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de Grunt MN, de Jong B, Hollmann MW, Ridderikhof ML, Weenink RP. Parenteral, Non-Intravenous Analgesia in Acute Traumatic Pain-A Narrative Review Based on a Systematic Literature Search. J Clin Med 2024; 13:2560. [PMID: 38731088 PMCID: PMC11084350 DOI: 10.3390/jcm13092560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Traumatic pain is frequently encountered in emergency care and requires immediate analgesia. Unfortunately, most trauma patients report sustained pain upon arrival at and discharge from the Emergency Department. Obtaining intravenous access to administer analgesics can be time-consuming, leading to treatment delay. This review provides an overview of analgesics with both fast onset and parenteral, non-intravenous routes of administration, and also indicates areas where more research is required.
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Affiliation(s)
- Midas N. de Grunt
- Department of Anaesthesiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (M.N.d.G.); (B.d.J.); (M.W.H.)
| | - Bianca de Jong
- Department of Anaesthesiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (M.N.d.G.); (B.d.J.); (M.W.H.)
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (M.N.d.G.); (B.d.J.); (M.W.H.)
| | - Milan L. Ridderikhof
- Department of Emergency Medicine, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands;
| | - Robert P. Weenink
- Department of Anaesthesiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (M.N.d.G.); (B.d.J.); (M.W.H.)
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Lvovschi VE, Carrouel F, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription. Front Public Health 2024; 12:1352833. [PMID: 38454991 PMCID: PMC10918692 DOI: 10.3389/fpubh.2024.1352833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Background Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon. Objective This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED. Methods A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression. Results A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not. Conclusion This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.
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Affiliation(s)
- Virginie E. Lvovschi
- Emergency Department, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Laboratory “Research on Healthcare Performance” (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Florence Carrouel
- Laboratory “Health, Systemic, Process” (P2S), UR4129, University Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | - Karl Hermann
- Rouen University Hospital, CIC-CRB 1404, Rouen, France
| | - Frédéric Lapostolle
- SAMU 93, UF Research and Teaching quality, Avicenne Hospital-APHP, Bobigny, France
- INSERM U942, Sorbonne Paris Cité, Paris 13 University, Paris, France
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, Rouen, France
| | - Marie-Pierre Tavolacci
- Rouen University Hospital, CIC-CRB 1404, Rouen, France
- Univ Rouen Normandie, UMR1073 ADEN, Rouen, France
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Qizilbash N, Kataria H, Jarman H, Bloom B, Bradney M, Oh M, Yee SA, Roncero A, Mendez I, Pocock S. Real world safety of methoxyflurane analgesia in the emergency setting: a comparative hybrid prospective-retrospective post-authorisation safety study. BMC Emerg Med 2023; 23:100. [PMID: 37649004 PMCID: PMC10469512 DOI: 10.1186/s12873-023-00862-2] [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: 11/29/2022] [Accepted: 08/03/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Low-dose analgesic methoxyflurane (Penthrox®) was approved in Europe for emergency relief of moderate to severe pain in conscious adults with trauma in 2015. A comparative post-authorisation safety study (PASS) was conducted to assess the risk of hepatotoxicity and nephrotoxicity with methoxyflurane during routine clinical practice. METHODS This was a comparative hybrid prospective-retrospective cohort study. The comparative cohorts consisted of adults who were given methoxyflurane (methoxyflurane cohort) or another analgesic (concurrent cohort) routinely used for moderate to severe trauma and associated pain in the emergency setting (ambulance and Emergency Department) in the UK between December 2016 and November 2018. Hepatic and renal events were captured in the ensuing 12 weeks. A blinded clinical adjudication committee assessed events. A historical comparator cohort (non-concurrent cohort) was identified from patients with fractures in the English Hospital Episode Statistics (HES) accident and emergency database from November 2013 and November 2015 (before commercial launch of methoxyflurane). Hepatic and renal events were captured in the ensuing 12 weeks via linkage with the Clinical Practice Research Datalink (CPRD) and HES hospital admissions databases. RESULTS Overall, 1,236, 1,101 and 45,112 patients were analysed in the methoxyflurane, concurrent and non-concurrent comparator cohorts respectively. There was no significant difference in hepatic events between the methoxyflurane and concurrent cohorts (1.9% vs. 3.0%, P = 0.079) or between the methoxyflurane and non-concurrent cohorts (1.9% vs. 2.5%, P = 0.192). Renal events were significantly less common in the methoxyflurane cohort than in the concurrent cohort (2.3% vs. 5.6%, P < 0.001). For methoxyflurane versus non-concurrent cohort the lower occurrence of renal events (2.3% vs. 3.2%, P = 0.070) was not statistically significant. Multivariable adjustment did not change these associations. CONCLUSIONS Methoxyflurane administration was not associated with an increased risk of hepatotoxicity or nephrotoxicity compared with other routinely administered analgesics and was associated with a reduced risk of nephrotoxicity compared with other routinely administered analgesics. TRIAL REGISTRATION Study registered in the EU PAS Register (ENCEPP/SDPP/13040).
