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Wennberg P, Pakpour A, Broström A, Karlsson K, Magnusson C. Alfentanil for Pain Relief in a Swedish Emergency Medical Service - An Eleven-Year Follow-up on Safety and Effect. PREHOSP EMERG CARE 2024:1-6. [PMID: 38830199 DOI: 10.1080/10903127.2024.2363509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/25/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Pain is a common symptom in prehospital emergency care and pain treatment in this context can be challenging. While previous research has assessed the use of morphine and other synthetic opioids for pain management in this setting, the evaluation of alfentanil is limited. The objective of this study was to evaluate the safety and effect of intravenous alfentanil when administered by ambulance nurses in prehospital emergency care. METHODS This retrospective observational study consecutively included patients suffering from pain, treated with alfentanil in a Swedish EMS service from September 2011 to 31 September 2022. Data regarding occurrence of adverse events (AE), serious adverse events (SAE) - were used for safety evaluation and pain scores with a visual analogue scale (VAS) before and after treatment were used for evaluation of pain treatment. These data were extracted from the electronic patients' medical records database for analysis. Univariate logistic regression analysis was used to identify significant predictors of AE following injection of alfentanil by nurses in prehospital emergency care. RESULTS During the evaluation period 17,796 patients received pain relief with alfentanil. Adverse events affected 2.5% of the patients, while serious adverse events were identified in 25 cases (0.01%). Out of the 5970 patients with a complete VAS score for pain, the median VAS score was 8 (IQR 3) before treatment and 4 (IQR 3) after treatment. The mean reduction in pain measured by VAS was -4.1 ± 2.6 from the time before, to the evaluation after alfentanil administration. The administration frequency increased during the first year up to a steady level during the later part of the evaluation period. CONCLUSIONS This study proposes that alfentanil represents a safe and efficacious alternative for addressing urgent pain relief within the prehospital emergency context. Alfentanil demonstrates efficacy in alleviating pain across various conditions, with a relatively low risk of adverse events or serious adverse events when administered cautiously.
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Affiliation(s)
- Pär Wennberg
- School of Health Sciences, Jönköping University, Jönköping, Sweden
- Ambulance Services, Skaraborg Hospital, Skövde, Sweden
| | - Amir Pakpour
- School of Health Sciences, Jönköping University, Jönköping, Sweden
| | - Anders Broström
- School of Health Sciences, Jönköping University, Jönköping, Sweden
- Department of Clinical Neurophysiology, Linköping University Hospital, Linköping, Sweden
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Vestlandet, Norway
| | - Kåre Karlsson
- Ambulance Services, Skaraborg Hospital, Skövde, Sweden
| | - Carl Magnusson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Le Cornec C, Le Pottier M, Broch H, Marguinaud Tixier A, Rousseau E, Laribi S, Janière C, Brenckmann V, Guillerm A, Deciron F, Kabbaj A, Jenvrin J, Péré M, Montassier E. Ketamine Compared With Morphine for Out-of-Hospital Analgesia for Patients With Traumatic Pain: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2352844. [PMID: 38285446 PMCID: PMC10825723 DOI: 10.1001/jamanetworkopen.2023.52844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024] Open
Abstract
Importance Pain is a common out-of-hospital symptom among patients, and opioids are often prescribed. Research suggests that overprescribing for acute traumatic pain is still prevalent, even when limits restricting opioid prescriptions have been implemented. Ketamine hydrochloride is an alternative to opioids in adults with out-of-hospital traumatic pain. Objective To assess the noninferiority of intravenous ketamine compared with intravenous morphine sulfate to provide pain relief in adults with out-of-hospital traumatic pain. Design, Setting, and Participants The Intravenous Subdissociative-Dose Ketamine Versus Morphine for Prehospital Analgesia (KETAMORPH) study was a multicenter, single-blind, noninferiority randomized clinical trial comparing ketamine hydrochloride (20 mg, followed by 10 mg every 5 minutes) with morphine sulfate (2 or 3 mg every 5 minutes) in adult patients with out-of-hospital trauma and a verbal pain score equal to or greater than 5. Enrollment occurred from November 23, 2017, to November 26, 2022, in 11 French out-of-hospital emergency medical units. Interventions Patients were randomly assigned to ketamine (n = 128) or morphine (n = 123). Main Outcomes and Measures The primary outcome was the between-group difference in mean change in verbal rating scale pain scores measured from the time before administration of the study drug to 30 minutes later. A noninferiority margin of 1.3 was chosen. Results A total of 251 patients were randomized (median age, 51 [IQR, 34-69] years; 111 women [44.9%] and 140 men [55.1%] among the 247 with data available) and were included in the intention-to-treat population. The mean pain score change was -3.7 (95% CI, -4.2 to -3.2) in the ketamine group compared with -3.8 (95% CI, -4.2 to -3.4) in the morphine group. The difference in mean pain score change was 0.1 (95% CI, -0.7 to 0.9) points. There were no clinically meaningful differences for vital signs between the 2 groups. The intravenous morphine group had 19 of 113 (16.8% [95% CI, 10.4%-25.0%]) adverse effects reported (most commonly nausea [12 of 113 (10.6%)]) compared with 49 of 120 (40.8% [95% CI, 32.0%-49.6%]) in the ketamine group (most commonly emergence phenomenon [24 of 120 (20.0%)]). No adverse events required intervention. Conclusions and Relevance In the KETAMORPH study of patients with out-of-hospital traumatic pain, the use of intravenous ketamine compared with morphine showed noninferiority for pain reduction. In the ongoing opioid crisis, ketamine administered alone is an alternative to opioids in adults with out-of-hospital traumatic pain. Trial Registration ClinicalTrials.gov Identifier: NCT03236805.
