Effectiveness and safety of fentanyl compared with morphine for out-of-hospital analgesia

[Prehospital analgesia with nalbuphine and paracetamol compared to piritramide by paramedics-A multicenter observational study]

OBJECTIVE

Following recent changes to the German Narcotics Act, this article examines prehospital analgesia by paramedics using piritramide vs. nalbuphine + paracetamol.

MATERIAL AND METHODS

Prehospital analgesia administered by paramedics from the Fulda (piritramide) and Gütersloh (nalbuphine + paracetamol) emergency services was compared regarding pain intensity at the beginning and end of the mission, measured using the numeric rating scale (NRS). Additionally, an analysis of the resulting complications was carried out.

RESULTS

In this study 2429 administrations of analgesia were evaluated (nalbuphine + paracetamol: 1635, 67.3%, initial NRS: 8.0 ± 1.4, end of NRS: 3.7 ± 2.0; piritramide: 794, 32.7%, initial NRS: 8.5 ± 1.1, end of NRS: 4.5 ± 1.6). Factors influencing NRS change were initial NRS (regression coefficient, RC: 0.7075, 95% confidence interval, CI: 0.6503-0.7647, p < 0.001), treatment with nalbuphine + paracetamol (RC: 0.6048, 95% CI: 0.4396-0.7700, p < 0.001). Treatment with nalbuphine + paracetamol (n = 796 (48.7%)) compared to piritramide (n = 190 (23.9%)) increased the odds of achieving NRS < 4 (odds ratio, OR: 2.712, 95% CI: 2.227-3.303, p < 0.001). Complications occurred in n = 44 (5.5%) with piritramide and in n = 35 (2.1%) with nalbuphine + paracetamol. Risk factors for complications were analgesia with piritramide (OR: 2.699, 95% CI: 1.693-4.301, p < 0.001), female sex (OR: 2.372, 95% CI: 1.396-4.029, p = 0.0014), and age (OR: 1.013, 95% CI: 1.002-1.025, p = 0.0232).

CONCLUSION

Compared with piritramide, prehospital analgesia with nalbuphine + paracetamol has favorable effects in terms of analgesic efficacy and complication rates and should therefore be considered in future recommendations for paramedics.

Alfentanil for Pain Relief in a Swedish Emergency Medical Service - An Eleven-Year Follow-up on Safety and Effect

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.

Beyond Traditional Pain Relief: A Review of Alternative Analgesics in Myocardial Infarction Patient Management

While morphine is the recommended first-line treatment for pain management in patients with acute coronary syndrome, recent studies have raised concerns about its association with adverse outcomes. Morphine has been found to cause delayed antiplatelet effects, decreased ticagrelor absorption, increased platelet reactivity, and compromised efficacy of dual antiplatelet therapy (DAPT). Alternative analgesics, such as lidocaine, fentanyl, and acetaminophen, have begun to emerge as viable alternatives, each with unique mechanisms and potential benefits. Lidocaine is demonstrated to have superior effects in reducing microvascular obstruction and fewer adverse events compared to fentanyl, despite being less effective in pain reduction. Fentanyl, which shows rapid onset and powerful analgesic properties, may interfere with ticagrelor absorption, potentially affecting platelet inhibition. Acetaminophen, a centrally acting analgesic, emerges as a safer alternative with comparable pain relief efficacy and minimal side effects. The results of multiple clinical trials emphasize the significance of customizing pain management approaches to match individual patient profiles and achieving the optimal balance between pain relief and potential adverse outcomes.

Effectiveness and safety of prehospital analgesia with nalbuphine and paracetamol versus morphine by paramedics - an observational study

BACKGROUND

Despite the development of various analgesic concepts, prehospital oligoanalgesia remains very common. The present work examines prehospital analgesia by paramedics using morphine vs. nalbuphine + paracetamol.

METHODS

Patients with out-of-hospital-analgesia performed by paramedics from the emergency medical services of the districts of Fulda (morphine) and Gütersloh (nalbuphine + paracetamol) were evaluated with regards to pain intensity at the beginning and the end of prehospital treatment using the Numeric-Rating-Scale for pain (NRS), sex, age, and complications. The primary endpoint was achievement of adequate analgesia, defined as NRS < 4 at hospital handover, depending on the analgesics administered (nalbuphine + paracetamol vs. morphine). Pain intensity before and after receiving analgesia using the NRS, sex, age and complications were also monitored.