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Affiliation(s)
- Nawab Qizilbash
- OXON Epidemiology, London, UK.
- London School of Hygiene & Tropical Medicine, London, UK.
| | - Himanshu Kataria
- St Helens and Knowsley NHS Foundation Trust (Whiston Hospital), Prescot, UK
| | | | | | | | - Maggie Oh
- Medical Developments International Limited, Victoria, Australia
| | - Sue Anne Yee
- Medical Developments International Limited, Victoria, Australia
| | | | | | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, London, UK
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Ghazali DA, Bouzid D, Frachon A, Ait-Abdesselam S, Kenway P, Choquet C, Casalino E. Pain Self-Management with Inhaled Methoxyflurane by Emergency Department Trauma Patients: A Prospective, Interventional, Single-Center Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6107. [PMID: 37372694 DOI: 10.3390/ijerph20126107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has led to overcrowding in many emergency departments (EDs). The present single-center, prospective, interventional study (conducted at Bichat University Medical Center (Paris, France)) was designed to assess the impact of self-administered, inhaled, low-dose methoxyflurane on trauma pain in a pre-ED fast-track zone dedicated to the management of lower-acuity non-COVID-19 patients. In the first phase of the study, the control group consisted of patients with mild-to-moderate trauma pain, for whom the triage nurse initiated pain management (based on the World Health Organization (WHO)'s analgesic ladder). In the second phase, the intervention group consisted of similar patients who self-administered methoxyflurane as an adjuvant to the standard analgesic ladder. The primary endpoint was the numerical pain rating scale (NPRS) score (from 0 to 10) recorded at different time points during the patient's care (T0: arrival in the ED, T1: exit from the triage box, T2: in the radiology department, T3: clinical examination, and T4: discharge from the ED). The level of agreement between the NPRS and the WHO analgesic ladder was assessed by the calculation of Cohen's kappa. Pairwise comparisons of continuous variables were performed with Student's t-test or a non-parametric Mann-Whitney U test. Changes over time in the NPRS were analyzed in an analysis of variance (with Scheffe's post hoc test if a pairwise comparison was significant) or a non-parametric Kruskal-Wallis H test. In all, 268 and 252 patients were included in the control and intervention groups, respectively. The two groups had similar characteristics. The level of agreement between the NPRS score and the analgesic ladder was high in both the control and intervention groups (Cohen's kappa: 0.74 and 0.70, respectively). The NPRS score decreased significantly between T0 and T4 in both groups (p < 0.001), but the decrease between T2 and T4 was significantly greater in the intervention group (p < 0.001). The proportion of patients still in pain on discharge was significantly lower in the intervention group than in the control group (p = 0.001). In conclusion, a combination of self-administered methoxyflurane and the WHO analgesic ladder improves pain management in the ED.
