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Allergies to analgesic medications in ED patients
Correspondence [4] Centers for Disease Control and Prevention. Post-earthquake injuries treated at a field hospital—Haiti, 2010. MMWR Morb Mortal Wkly Rep 2011;59(51):1673-7. [5] Redmond AD, Mardel S, Taithe B, Calvot T, Gosney J, Duttine A, et al. A qualitative and quantitative study of the surgical and rehabilitation response to the earthquake in Haiti, January 2010. Prehosp Disaster Med 2011;26(6):449-56. [6] McIntyre T, Hughes CD, Pauyo T, Sullivan SR, Rogers Jr SO, Raymonville M, et al. Emergency surgical care delivery in postearthquake Haiti: Partners in Health and Zanmi Lasante experience. World J Surg 2011;35(4):745-50. [7] Department of Emergency and Humanitarian Action, the World Health Organization, Area on Emergency Preparedness and Disaster Relief, the Pan-American Health Organization. Guidelines for the use of foreign field hospitals in the aftermath of sudden-impact disaster. Prehosp Disaster Med 2003;18(4):278-90. [8] de Ville de Goyet C. Editorial comments: surgery under extreme conditions in the aftermath of the 2010 Haiti earthquake. Prehosp Disaster Med 2011;25(6):494-5. [9] Gerdin M, Wladis A, von Schreeb J. Foreign field hospitals after the 2010 Haiti earthquake: how good were we? Emerg Med J 2012 [Epub ahead of print].
Allergies to analgesic medications in ED patientsB,BB To the Editor, Analgesics are the most frequently used and prescribed medications in the emergency department (ED) [1]. However, little research has focused on analgesic allergies in an ED population [2]. In this study, we report the prevalence of selfreported analgesic allergies in an adult ED patient population as well as the characteristics of patients reporting allergies. This study was a retrospective chart review design, reviewed and approved by the local institutional review board. The site was the ED of a tertiary care center with an annual adult census of approximately 60000 patients. The paper charts for adult (age ≥18 years) ED visits for the period of February 2010 were requested for review; records were obtained from the department's financial staff. Each chart had the following data abstracted: age, sex, ethnicity, and analgesic drug allergies. Information on drug allergies is usually based on patient self-report. Opioids included were morphine, codeine, oxycodone, hydrocodone, hydromorphone, and fentanyl. For combination products (eg, Vicodin, Percocet, etc), the allergy was listed under the opioid ingredient. Nonsteroidal anti-inflammatory drugs (NSAIDs) included were ibuprofen, ketorolac, naproxen, and NSAID (unspecified). Allergies were entered as NSAID (unspecified) if “NSAID” or “all NSAIDs” were the reported allergy or for an NSAID besides ibuprofen, ketorolac, or naproxen. Because the study's focus was on medications likely to be ordered or prescribed by ED physicians as analgesics, acetaminophen ☆ External funding: The authors did not receive any external financial support for this study. ☆☆ Conflict of interest: The authors have no financial conflicts of interest regarding the content of this study.
431 alone and aspirin were not included for analysis. Patients with multiple visits during the study period were considered to have an analgesic allergy if it was recorded on at least 1 visit. A supplemental electronic record was used to obtain data on disposition (discharged, admitted, expired). Prevalence of analgesic allergy was reported as a proportion. Demographic data and disposition were compared using t test and χ2 analysis. Statistical calculations were performed using GraphPad InStat (GraphPad Software, Inc, La Jolla, CA). Statistical analyses used only unique patients identified during the study period; the exception was patient disposition, which analyzed all visits. Records for 2988 nonconsecutive ED visits (2771 unique patients) were available for review. Among unique patients, 283 patients (10.2%; 95% confidence interval, 9.1%-11.4%) had a recorded opioid or NSAID analgesic allergy. A total of 2389 patients (86.2%) had no known drug allergies; 99 cases (3.6%) had no documentation of any drug allergy information. Seventy-four patients (26.1%) reported multiple analgesic allergies. Analgesic allergic patients were older than nonallergic patients (mean age, 47.9 vs 42.2 years; unpaired t test, P b .0001) and more likely to be female (67.8% vs 48.1%; χ2 test, P b .0001). Distribution of ethnic background did not significantly differ between groups (χ2 test, P = .118). Allergic patients had a significantly higher rate of hospital admission or death at any given visit (26.9%) compared with nonallergic patients (16.7%) (χ2 test, P b .0001) (Table 1). Three patient deaths were recorded in the collection period, all occurring in nonallergic subjects. Among 404 total reported allergies, codeine (105 patients) and hydrocodone (57 patients) were most frequent (Table 2). Opioids accounted for approximately 74% of analgesic allergies. To our knowledge, this study is among the first to specifically examine the prevalence of analgesic allergies in
Table 1
Patient characteristics Allergic patients
n (% total) 283 (10.2) Mean age (SD) 47.9 (17.5) ⁎ Female patients, 192 (67.8) † n (%) Ethnicity, n (%) a White 233 (82.3) Black/African 12 (4.2) American Hispanic 36 (12.7) Other 2 (0.7) Admissions/ 88 (26.9) † death, n (%)
Nonallergic Unadjusted odds patients ratio (95% confidence interval) 2389 (86.2) 42.2 (17.9) 1148 (48.1) 2.28 (1.76-2.96)
1758 (73.6) 156 (6.5) 379 (15.9) 96 (4.0) 429 (16.7) 1.83 (1.40-2.39)
a No significant group differences by χ2 test. ⁎ P b .0001, unpaired t test. † P b .0001, χ2 test.
