Finding an easy, effective, and safe procedural pain management approach could help many older patients improve their end-of-life palliative care with reduced side effects. |
Intranasal dexmedetomidine administration is feasible in elderly patients and may have the potential to provide better short-term analgesia, anxiolysis, and light-to-mild sedation during daily nursing care than subcutaneous opioids. |
Future similar trials should consider less restrictive inclusion criteria and including the next-of-kin in a patient and public involvement approach to ensure sufficient enrollment. |
1 Background
1.1 Objective
2 Methods
2.1 Trial Design
2.2 Participants
2.3 Eligibility Criteria
Inclusion criteria | Patients aged 65 years or older Undergoing, minimum once a day, a 15- to 30-min nursing care procedure, causing anxiety and/or pain, and therefore requiring the administration of an extra dose of subcutaneous morphine or hydromorphone before nursing care Taking on a continuous, or regularly by the clock, basis one of the following opioids: morphine or hydromorphone Informed consent signed by the patient or next of kin |
Non-inclusion criteria | Known hypersensitivity or allergy to dexmedetomidine or midazolam Fentanyl extra dose medication before nursing care as SC/IV/mucosal fentanyl extra dose analgesic effect would not last up for 30 min Psychomotor agitation Weight > 80 kg Documented risk of bronchial aspiration: ileus, vomiting, nausea, clinically relevant gastroesophageal reflux Documented risk of respiratory distress: recent need (< 7 days) to be ventilated, recent respiratory impairment (< 2 days) with an increased degree of dyspnea or a recent tachypnea (> 20/min), known sleep apnea without non-invasive ventilation support Contraindication for nasal drug administration: nasal trauma or obstruction: copious mucous, bleeding, anatomic, tumoral or foreign body obstruction Documented cardiac risk: congestive heart failure (< 7 days), known life-threatening heart rhythm or conduction disorders, bradycardia < 60 bpm or level II or III atrioventricular block without pacemaker, systolic blood pressure ≤ 100 mmHg, digoxin treatment Recent stroke (< 1 month) Participation in another study within the 30 days preceding or during the present study |
2.4 Study Interventions
2.5 Outcome Measures
Time | Primary and secondary outcomes | Safety outcomes |
---|---|---|
Before study treatment administration | VAS (cm) Depth of sedation (mOAA/s) | Heart rate (bpm) SaO2 (%) |
15, 30, and 45 min after study treatment administration | VAS (cm) Depth of sedation (mOAA/s) | Heart rate (bpm) SaO2 (%) |
Before beginning nursing care | ECPA, first part (score/16) | – |
During nursing care | ECPA part 2 (the highest score of each item) Need for rescue midazolam (yes/no) | Presence of bradycardia (< 60 bpm more than 30 s) (yes/no) Presence of hypoxemia (< 85% more than 60 s) (yes/no) |