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Affiliation(s)
- Daniel Aiham Ghazali
- Emergency Department and Emergency Medical Services, Amiens University Medical Center, 1 Rond-Point du Professeur Christian Cabrol, 80000 Amiens, France
- DREAMS (Department of Research in Emergency Medicine and Simulation) Research Unit, Amiens University Medical Center and Jules Verne University of Picardie, 80000 Amiens, France
- IAME "Infection, Antimicrobials, Modelling, Evolution" Research Unit, INSERM UMR1137, University of Paris Cité, 75018 Paris, France
| | - Donia Bouzid
- IAME "Infection, Antimicrobials, Modelling, Evolution" Research Unit, INSERM UMR1137, University of Paris Cité, 75018 Paris, France
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
| | - Alix Frachon
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
| | | | - Philippe Kenway
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
| | - Christophe Choquet
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
| | - Enrique Casalino
- IAME "Infection, Antimicrobials, Modelling, Evolution" Research Unit, INSERM UMR1137, University of Paris Cité, 75018 Paris, France
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
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Türkmen S, Zaki H, Azad A, Bashir K, Elmoheen A, Shaban E, Iftikhar H, Shallik N. Clinical assessment and risk stratification for prehospital use of methoxyflurane versus standard analgesia in adult patients with trauma pain. Turk J Emerg Med 2023; 23:65-74. [PMID: 37169029 PMCID: PMC10166294 DOI: 10.4103/tjem.tjem_229_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/11/2022] [Accepted: 09/22/2022] [Indexed: 01/28/2023] Open
Abstract
Oligoanalgesia, the undertreatment of trauma-related pain using standard analgesics in prehospital and emergency departments, has been extensively documented as one of the major challenges affecting the effective treatment of trauma-related pain. When administered in low doses, methoxyflurane has been highlighted by numerous medical works of literature to provide an effective, nonopioid, nonnarcotic treatment alternative to standard analgesics for prehospital and emergency department use. Low-dose methoxyflurane has been associated with fast-pain relief in adult patients manifesting moderate-to-severe pain symptoms. This systematic review and meta-analysis aimed to assess the clinical implication of low-dose methoxyflurane use in prehospital and emergency departments in adult patients with moderate-to-severe trauma-related pain. Moreover, the review aimed at assessing the risk stratification associated with using low-dose methoxyflurane in prehospital and emergency departments. The systematic review and meta-analysis performed a comprehensive search for pertinent literature assessing the implications and risks of using low-dose methoxyflurane in adult patients exhibiting moderate-to-severe trauma-related pain in prehospital settings. A comparison between the use of low-dose methoxyflurane and standard-of-care analgesics, placebo, in prehospital settings was reported in four clinically conducted randomized controlled trials (RCTs). These RCTs included the STOP! trial, InMEDIATE, MEDIATA, and the PenASAP trials. A meta-analysis comparing the time taken to achieve first pain relief on initial treatment of patients with moderate-to-severe trauma-related pain favored the use of low-dose methoxyflurane to the standard-of-care analgesics (mean difference = -6.63, 95% confidence interval = -7.37, -5.09) on time taken to establish effective pain relief. Low-dose methoxyflurane has been associated with superior and faster pain relief in prehospital and emergency departments in adult patients exhibiting moderate-to-severe trauma-related pain compared to other standard analgesics.