432 Table 2
Correspondence Number of individual analgesic mentions
Drug Codeine Morphine Hydrocodone Oxycodone Hydromorphone Fentanyl Ibuprofen Ketorolac Naproxen NSAID (unspecified)
Allergies reported (n)
a
105 69 57 50 16 3 50 13 13 28
hospital admission. Further research will need to determine whether these data represent the true prevalence of analgesic allergies. Sean H. Rhyee MD, MPH Department of Emergency Medicine University of Massachusetts Medical School Worcester, MA, USA E-mail address: [email protected] Lisa Bienia-Kenton MD Department of Emergency Medicine Harrington Hospital Southbridge, MA, USA
a Because of 74 patients with multiple allergies, the total number of allergies reported (404) exceeds the number of analgesic allergic patients (283).
an adult ED population. In the study group, 10.2% of patients had a recorded allergy to an opioid or NSAID analgesic. Compared with nonallergic patients, analgesic allergic patients were older and more likely to be women. These patients were also more likely to be admitted to the hospital. The study's findings differ from prior reports, where the total prevalence of drug allergy in ED patients is 8% to 10% [2,3]. Analgesics comprised a small minority of cases in those studies. Even in a selected adult population of 9067 patients presenting to an allergy clinic, the rate of NSAID allergy was approximately 3% with 1 case reporting past reactions to tramadol [4]. The most likely explanation is accuracy of reported allergy information. High inaccuracy of drug allergy data has been previously reported in ED settings [5,6]. The finding of a disproportionate number of female patients reporting analgesic allergy is consistent with prior reports [4,7]. The significance of the higher age found in analgesic allergic patients is uncertain, as age has not been found to be a consistent contributor to drug allergy risk [7]. Similarly, the relationship between higher admission rates and analgesic allergy is unclear and has not been addressed in prior studies. In regard to this study's limitations, the study group was predominantly white; a similar review in a facility serving a larger ethnic minority population could yield differing results. In addition, the study's design cannot verify the accuracy of recorded drug allergy information. Patient records did not include documentation on the nature of a reported analgesic allergy. Hence, it was not possible to determine whether patients had a history of true hypersensitivity reactions or other adverse drug effects. In addition, study data did not include presenting complaints or final diagnoses, limiting analysis of the relationships between allergy status and age and disposition. In summary, the prevalence of self-reported analgesic allergies in this single-center study was higher than reported in prior studies. Patients reporting allergies differed from nonallergic patients in regard to age, sex, and rate of
Amanda Collins DO Department of Emergency Medicine St Elizabeth Health Center Youngstown, OH, USA http://dx.doi.org/10.1016/j.ajem.2012.10.016
References [1] Nawar EW, Niska RW, Xu J. National hospital ambulatory medical care survey: 2005 emergency department summary. Advance Data from Vital and Health Statistics. No. 386. Hyattsville, MD: National Center for Health Statistics; 2007. [2] Wyatt JP. Patients' knowledge about their drug allergies. J Accid Emerg Med 1996;13:114-5. [3] Reisfeld S, Goldberg A, Confino-Cohen R. Management of patients with known drug hypersensitivity in an emergency department in Israel. Int Arch Allergy Immunol 2011;155:361-6. [4] Palma-Carlos AG, Medina M, Palma-Carlos ML. Prevalence of drug allergy in an out-patient population. Eur Ann Allergy Clin Immunol 2006;38(5):142-5. [5] Raja AS, Lindsell CJ, Bernstein JA, et al. The use of penicillin skin testing to assess the prevalence of penicillin allergy in an emergency department setting. Ann Emerg Med 2009;54(1):72-7. [6] Porter SC, Manzi SF, Volpe D. Getting the data right: information accuracy in pediatric emergency medicine. Qual Saf Health Care 2006; 15:296-301. [7] Gomes ER, Demoly P. Epidemiology of hypersensitivity drug reactions. Curr Opin Allergy Clin Immunol 2005;5:309-16.