30, 60, 90, and 120 min after nursing care until patients reach their initial sedation state (mOAA/s) within a maximum 2 h | VAS (not assessed if midazolam was administered) Depth of sedation (mOAA/s) (not assessed if midazolam, was administered) | Heart rate (bpm) SaO2 (%) |
2.6 Primary Outcome Measures
2.6.1 Secondary Outcome Measures
2.6.1.1 ECPA During Nursing Care, Detailed
2.6.1.2 Pain Intensity (Visual Analog Scale)
2.6.1.3 Sedation (mOAA/S)
2.6.2 Safety Outcomes
2.7 Sample Size
2.8 Randomization
2.9 Blinding
2.9.1 Statistical Methods
3 Results
3.1 Participant Flow
3.2 Recruitment
3.3 Baseline Data
Total | SC opioid/IN dexmedetomidine | IN dexmedetomidine/SC opioid | |
---|---|---|---|
N | 21 | 11 | 10 |
Demographics | |||
Men | 9 (42.9%) | 6 (54.5%) | 3 (30%) |
Age, years | 84 [75–87] (65–93) | 85 [75–87] (65–93) | 82.5 [75–84] (69–92) |
Weight, kg | 57 [46–72] (42–78) | 69 [57–75] (55–78) | 46 [45–57] (42–72) |
Clinical characteristics | |||
Hypoactive delirium | 4 (19%) | 2 (18.2%) | 2 (20%) |
Skin wound | 9 (42.9%) | 4 (36.4%) | 5 (50%) |
Oncological disease | 8 (38.1%) | 6 (54.5%) | 2 (20%) |
Recent fracture, with conservative treatment | 5 (23.8%) | 2 (18.2%) | 3 (30%) |
Palliative Performance Scale, % | 40 [30–50] (20–50) | 30 [30–40] (20–50) | 40 [30–50] (20–50) |
Baseline values of outcomes | |||
Pain VAS, cm | 3 [2–5] (0–8) | 4 [2–4] (0–8) | 3 [1–5] (0–8) |
mOAA/S | 5 [5–5] (4–6) | 5 [5–5] (4–6) | 5 [5–5] (4–5) |
SaO2 % | 94 [93–95] (89–99) | 94 [93–95] (89–98) | 94 [93–95] (89–99) |
Heart rate, bpm | 91 [82–105] (61–139) | 93 [83–103] (76–139) | 90 [82–105] (61–134) |
3.4 Outcomes
Missing | Total | SC opioid | IN dexmedetomidine | |
---|---|---|---|---|
N | 42 | 21 | 21 | |
Primary endpoint | ||||
ECPA | ||||
Before nursing care, 45 min after study drug administration (score/16) | 0 | 0 [0–1] (0–5) | 1 [0–1] (0–5) | 0 [0–1] (0–4) |
During nursing care, total (score/32) | 0 | 4 [2–8] (0–15) | 5 [2–6] (0–15) | 4 [2–8] (1–14) |
Number of patients with a total score > 5 during nursing care | 0 | 16 (38.1%) | 9 (42.9%) | 7 (33.3%) |
Secondary endpoints | ||||
ECPA, detailed (during nursing care): see Online Resource 1a | ||||
Number of patients with rescue dose of midazolam administered | 0 | 2 (4.8%) | 1 (4.8%) | 1 (4.8%) |
Pain VAS, cm | ||||
Time after study drug administration | ||||
15 min | 0 | 3 [0–4] (0–10) | 3 [0–4] (0–10) | 3 [0–4] (0–7) |
30 min | 0 | 2 [0–4] (0–8) | 2 [0–4] (0–8) | 2 [0–4] (0–7) |
45 min | 1 | 1 [0–4] (0–7) | 1 [0–4] (0–6) | 1 [0–3.5] (0–7) |
Maximum VAS during nursing care | 2 | 5 [3–7] (0–10) | 6 [4–7.5] (0–9) | 4 [2.5–6.5] (0–10) |
Time after the end of nursing care | ||||
30 min | 2 | 2 [0–4] (0–8) | 3.5 [0–4] (0–6) | 2 [0–4.5] (0–8) |
60 min | 13 | 1 [0–5] (0–7) | 1 [0–5] (0–6) | 2 [0–4.5] (0–7) |
90 min | 23 | 2 [0–4] (0–7) | 2 [0–4] (0–5) | 1.5 [0–4] (0–7) |
120 min | 34 | 1.5 [0–6.5] (0–8) | 2 [0–8] (0–8) | 1 [0–6] (0–7) |
mOAA/S | ||||
Time after study drug administration | ||||
15 min | 0 | 5 [4–5] (3–5) | 5 [5–5] (3–5) | 5 [4–5] (3–5) |
30 min | 0 | 5 [4–5] (3–6) | 5 [4–5] (3–6) | 4 [4–5] (3–5) |
45 min | 0 | 5 [4–5] (3–6) | 5 [4–5] (4–6) | 5 [4–5] (3–5) |