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Smith MD, Rowan E, Spaight R, Siriwardena AN. Evaluation of the effectiveness and costs of inhaled methoxyflurane versus usual analgesia for prehospital injury and trauma: non-randomised clinical study. BMC Emerg Med 2022; 22:122. [PMID: 35799131 PMCID: PMC9261021 DOI: 10.1186/s12873-022-00664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/01/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We aimed to investigate clinical benefits and economic costs of inhaled methoxyflurane when used by ambulance staff for prehospital emergency patients with trauma. Comparison is to usual analgesic practice (UAP) in the UK in which patient records were selected if treatment had been with Entonox® or intravenous morphine or intravenous paracetamol. METHODS Over a 12-month evaluation period, verbal numerical pain scores (VNPS) were gathered from adults with moderate to severe trauma pain attended by ambulance staff trained in administering and supplied with methoxyflurane. Control VNPS were obtained from ambulance database records of UAP in similar patients for the same period. Statistical modelling enabled comparisons of methoxyflurane to UAP, where we employed an Ordered Probit panel regression model for pain, linked by observational rules to VNPS. RESULTS Overall, 96 trained paramedics and technicians from the East Midlands Ambulance Service NHS Trust (EMAS) prepared 510 doses of methoxyflurane for administration to a total of 483 patients. Comparison data extracted from the EMAS database of UAP episodes involved: 753 patients using Entonox®, 802 patients using intravenous morphine, and 278 patients using intravenous paracetamol. Modelling results included demonstration of faster pain relief with inhaled methoxyflurane (all p-values < 0.001). Methoxyflurane's time to achieve maximum pain relief was estimated to be significantly shorter: 26.4 min (95%CI 25.0-27.8) versus Entonox® 44.4 min (95%CI 39.5-49.3); 26.5 min (95%CI 25.0-27.9) versus intravenous morphine 41.8 min (95%CI 38.9-44.7); 26.5 min (95%CI 25.1-28.0) versus intravenous paracetamol 40.8 (95%CI 34.7-46.9). Scenario analyses showed that durations spent in severe pain were significantly less for methoxyflurane. Costing scenarios showed the added benefits of methoxyflurane were achieved at higher cost, eg versus Entonox® the additional cost per treated patient was estimated to be £12.30. CONCLUSION When administered to adults with moderate or severe pain due to trauma inhaled methoxyflurane reduced pain more rapidly and to a greater extent than Entonox® and parenteral analgesics. Inclusion of inhaled methoxyflurane to the suite of prehospital analgesics provides a clinically useful addition, but one that is costlier per treated patient.
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Affiliation(s)
- Murray D Smith
- Community and Health Research Unit, University of Lincoln, Lincoln, UK.
| | - Elise Rowan
- Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - Robert Spaight
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust, Nottingham, UK
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Abu-Snieneh HM, Alsharari AF, Abuadas FH, Alqahtani ME. Effectiveness of pain management among trauma patients in the emergency department, a systematic review. Int Emerg Nurs 2022; 62:101158. [DOI: 10.1016/j.ienj.2022.101158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/10/2022] [Accepted: 02/24/2022] [Indexed: 11/05/2022]
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Trimmel H, Egger A, Doppler R, Pimiskern M, Voelckel WG. Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study. BMC Emerg Med 2022; 22:8. [PMID: 35033003 PMCID: PMC8760876 DOI: 10.1186/s12873-021-00565-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/23/2021] [Indexed: 12/17/2022] Open
Abstract
Background Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria. Methods Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients. Results Median numeric pain rating was 8.0 (7.0–8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed. Conclusion In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.
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Affiliation(s)
- Helmut Trimmel
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, General Hospital, Corvinusring 3-5, A-2700, Wiener Neustadt, Austria. .,Karl Landsteiner Institute for Emergency Medicine, Corvinusring 3-5, A-2700, Wiener Neustadt, Austria. .,Christophorus Air Rescue, OeAMTC, Baumgasse 129, A-1030, Vienna, Austria.
| | - Alexander Egger
- Christophorus Air Rescue, OeAMTC, Baumgasse 129, A-1030, Vienna, Austria.,Department of Anaesthesiology and Intensive Care Medicine, General Hospital Scheibbs, Eisenwurzenstraße 26, A-3270, Scheibbs, Austria
| | - Reinhard Doppler
- Christophorus Air Rescue, OeAMTC, Baumgasse 129, A-1030, Vienna, Austria.,Department of Anaesthesiology and Intensive Care Medicine, General Hospital Rottenmann, St. Georgen 2-4, A-8786, Rottenmann, Austria
| | - Mathias Pimiskern
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, General Hospital, Corvinusring 3-5, A-2700, Wiener Neustadt, Austria.,Christophorus Air Rescue, OeAMTC, Baumgasse 129, A-1030, Vienna, Austria
| | - Wolfgang G Voelckel
- Christophorus Air Rescue, OeAMTC, Baumgasse 129, A-1030, Vienna, Austria.,Department of Anaesthesiology and Critical Care Medicine, AUVA Trauma Centre Salzburg, Salzburg, Austria.,Paracelsus Private Medical University of Salzburg, Salzburg, Austria.,Department of Health Studies, University of Stavanger, Stavanger, Norway
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Effect of a reminder on the pain relief of morphine-requesting patients in an emergency department. Eur J Emerg Med 2021; 28:476-478. [PMID: 34714815 DOI: 10.1097/mej.0000000000000813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lvovschi VE, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices. J Clin Med 2021; 10:jcm10215089. [PMID: 34768612 PMCID: PMC8584399 DOI: 10.3390/jcm10215089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.