RESULTS

A total of 1,808 patients who received out-of-hospital-analgesia were evaluated (nalbuphine + paracetamol: 1,635 (90.4%), NRS-initial: 8.0 ± 1.4, NRS-at-handover: 3.7 ± 2.0; morphine: 173(9.6%), NRS-initial: 8.5 ± 1.1, NRS-at-handover: 5.1 ± 2.0). Factors influencing the difference in NRS were: initial pain intensity on the NRS (regression coefficient (RK): 0.7276, 95%CI: 0.6602-0.7950, p < 0.001), therapy with morphine vs. nalbuphine + paracetamol (RK: -1.2594, 95%CI: -1.5770 - -0.9418, p < 0.001) and traumatic vs. non-traumatic causes of pain (RK: -0.2952, 95%CI: -0.4879 - -0.1024, p = 0.002). Therapy with morphine (n = 34 (19.6%)) compared to nalbuphine + paracetamol (n = 796 (48.7%)) (odds ratio (OR): 0.274, 95%CI: 0.185-0.405, p < 0.001) and the initial NRS score (OR:0.827, 95%CI: 0.771-0.887, p < 0.001) reduced the odds of having an NRS < 4 at hospital handover. Complications occurred with morphine in n = 10 (5.8%) and with nalbuphine + paracetamol in n = 35 (2.1%) cases. Risk factors for complications were analgesia with morphine (OR: 2.690, 95%CI: 1.287-5.621, p = 0.008), female sex (OR: 2.024, 95%CI: 1.040-3.937, p = 0.0379), as well as age (OR: 1.018, 95%CI: 1.003-1.034, p = 0.02).

CONCLUSIONS

Compared to morphine, prehospital analgesia with nalbuphine + paracetamol yields favourable effects in terms of analgesic effectiveness and a lower rate of complications and should therefore be considered in future recommendations for prehospital analgesia.

Effectiveness and safety of prehospital analgesia including nalbuphine and paracetamol by paramedics: an observational study

BACKGROUND

The aim of this study was to examine the effectiveness and safety of prehospital analgesia with nalbuphine and/or paracetamol by paramedics.

METHODS

In this retrospective trial, following the implementation of a standard-operating-procedure for pain requiring treatment as defined as a score ≥4 on the 0-10 Numeric Rating Scale for pain, all emergency operations in the district of Gütersloh between January 1, 2020, and June 30, 2022, with analgesic administration by paramedics in patients ≥18 years were included in the study. Analgesic agents employed by the paramedics included nalbuphine and/or paracetamol, butylscopolamine for abdominal colic, and esketamine in case of failure of the other analgesics. The primary endpoint was the patients' rating of their pain on the Numeric Rating Scale at the end of the operation. Additional covariates included sex, cause of pain, analgesics used, Numeric Rating Scale at beginning and analgesic-associated complications (reduced level of consciousness, hypotension, desaturation, a- or bradypnea).

RESULTS

A total of 1931 emergency operations (female: N.=1039 [53.8%]) with pain requiring treatment (non-traumatic cause: N.=1106 [57.3%]; initial Numeric Rating Scale: 8.0±1.4). Analgesics applied were nalbuphine + paracetamol (50.6%), paracetamol (38.7%), butylscopolamine (13.4%), nalbuphine (7.7%), and esketamine (4.9%). Mean pain reduction was 4.3±2.3 (nalbuphine + paracetamol: 5.0±2.1; nalbuphine: 4.7±2.3) and paracetamol: 3.3±2.2, respectively. Factors influencing a change in the Numeric Rating Scale were trauma (regression-coefficient: -0.308, 95% CI: -0.496 - -0.119, P=0.0014 vs. non-trauma; nalbuphine [yes vs. no]: regression-coefficient 0.684, 95% CI 0.0774-1.291, P=0.03; nalbuphine + paracetamol: regression-coefficient 0.763, 95% CI 0.227-1.299, P=0.005). At the end of the operation, 49.7% had a Numeric Rating Scale <4, 34.3% had a Numeric Rating Scale 4-5, and 16.0% had a Numeric Rating Scale ≥6. Factors influencing a Numeric Rating Scale <4 at end of use were trauma vs. non-trauma: odds ratio 0.788, 95% CI 0.649-0.957, P=0.02. The Numeric Rating Scale at beginning reported: odds ratios 0.754, 95% CI 0.700-0.812, P<0.0001. Analgesic-associated complications were not observed.

