischarge data, 43.2% showed sustained improvements. Average pain remained below baseline at the postdischarge visit, with a median score of 5.5, and the patients reported fewer headache days in the previous month compared to baseline: 22.5 days vs. 26.8 days.
The high acute responder rate is an encouraging finding, providing evidence of rapid relief for these patients. The waning of the effect seen over follow-up reflects the challenges presented by refractory chronic migraine. These results should offer support for design and implementation of randomized, controlled studies of lidocaine infusions to allow increased use of this treatment. Clinicians meanwhile can use these study results in their communications with patients, describing the likelihood of relief and the expected duration of that relief. (Shukla, D. (2022). Chronic migraine: Common anesthetic relieves pain in new study. Medical News Today. Retrieved June 2022 from https://www.medicalnewstoday.com/articles/chronic-migraine-common-anesthetic-relieves-pain-in-new-study; Schwenk, E. S., et al. (2022). Lidocaine infusions for refractory chronic migraine: A retrospective analysis. Region Anesth Pain Med, 47(7), 408–413. Retrieved June 2022 from https://rapm.bmj.com/content/47/7/408)
Released: July 2022
Nursing Drug Handbook
© 2022 Wolters Kluwer
Maternal Vaccination for COVID-19 Offers Some Protection for Their Infants
Vaccination against SARS-CoV2 during pregnancy is known to result in detectable maternal antibodies to the virus in cord blood, human milk, and serum specimens from infants, but it’s unknown how this fact correlates with protection against COVID-19 in infants under age 6 months, who are at high risk for complications of COVID-19 but aren’t eligible for vaccination. A case-control study published in the New England Journal of Medicine assessed the effectiveness of full maternal vaccination (that is, two doses of an mRNA SARS-CoV2 vaccine) against hospitalization for COVID-19 in infants younger than age 6 months. Between July 2021 and March 2022, the study enrolled infants hospitalized for COVID-19 (case infants; n = 537) and matched them with hospitalized infants who didn’t have COVID-19 (control infants; n = 521) at 30 hospitals across 22 U.S. states. Median age of infants was 2 months; 19% of case infants and 24% of control infants had at least one underlying health condition. All case infants were identified with COVID-19 as the primary reason for their admission or with a clinical syndrome consistent with acute COVID-19 who then tested positive on a SARS-CoV2 PCR test; control infants were hospitalized for other reasons and tested negative on a PCR test. Researchers attempted to enroll a control infant for every case infant, with a date of hospital admission that was within 4 weeks of the admission date of the case infants.
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The overall effectiveness of maternal vaccination against COVID-associated hospitalization in their infants age 6 months and younger was 52%; its effectiveness against intensive care unit admission was 70%. Among case infants, 113 (21%) required intensive care treatment for COVID-19, including 64 (12%) who required mechanical ventilation or vasoactive infusions. Two infants died and two required ECMO treatment; none of these four infants was born to fully vaccinated mothers.
The study examined appropriate timing of maternal vaccination to facilitate the greatest transfer of maternal antibodies. In this study, effectiveness at preventing hospitalization was 69% when vaccinated after 20 weeks of pregnancy and 38% when the last vaccination was given during the first 20 weeks of pregnancy. The researchers were also able to examine results during the period of the circulation of the delta and omicron variants of the virus. Of the 537 case infants, 181 were admitted during the delta circulation period and 356 during the omicron circulation period. The effectiveness of the maternal vaccination against COVID-19 hospitalization was 80% during the delta period and 38% during the omicron period.
These data support the safety of COVID-19 vaccination during pregnancy. The CDC recommends vaccination, including boosters, for pregnant people. Despite the known benefits and safety of the mRNA vaccine, vaccination rates during pregnancy still lag: only 71% of pregnant people in the United States were fully vaccinated, with an even lower rate among non-Hispanic Black people (58%). (Halasa, N. B., et al. (2022). Maternal vaccination and risk of hospitalization for Covid-19 among infants. New Engl J Med, 387, 109–119. Retrieved June 2022 from https://www.nejm.org/doi/full/10.1056/NEJMoa2204399?query=featured_coronavirus; Rasmussen, S. A., & Jamieson, D. J. (2022). Covid-19 vaccination during pregnancy—Two for the price of one. New Engl J Med, 387, 178–179. Retrieved June 2022 from https://www.nejm.org/doi/full/10.1056/NEJMe2206730?query=recirc_curatedRelated_article)
Released: July 2022
Nursing Drug Handbook
© 2022 Wolters Kluwer
Newer P2Y12 Inhibitors Improve Mortality in Patients with MI Complicated by Cardiac Arrest or Cardiogenic Shock
Management of acute myocardial infarction (MI) complicated by cardiac arrest or cardiogenic shock is challenging, and current treatment is less successful in these patients. A review and meta-analysis published in Mayo Clinic Proceedings offers evidence that “newer” P2Y12 receptor inhibitors should be preferred when treating this high-risk population.
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Current treatment of acute MI complicated by cardiac arrest or cardiogenic shock includes percutaneous coronary intervention followed by use of dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor. Clopidogrel, the first P2Y12 inhibitor on the market, has been the standard of care; this study examined results of trials that compared outcomes with other P2Y12 inhibitors ticagrelor and prasugrel vs. clopidogrel.
Because the large sample sizes seen in other studies of MI are not possible for these conditions, the review identified only eight studies, seven of them cohort studies. The studies comprised 1100 patients; 695 patients (63.2%) received clopidogrel and 405 patients (36.8%) received the newer P2Y12 inhibitors ticagrelor or prasugrel. They compared outcomes: early mortality, either in-hospital or 30-day all-cause mortality; 1-year, all-cause mortality; and the incidence of major bleeding and stent thrombosis.
The “newer” P2Y12 cohort (prasugrel and ticagrelor) had lower rates of early mortality (odds ratio [OR], 0.60) and of 1-year mortality (OR, 0.51). The analysis did not find a significant difference in major bleeding (OR, 1.21) or in stent thrombosis (OR, 2.01) with use of ticagrelor or prasugrel, although there were numerically more bleeding events with the “newer” drugs.
The study is limited by the retrospective, observational character of most of the studies involved; there is the risk that selection bias comes into play, as clinicians determine that certain patients would benefit from the more potent newer P2Y12 receptor inhibitors. In addition, it would be valuable to design a study that examined these complications separately, recognizing that cardiac arrest and cardiogenic shock have different effects on, for example, perfusion of other organs. (Patlolla, S. H., et al. (2022). Newer P2Y12 inhibitors vs clopidogrel in acute myocardial infarction with cardiac arrest or cardiogenic shock: A systematic review and meta-analysis. Mayo Clin Proceed, 97(6), 1074–1085. Retrieved June 2022 from https://www.mayoclinicproceedings.org/article/S0025-6196(22)00120-3/fulltext; Effron, M. B. (2022). Importance of more potent antiplatelet therapy in myocardial infarction with cardiac arrest or cardiogenic shock. Mayo Clin Proceed, 97(6), 1041–1043. Retrieved June 2022 from https://www.mayoclinicproceedings.org/article/S0025-6196(22)00255-5/fulltext)
Released: July 2022
Nursing Drug Handbook
© 2022 Wolters Kluwer