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Affiliation(s)
- Clément Le Cornec
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | | | - Hélène Broch
- Urgences Service Mobile d’Urgence et de Réanimation (SMUR), Centre Hospitalier Chateaubriant, Chateaubriant, France
| | - Alexandre Marguinaud Tixier
- Pôle Urgences Adultes–Service d’Aide Médicale Urgente (SAMU), Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | | | - Said Laribi
- Centre Hospitalier Régional et Universitaire Tours Urgences SAMU 37 SMUR de Tours, Tours, France
| | - Charles Janière
- SAMU85 Centre Hospitalier Départemental Vendée la Roche sur Yon, la Roche sur Yon, France
| | | | | | - Florence Deciron
- Centre Hospitalier Le Mans SAMU 72 SMUR du Mans, Le Mans, France
| | - Amine Kabbaj
- Centre Hospitalier Saint Nazaire Urgences SMUR de Saint Nazaire, Saint Nazaire, France
| | - Joël Jenvrin
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | - Morgane Péré
- Plateforme de Méthodologie et Biostatistique, CHU Nantes, Nantes, France
| | - Emmanuel Montassier
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
- Center for Research in Transplantation and Translational Immunology, Unité Mixte de Recherche 1064, Nantes Université, CHU Nantes, Institut National de la Santé et de la Recherche Médicale, Nantes, France
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Simensen R, Fjose LO, Rehn M, Hagemo J, Thorsen K, Heyerdahl F. Comparison of three regimens with inhalational methoxyflurane versus intranasal fentanyl versus intravenous morphine in pre-hospital acute pain management: study protocol for a randomized controlled trial (PreMeFen). Trials 2023; 24:571. [PMID: 37670364 PMCID: PMC10478438 DOI: 10.1186/s13063-023-07590-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Pre-hospital pain management has traditionally been performed with intravenous (IV) morphine, but oligoanalgesia remain a recognized problem. Pain reduction is essential for patient satisfaction and is regarded as a measure of successful treatment. We aim to establish whether non-invasive methods such as inhalation of methoxyflurane is non-inferior to intranasal fentanyl or non-inferior to the well-known IV morphine in the pre-hospital treatment of acute pain. METHOD/DESIGN The PreMeFen study is a phase three, three-armed, randomized, controlled, non-inferiority trial to compare three regimens of analgesics: inhalation of methoxyflurane and intranasal (IN) fentanyl versus IV morphine. It is an open-label trial with a 1:1:1 randomization to the three treatment groups. The primary endpoint is the change in pain numeric rating scale (NRS) (0-10) from baseline to 10 min after start of investigational medicinal product administration (IMP). The non-inferiority margin was set to 1.3, and a sample size of 270 patients per protocol (90 in each treatment arm) will detect this difference with 90% power. DISCUSSION We chose a study design with comparison of analgesic regimens rather than fixed doses because of the substantial differences in drug characteristics and for the results to be relevant to inform policymakers in the pre-hospital setting. We recognize that easier administration of analgesics will lead to better pain management for many patients if the regimens are as good as the existing, and hence, we chose a non-inferiority design. The primary endpoint, the change in pain (NRS) after 10 min, is set to address the immediate need of pain reduction for patients with acute prehospital pain. On a later stage, more analgesic methods are often available. PreMeFen is a non-inferiority randomized controlled trial comparing three analgesic regimens aiming to establish whether inhalation of methoxyflurane or intranasal fentanyl is as good as IV morphine for fast reduction of acute pain in the prehospital setting.