Time after the end of nursing care | ||||
30 min | 2 | 5 [5–5] (2–5) | 5 [5–5] (4–5) | 5 [4.5–5] (2–5) |
60 min | 13 | 5 [5–5] (1–6) | 5 [5–5] (4–6) | 5 [5–5] (1–5) |
90 min | 23 | 5 [5–5] (1–5) | 5 [5–5] (5–5) | 5 [5–5] (1–5) |
120 min | 34 | 5 [4–5] (2–5) | 5 [4–5] (4–5) | 5 [4–5] (2–5) |
Number of patient returned to initial mOAA/S < 120 min | 0 | |||
Yes | 37 (88.1%) | 19 (90.5%) | 18 (85.7%) | |
No | 3 (7.1%) | 1 (4.8%) | 2 (9.5%) | |
Not applicable (rescue treatment received) | 2 (4.8%) | 1 (4.8%) | 1 (4.8%) | |
Safety outcomes | ||||
SaO2, % | ||||
Time after study drug administration | ||||
15 min | 0 | 94 [92–96] (80–98) | 95 [92–96] (89–97) | 94 [93–95] (80–98) |
30 min | 0 | 94 [92–95] (88–99) | 95 [92–95] (88–97) | 94 [92–95] (90–99) |
45 min | 0 | 94 [92–96] (90–98) | 95 [92–96] (90–97) | 93 [92–95] (90–98) |
Number of patients with desaturation treated with O2 during nursing care | 0 | 1 (2.4%) | 1 (4.8%) | 0 (0%) |
Time after the end of nursing care | ||||
30 min | 0 | 94 [92–95] (72–99) | 94 [92–95] (72–99) | 94 [93–95] (91–97) |
60 min | 11 | 94 [93–95] (80–99) | 94 [92–95] (80–99) | 94 [94–95] (90–97) |
90 min | 21 | 94 [92–96] (91–100) | 94 [92–95] (92–100) | 94 [92–97] (91–98) |
120 min | 32 | 95 [93–96] (90–98) | 95 [92–97] (90–98) | 95 [93–96] (91–97) |
Heart rate, bpm | ||||
Time after study drug administration | ||||
15 min | 0 | 87 [78–100] (60–138) | 87 [80–99] (64–138) | 86 [78–100] (60–132) |
30 min | 0 | 87 [77–99] (62–138) | 88 [81–99] (71–138) | 85 [77–99] (62–134) |
45 min | 0 | 86 [78–99] (64–138) | 86 [80–99] (69–138) | 85 [78–96] (64–133) |
Number of patients with bradycardia during nursing care | 0 | 0 (0%) | 0 (0%) | 0 (0%) |
Time after the end of nursing care | ||||
30 min | 0 | 83 [72–96] (60–138) | 83 [78–97] (63–138) | 80 [69–93] (60–114) |
60 min | 11 | 78 [71–95] (61–115) | 78 [74–95] (67–107) | 78 [70–94] (61–115) |
90 min | 21 | 76 [69–86] (61–104) | 76 [68–86] (65–96) | 76 [69–90] (61–104) |
120 min | 32 | 76 [69–83] (60–85) | 73 [71–79] (69–85) | 79 [64–83] (60–84) |
3.4.1 Primary Endpoint (ECPA Score)
3.4.2 Secondary Endpoints
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The ECPA during nursing care. Details of the four items of the ECPA during nursing care are reported in the Electronic Supplementary Material.
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Pain intensity (VAS). Following study drug administration, VAS scores decreased progressively with time and reached a median [IQR] of 1 [0–4] after 45 min, before the start of the nursing care sessions. During the nursing care period, the maximum VAS reached a median [IQR] of 6 [4–7.5] in patients receiving SC opioids and 4 [2.5–6.5] in those receiving IN DEX. After the nursing care, VAS scores decreased in both groups.
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Sedation (mOAA/S). Before starting nursing care, following study drug administration, the mOAA/S scores remained stable. Most (88.1%) patients returned to their initial mOAA/S value during the 120-min follow-up period.