Management of 7 earthquake crush syndrome victims with long-term continuous renal replacement therapy To the Editor, On May 12, 2008, a catastrophic earthquake measuring 8.1 on the Richter scale struck the Wenchuan region of Sichuan province, China, causing approximately 70000 deaths and even more injuries. From May 12 to 20, 2008, 7 seriously injured patients with crush syndrome were admitted to the Chengdu Military General Hospital, including 5 males and 2 females, with a mean age of 37.9 ± 8.4 years. These patients
Allergies to analgesic medications in ED patientsB,BB To the Editor, Analgesics are the most frequently used and prescribed medications in the emergency department (ED) [1]. However, little research has focused on analgesic allergies in an ED population [2]. In this study, we report the prevalence of selfreported analgesic allergies in an adult ED patient population as well as the characteristics of patients reporting allergies. This study was a retrospective chart review design, reviewed and approved by the local institutional review board. The site was the ED of a tertiary care center with an annual adult census of approximately 60000 patients. The paper charts for adult (age ≥18 years) ED visits for the period of February 2010 were requested for review; records were obtained from the department's financial staff. Each chart had the following data abstracted: age, sex, ethnicity, and analgesic drug allergies. Information on drug allergies is usually based on patient self-report. Opioids included were morphine, codeine, oxycodone, hydrocodone, hydromorphone, and fentanyl. For combination products (eg, Vicodin, Percocet, etc), the allergy was listed under the opioid ingredient. Nonsteroidal anti-inflammatory drugs (NSAIDs) included were ibuprofen, ketorolac, naproxen, and NSAID (unspecified). Allergies were entered as NSAID (unspecified) if “NSAID” or “all NSAIDs” were the reported allergy or for an NSAID besides ibuprofen, ketorolac, or naproxen. Because the study's focus was on medications likely to be ordered or prescribed by ED physicians as analgesics, acetaminophen ☆ External funding: The authors did not receive any external financial support for this study. ☆☆ Conflict of interest: The authors have no financial conflicts of interest regarding the content of this study.
431 alone and aspirin were not included for analysis. Patients with multiple visits during the study period were considered to have an analgesic allergy if it was recorded on at least 1 visit. A supplemental electronic record was used to obtain data on disposition (discharged, admitted, expired). Prevalence of analgesic allergy was reported as a proportion. Demographic data and disposition were compared using t test and χ2 analysis. Statistical calculations were performed using GraphPad InStat (GraphPad Software, Inc, La Jolla, CA). Statistical analyses used only unique patients identified during the study period; the exception was patient disposition, which analyzed all visits. Records for 2988 nonconsecutive ED visits (2771 unique patients) were available for review. Among unique patients, 283 patients (10.2%; 95% confidence interval, 9.1%-11.4%) had a recorded opioid or NSAID analgesic allergy. A total of 2389 patients (86.2%) had no known drug allergies; 99 cases (3.6%) had no documentation of any drug allergy information. Seventy-four patients (26.1%) reported multiple analgesic allergies. Analgesic allergic patients were older than nonallergic patients (mean age, 47.9 vs 42.2 years; unpaired t test, P b .0001) and more likely to be female (67.8% vs 48.1%; χ2 test, P b .0001). Distribution of ethnic background did not significantly differ between groups (χ2 test, P = .118). Allergic patients had a significantly higher rate of hospital admission or death at any given visit (26.9%) compared with nonallergic patients (16.7%) (χ2 test, P b .0001) (Table 1). Three patient deaths were recorded in the collection period, all occurring in nonallergic subjects. Among 404 total reported allergies, codeine (105 patients) and hydrocodone (57 patients) were most frequent (Table 2). Opioids accounted for approximately 74% of analgesic allergies. To our knowledge, this study is among the first to specifically examine the prevalence of analgesic allergies in
Table 1
Patient characteristics Allergic patients
n (% total) 283 (10.2) Mean age (SD) 47.9 (17.5) ⁎ Female patients, 192 (67.8) † n (%) Ethnicity, n (%) a White 233 (82.3) Black/African 12 (4.2) American Hispanic 36 (12.7) Other 2 (0.7) Admissions/ 88 (26.9) † death, n (%)
Nonallergic Unadjusted odds patients ratio (95% confidence interval) 2389 (86.2) 42.2 (17.9) 1148 (48.1) 2.28 (1.76-2.96)
1758 (73.6) 156 (6.5) 379 (15.9) 96 (4.0) 429 (16.7) 1.83 (1.40-2.39)
a No significant group differences by χ2 test. ⁎ P b .0001, unpaired t test. † P b .0001, χ2 test.