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Affiliation(s)
- Virginie Eve Lvovschi
- Emergency Department, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France
- Correspondence:
| | - Karl Hermann
- Rouen University Hospital, INSERM CIC-CRB 1404, F-76000 Rouen, France;
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, INSERM U 942, Hôpital Avicenne, F-93009 Bobigny, France;
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, F-76031 Rouen, France;
| | - Marie-Pierre Tavolacci
- Normandie University, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France;
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[Volatile anesthetics for prehospital analgesia by paramedics-An overview]. Anaesthesist 2021; 71:233-242. [PMID: 34664081 PMCID: PMC8522536 DOI: 10.1007/s00101-021-01051-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 10/28/2022]
Abstract
Treatment of acute pain is a central task in emergency medicine. Yet, prehospital pain relief is often insufficient or delayed since the administration of potent intravenous analgesic drugs (such as opioids) is mostly limited to physicians due to legal restrictions or training deficiencies in Germany and Austria. Frequently, prehospitally operating emergency physicians have to be demanded later for anguished patients limiting disposability of physicians for patients who are in a potentially life-threatening condition. Thus, inhaled analgesics could represent an interesting alternative.A mixture of 50% nitrous oxide and 50% oxygen (N2O, Livopan®) has been available in Germany and Austria for several years; however, prehospital use of Livopan has been merely realized and only one trial has been published. In addition, methoxyflurane (Penthrop®), a volatile anesthetic from the group of the dialkyl esters (2-dichloro-1:1-difluoroethyl-methyl-ester) was approved for the treatment of moderate to severe pain following trauma in adults in many European countries in recent years and was brought onto the market in Austria in 2018. Several in-hospital trials demonstrated high effectiveness in this setting.This article discusses the effects and prehospital areas of application of both substances in the light of the existing literature. We provide a narrative overview of the current study situation and report on a recently performed prehospital application study of methoxyflurane (Penthrop®) from Austria.The need for pressurized gas cylinders for the use of N2O represents a certain limitation in prehospital use. Furthermore, in certain injuries such as of the inner ear or a pneumothorax N2O should not be used and the risk of diffusion hypoxemia has to be addressed. Users should be particularly careful and limit the use in alcohol addicts and vegans. The advances of N2O are that it is odorless, has a fast onset of action, the usability in patients over 1 month old and has stabilizing effects on the circulation. Plenty of literature regarding prehospital as well as in-hospital use of nitrous oxide in emergency, obstetric and pediatric settings show its effectiveness as a single drug as well as in combination with other analgesics, such as paracetamol or various opioids. Its long tradition in Anglo-American countries is also based on its safety and low rate of side effects.Methoxyflurane is easier to store and handle and may be slightly more effective in severe pain after trauma; however, its approval is restricted to adults, where it works significantly better with increasing age, based on the declining minimal alveolar concentration (MAC) of all inhaled anesthetics with increasing age. Furthermore, decades of use of inhaled methoxyflurane in Australia have shown the drug is effective, safe and low in side effects and has a broad spectrum of applications. The use of methoxyflurane is limited in patients with severe hepatic or renal insufficiency and the characteristic odor has been described as unpleasant by some patients. In Europe, three large in-hospital trials showed strong pain relief in trauma patients, even comparable to opioids.Overall, based on the current evidence, the use of nitrous oxide and even more of methoxyflurane may be recommended also for prehospital use by skilled paramedics.