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Affiliation(s)
- Randi Simensen
- Division of Pre-Hospital Services, Innlandet Hospital Trust, Kastbakkvegen 9, 2390, Moelv, Norway.
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Division of Pre-Hospital Services, Oslo University Hospital, Oslo, Norway.
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Lars Olav Fjose
- Division of Pre-Hospital Services, Innlandet Hospital Trust, Kastbakkvegen 9, 2390, Moelv, Norway
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Marius Rehn
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Pre-Hospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Hagemo
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Pre-Hospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjetil Thorsen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Fridtjof Heyerdahl
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Pre-Hospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Esteves AM, Gilchrist HE, Markwood JM, Bondurant M, Roginski MA. Evaluation of Nonintubated Analgesia Practices in Critical Care Transport. Air Med J 2023; 42:259-262. [PMID: 37356886 DOI: 10.1016/j.amj.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/15/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Current analgesia recommendations in the prehospital setting are not specific to critical care transport. Variation exists in the recommended agent and dosing strategies. Furthermore, there is a paucity of literature evaluating benzodiazepine and opiate coadministration, which may place patients at risk for respiratory decompensation. METHODS This was a retrospective chart review of nonintubated adult critical care transport patients between July 1, 2020, and July 1, 2022, who received fentanyl or ketamine during transport. The primary outcome was the proportion of patients oversedated. The secondary outcomes were characterization of analgesic medication use during transport, the percentage of patients coadministered benzodiazepines, naloxone administration, and escalation of respiratory intervention. RESULTS Three hundred seventy-six patients were administered fentanyl or ketamine during transport. Eleven patients were oversedated. Three hundred twenty-four patients received fentanyl monotherapy, and 52 received combination therapy. Patients who received benzodiazepines had higher odds of oversedation (odds ratio = 5.75; 95% confidence interval, 1.6-20.7). Two hundred thirty-six patients required an escalation in respiratory support, most commonly an increase from room air to nasal cannula. No patients had naloxone administered. CONCLUSION The rate of oversedation of nonintubated adult critical care transport patients receiving fentanyl or ketamine is low. Coadministration of benzodiazepines increases the risk of oversedation.
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Affiliation(s)
| | | | | | | | - Matthew A Roginski
- Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH.
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Fabbri A, Voza A, Riccardi A, Serra S, Iaco FD. The Pain Management of Trauma Patients in the Emergency Department. J Clin Med 2023; 12:jcm12093289. [PMID: 37176729 PMCID: PMC10179230 DOI: 10.3390/jcm12093289] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/20/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
The vast majority of injured patients suffer from pain. Systematic assessment of pain on admission to the emergency department (ED) is a cornerstone of translating the best treatment strategies for patient care into practice. Pain must be measured with severity scales that are validated in clinical practice, including for specific populations (such as children and older adults). Although primary care ED of trauma patients focuses on resuscitation, diagnosis and treatment, pain assessment and management remains a critical element as professionals are not prepared to provide effective and early therapy. To date, most EDs have pain assessment and management protocols that take into account the patient's hemodynamic status and clinical condition and give preference to non-pharmacological approaches where possible. When selecting medications, the focus is on those that are least disruptive to hemodynamic status. Pain relief may still be necessary in hemodynamically unstable patients, but caution should be exercised, especially when using opioids, as absorption may be impaired or shock may be exacerbated. The analgesic dose of ketamine is certainly an attractive option. Fentanyl is clearly superior to other opioids in initial resuscitation and treatment as it has minimal effects on hemodynamic status and does not cause central nervous system depression. Inhaled analgesia techniques and ultrasound-guided nerve blocks are also increasingly effective solutions. A multimodal pain approach, which involves the use of two or more drugs with different mechanisms of action, plays an important role in the relief of trauma pain. All EDs must have policies and promote the adoption of procedures that use multimodal strategies for effective pain management in all injured patients.
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Affiliation(s)
- Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Antonio Voza
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, 20089 Milano, Italy
| | | | - Sossio Serra
- Emergency Department, AUSL Romagna, Ospedale M. Bufalini, 47521 Cesena, Italy
| | - Fabio De Iaco
- Struttura Complessa di Medicina di Emergenza Urgenza, Ospedale Maria Vittoria, ASL Città di Torino, 10144 Torino, Italy
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