432 Table 2
Correspondence Number of individual analgesic mentions
Drug Codeine Morphine Hydrocodone Oxycodone Hydromorphone Fentanyl Ibuprofen Ketorolac Naproxen NSAID (unspecified)
Allergies reported (n)
a
105 69 57 50 16 3 50 13 13 28
hospital admission. Further research will need to determine whether these data represent the true prevalence of analgesic allergies. Sean H. Rhyee MD, MPH Department of Emergency Medicine University of Massachusetts Medical School Worcester, MA, USA E-mail address: [email protected] Lisa Bienia-Kenton MD Department of Emergency Medicine Harrington Hospital Southbridge, MA, USA
a Because of 74 patients with multiple allergies, the total number of allergies reported (404) exceeds the number of analgesic allergic patients (283).
an adult ED population. In the study group, 10.2% of patients had a recorded allergy to an opioid or NSAID analgesic. Compared with nonallergic patients, analgesic allergic patients were older and more likely to be women. These patients were also more likely to be admitted to the hospital. The study's findings differ from prior reports, where the total prevalence of drug allergy in ED patients is 8% to 10% [2,3]. Analgesics comprised a small minority of cases in those studies. Even in a selected adult population of 9067 patients presenting to an allergy clinic, the rate of NSAID allergy was approximately 3% with 1 case reporting past reactions to tramadol [4]. The most likely explanation is accuracy of reported allergy information. High inaccuracy of drug allergy data has been previously reported in ED settings [5,6]. The finding of a disproportionate number of female patients reporting analgesic allergy is consistent with prior reports [4,7]. The significance of the higher age found in analgesic allergic patients is uncertain, as age has not been found to be a consistent contributor to drug allergy risk [7]. Similarly, the relationship between higher admission rates and analgesic allergy is unclear and has not been addressed in prior studies. In regard to this study's limitations, the study group was predominantly white; a similar review in a facility serving a larger ethnic minority population could yield differing results. In addition, the study's design cannot verify the accuracy of recorded drug allergy information. Patient records did not include documentation on the nature of a reported analgesic allergy. Hence, it was not possible to determine whether patients had a history of true hypersensitivity reactions or other adverse drug effects. In addition, study data did not include presenting complaints or final diagnoses, limiting analysis of the relationships between allergy status and age and disposition. In summary, the prevalence of self-reported analgesic allergies in this single-center study was higher than reported in prior studies. Patients reporting allergies differed from nonallergic patients in regard to age, sex, and rate of
Amanda Collins DO Department of Emergency Medicine St Elizabeth Health Center Youngstown, OH, USA http://dx.doi.org/10.1016/j.ajem.2012.10.016
References [1] Nawar EW, Niska RW, Xu J. National hospital ambulatory medical care survey: 2005 emergency department summary. Advance Data from Vital and Health Statistics. No. 386. Hyattsville, MD: National Center for Health Statistics; 2007. [2] Wyatt JP. Patients' knowledge about their drug allergies. J Accid Emerg Med 1996;13:114-5. [3] Reisfeld S, Goldberg A, Confino-Cohen R. Management of patients with known drug hypersensitivity in an emergency department in Israel. Int Arch Allergy Immunol 2011;155:361-6. [4] Palma-Carlos AG, Medina M, Palma-Carlos ML. Prevalence of drug allergy in an out-patient population. Eur Ann Allergy Clin Immunol 2006;38(5):142-5. [5] Raja AS, Lindsell CJ, Bernstein JA, et al. The use of penicillin skin testing to assess the prevalence of penicillin allergy in an emergency department setting. Ann Emerg Med 2009;54(1):72-7. [6] Porter SC, Manzi SF, Volpe D. Getting the data right: information accuracy in pediatric emergency medicine. Qual Saf Health Care 2006; 15:296-301. [7] Gomes ER, Demoly P. Epidemiology of hypersensitivity drug reactions. Curr Opin Allergy Clin Immunol 2005;5:309-16.
Management of 7 earthquake crush syndrome victims with long-term continuous renal replacement therapy To the Editor, On May 12, 2008, a catastrophic earthquake measuring 8.1 on the Richter scale struck the Wenchuan region of Sichuan province, China, causing approximately 70000 deaths and even more injuries. From May 12 to 20, 2008, 7 seriously injured patients with crush syndrome were admitted to the Chengdu Military General Hospital, including 5 males and 2 females, with a mean age of 37.9 ± 8.4 years. These patients