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Bussienne F, Reynaud T. Methoxyflurane May Be a Suitable Analgesic for Extreme Prehospital Conditions. Wilderness Environ Med 2021; 32:261-264. [PMID: 33839014 DOI: 10.1016/j.wem.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Frédéric Bussienne
- Department of Anaesthesia, University Hospital of Lausanne, Lausanne, Switzerland
| | - Thomas Reynaud
- Department of Anaesthesia, Hôpital de la Tour, Genève, Switzerland
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Liu H, Fu X, Ren YF, Tan SY, Xiang SR, Zheng C, You FM, Shi W, Li LJ. Does Inhaled Methoxyflurane Implement Fast and Efficient Pain Management in Trauma Patients? A Systematic Review and Meta-Analysis. Pain Ther 2021; 10:651-674. [PMID: 33837931 PMCID: PMC8119536 DOI: 10.1007/s40122-021-00258-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/16/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction Evidence on the use of inhaled methoxyflurane in the management of trauma pain is conflicting and obfuscated. This study aimed to determine the efficacy and safety of inhaled methoxyflurane for trauma pain on the basis of published randomized controlled trials (RCTs). Methods RCTs assessing the efficacy of methoxyflurane in adults or adolescents with acute trauma pain published in PubMed, Web of Science, Embase, Cochrane Library, and Google Scholar were searched. The control groups were those that received placebo or standard analgesic treatment (SAT). The primary outcome was the change from baseline in pain scores during the first 30 min of treatment. Secondary outcomes included time to first pain relief, the proportion of patients experiencing pain relief, rescue analgesia rate, the treatment satisfaction of patients and investigators, and the methoxyflurane-related treatment-emergent adverse events (TEAEs). Results A total of nine RCTs (1806 patients) were identified. Results revealed that methoxyflurane provided a clinically unimportant benefit by improving the mean difference of change from baseline in pain intensity (from − 0.44 to − 1.23 cm, p < 0.001) at various time points within the first 20 min compared to control treatment. Besides, methoxyflurane decreased the time of onset of pain relief (mean difference − 5.29 min; 95% CI − 6.97 to − 3.62) and the proportion of patients who needed rescue analgesic medication (risk ratio 1.41; 95% CI 1.17–1.70) despite it increasing the risk of non-severe TEAEs (risk ratio 3.09; 95% CI 1.72–5.57). Notably, the benefit of almost all secondary pain-related outcomes was rendered clinically nonsignificant between methoxyflurane and SAT strata besides the time of onset of pain relief. The quality of evidence was low or very low in all outcomes. Conclusions In emergency situations without effective therapy, this systematic review and meta-analysis provides low-quality evidence that methoxyflurane can be used as a rapid-acting and effective treatment for acute trauma pain, although its utilization is associated a risk of non-severe TEAEs. However, the current evidence does not support the notion that inhaled methoxyflurane offered superior analgesic efficacy to SAT. Clinical Trial Number PROSPERO registration number CRD42020223000. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-021-00258-9.
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Affiliation(s)
- Hong Liu
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Xi Fu
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Yi-Feng Ren
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China.
| | - Shi-Yan Tan
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Si-Rui Xiang
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Chuan Zheng
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Feng-Ming You
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Wei Shi
- Department of Anesthesiology, West China Hospital, Sichuan University and the Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China.
| | - Lin-Jiong Li
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China.
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Eager MM, Nolan GS, Tonks K, Ramjeeawon A, Taylor N. Inhaled methoxyflurane (Penthrox) for analgesia in trauma: a systematic review protocol. Syst Rev 2021; 10:47. [PMID: 33536052 PMCID: PMC7860209 DOI: 10.1186/s13643-021-01600-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/26/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND More than 75% of patients presenting to the Emergency Department are suffering symptoms of pain. Despite this, 67% will not receive any analgesia. Methoxyflurane is a fluorinated hydrocarbon gas which has analgesic properties when inhaled. Penthrox is a methoxyflurane autoinhaler recently licenced in Europe. Its ease of administration, safety, and fast onset of action make it of particular relevance to emergency medicine. Additionally, outside the hospital, it has the advantage of increased temperature stability and portability over current standard care. New evidence of its efficacy is emerging; however, currently, its use in Europe is not widespread. The objective of this study will be to systematically evaluate the evidence on inhaled methoxyflurane to determine if it is a superior analgesia in the acute trauma setting. METHODS We designed and registered a study protocol for a systematic review and meta-analysis on randomised controlled trials, comparing inhaled methoxyflurane and either placebo or standard care. A comprehensive search will be conducted from database inception onwards in MEDLINE, Embase, and the Cochrane CENTRAL database, concurrent with a search of the grey literature for other relevant studies, including clinical trial databases. Only randomised controlled trials will be included. No limitations will be imposed on publication status or language of publication. The primary outcome will be mean difference in patient-reported pain at time points within the first 30 min of administration. Secondary outcomes will be mean difference in time to clinically significant pain relief and relative risk of adverse effects. Two reviewers will independently screen all returned studies and collect data. Disagreements will be resolved through discussion or referral to a third reviewer. Individual study methodological quality will be appraised using an appropriate tool. If feasible, we will conduct a random effects meta-analysis; if this is not possible, we will construct a narrative synthesis. DISCUSSION This systematic review will summarise the best available evidence and definitively establish if inhaled methoxyflurane is a superior analgesia to standard care in the acute trauma setting. This knowledge will directly impact emergency care in the UK and worldwide and may require amendments to European pain relief guidelines. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020189119 .
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Affiliation(s)
- Michael M Eager
- Academic Department of Military General Practice & Primary Care, Research and Clinical Innovation, Royal Centre for Defence Medicine, HQ Joint Medical Group, ICT Centre, Vincent Drive, Edgbaston, Birmingham, B15 2SQ, UK.,Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Mindelsohn Way, Edgbaston, B15 2TH, UK
| | - Grant S Nolan
- Division of Surgery & Interventional Science, University College London, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.,Department of Plastic and Reconstructive Surgery, Whiston Hospital, St. Helens and Knowsley Teaching Hospitals NHS Trust, Warrington Road, Prescot, Merseyside, L35 5DR, UK
| | - Kathryn Tonks
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Mindelsohn Way, Edgbaston, B15 2TH, UK
| | - Anoopama Ramjeeawon
- Division of Surgery & Interventional Science, University College London, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.
| | - Natalie Taylor
- Academic Department of Military General Practice & Primary Care, Research and Clinical Innovation, Royal Centre for Defence Medicine, HQ Joint Medical Group, ICT Centre, Vincent Drive, Edgbaston, Birmingham, B15 2SQ, UK
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Fabbri A, Borobia AM, Ricard-Hibon A, Coffey F, Caumont-Prim A, Montestruc F, Soldi A, Traseira Lugilde S, Dickerson S. Low-Dose Methoxyflurane versus Standard of Care Analgesics for Emergency Trauma Pain: A Systematic Review and Meta-Analysis of Pooled Data. J Pain Res 2021; 14:93-105. [PMID: 33505170 PMCID: PMC7829133 DOI: 10.2147/jpr.s292521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/06/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Undertreatment of trauma-related pain is common in the pre-hospital and hospital settings owing to barriers to the use of traditional standard of care analgesics. Low-dose methoxyflurane is an inhaled non-opioid analgesic with a rapid onset of pain relief that is approved for emergency relief of moderate-to-severe trauma-related pain in adults. This analysis was performed to compare the efficacy and safety of low-dose methoxyflurane with standard of care analgesics in adults with trauma-related pain. Methods A meta-analysis was performed on pooled data from randomized controlled trials identified via a systematic review. The primary endpoint was the pain intensity difference between baseline and various time intervals (5, 10, 15, 20, and 30 minutes) after initiation of treatment. Results The pain intensity difference was statistically superior with low-dose methoxyflurane compared with standard of care analgesics (overall estimated treatment effect=11.88, 95% CI=9.75–14.00; P<0.0001). The superiority of low-dose methoxyflurane was demonstrated at 5 minutes after treatment initiation and was maintained across all timepoints. Significantly more patients treated with methoxyflurane achieved response criteria of pain intensity ≤30 mm on a visual analog scale, and relative reductions in pain intensity of ≥30% and ≥50%, compared with patients who received standard of care analgesics. The median time to pain relief was shorter with methoxyflurane than with standard of care analgesics. The findings were consistent in a subgroup of elderly patients (aged ≥65 years). Conclusion Methoxyflurane can be considered as an alternative to standard of care analgesics in pre-hospital and hospital settings for treatment of adult patients with acute trauma-related pain.
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Affiliation(s)
- Andrea Fabbri
- Department of Emergency Medicine, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Alberto M Borobia
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, Spain
| | - Agnes Ricard-Hibon
- Emergency Department SAMU-SMUR 95, CHG Pontoise-Beaumont/Oise, Pontoise, France
| | - Frank Coffey
- DREEAM: Department of Research and Education in Emergency Medicine, Acute Medicine and Major Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Affiliation(s)
| | - Said Laribi
- Emergency Medicine Department, CHU Tours
- Medical school, University of Tours, France
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17
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Fabbri A, Ruggiano G, Garcia Collado S, Ricard-Hibon A, Restelli U, Sbrana G, Marinangeli F, Farina A, Coffey F. Role of Inhaled Methoxyflurane in the Management of Acute Trauma Pain. J Pain Res 2020; 13:1547-1555. [PMID: 32612382 PMCID: PMC7323816 DOI: 10.2147/jpr.s252222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/06/2020] [Indexed: 11/23/2022] Open
Abstract
Adequate treatment of trauma pain is an integral part of the management of trauma patients, not just for ethical reasons but also because undertreated pain can lead to increased morbidities and worse long-term outcomes. Trauma pain management presents challenges in the pre-hospital setting, particularly in adverse or hostile environments as well as in busy emergency departments (EDs). Inhaled methoxyflurane, administered at analgesic doses via a disposable inhaler, has recently become available in Europe for the emergency treatment of moderate to severe pain in conscious adult trauma patients. A growing body of evidence demonstrates that inhaled methoxyflurane is well tolerated and effective in providing a rapid onset of analgesia. In this paper, we discuss the rationale for methoxyflurane use in trauma pain management, data from clinical trials recently conducted in Europe, its efficacy and safety profile compared to current standard treatments, its place in therapy and organizational impact. We conclude that inhaled methoxyflurane represents an effective treatment option in the different settings where trauma patients require rapid and flexible pain resolution, with potential organizational advantages.
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Affiliation(s)
- Andrea Fabbri
- Department of Emergency Medicine, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Germana Ruggiano
- Emergency Medicine Department, Santa Maria Annunziata Hospital, Florence, Italy
| | | | - Agnes Ricard-Hibon
- Service SAMU-SMUR-SAU, GHT Nord Ouest Vexin Val d’Oise, Pontoise95, France
| | - Umberto Restelli
- Center for Health Economics, Social and Health Care Management, LIUC - Università Cattaneo, Castellanza, VA, Italy
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Giovanni Sbrana
- Anaesthesia, Intensive Care, Emergency Medicine, Grosseto HEMS, ASL Toscana Sud Est, Grosseto, Italy
| | - Franco Marinangeli
- Department of Anesthesiology and Intensive Care, University of L’Aquila, L’Aquila, Italy
| | - Alberto Farina
- Medical Affairs Department, Mundipharma Pharmaceuticals Srl, Milan, Italy
| | - Frank Coffey
- DREEAM - Department of Research and Education in Emergency Medicine Acute Medicine and Major Trauma, Nottingham University Hospitals’ NHS Trust, Nottingham, UK
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