CONCLUSIONS

Prehospital analgesia by paramedics with nalbuphine as monotherapy or in combination with paracetamol allows for sufficient analgesia without the occurrence of complications.

Detection and confirmation of fentanyls in high clay-content soil by electron ionization gas chromatography-mass spectrometry

Detection of illicit drugs in the environment, particularly in soils, often suggests the present or past location of a clandestine production center for these substances. Thus, development of efficient methods for the analysis and detection of these chemicals is of paramount importance in the field of chemical forensics. In this work, a method involving the extraction and retrospective confirmation of fentanyl, acetylfentanyl, thiofentanyl, and acetylthiofentanyl using trichloroethoxycarbonylation chemistry in a high clay-content soil is presented. The soil was spiked separately with each fentanyl at two concentrations (1 and 10 μg/g) and their extraction accomplished using ethyl acetate and aqueous NH4 OH (pH ~ 11.4) with extraction recoveries ranging from ~56% to 82% for the high-concentration (10 μg/g) samples while ranging from ~68% to 83% for the low-concentration (1 μg/g) samples. After their extraction, residues containing each fentanyl were reacted with 2,2,2-trichloroethoxycarbonyl chloride (Troc-Cl) to generate two unique and predictable products from each opioid that can be used to retrospectively confirm their presence and identity using EI-GC-MS. The method's limit of detection (MDL/LOD) for Troc-norfentanyl and Troc-noracetylfentanyl were estimated to be 29.4 and 31.8 ng/mL in the organic extracts. In addition, the method's limit of quantitation for Troc-norfentanyl and Troc-noracetylfentanyl were determined to be 88.2 and 95.5 ng/mL, respectively. Collectively, the results presented herein strengthen the use of chloroformate chemistry as an additional chemical tool to confirm the presence of these highly toxic and lethal substances in the environment.

A Scalable Radiomics- and Natural Language Processing-Based Machine Learning Pipeline to Distinguish Between Painful and Painless Thoracic Spinal Bone Metastases: Retrospective Algorithm Development and Validation Study

BACKGROUND

The identification of objective pain biomarkers can contribute to an improved understanding of pain, as well as its prognosis and better management. Hence, it has the potential to improve the quality of life of patients with cancer. Artificial intelligence can aid in the extraction of objective pain biomarkers for patients with cancer with bone metastases (BMs).

OBJECTIVE

This study aimed to develop and evaluate a scalable natural language processing (NLP)- and radiomics-based machine learning pipeline to differentiate between painless and painful BM lesions in simulation computed tomography (CT) images using imaging features (biomarkers) extracted from lesion center point-based regions of interest (ROIs).

METHODS

Patients treated at our comprehensive cancer center who received palliative radiotherapy for thoracic spine BM between January 2016 and September 2019 were included in this retrospective study. Physician-reported pain scores were extracted automatically from radiation oncology consultation notes using an NLP pipeline. BM center points were manually pinpointed on CT images by radiation oncologists. Nested ROIs with various diameters were automatically delineated around these expert-identified BM center points, and radiomics features were extracted from each ROI. Synthetic Minority Oversampling Technique resampling, the Least Absolute Shrinkage And Selection Operator feature selection method, and various machine learning classifiers were evaluated using precision, recall, F1-score, and area under the receiver operating characteristic curve.

RESULTS

Radiation therapy consultation notes and simulation CT images of 176 patients (mean age 66, SD 14 years; 95 males) with thoracic spine BM were included in this study. After BM center point identification, 107 radiomics features were extracted from each spherical ROI using pyradiomics. Data were divided into 70% and 30% training and hold-out test sets, respectively. In the test set, the accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve of our best performing model (neural network classifier on an ensemble ROI) were 0.82 (132/163), 0.59 (16/27), 0.85 (116/136), and 0.83, respectively.

CONCLUSIONS

Our NLP- and radiomics-based machine learning pipeline was successful in differentiating between painful and painless BM lesions. It is intrinsically scalable by using NLP to extract pain scores from clinical notes and by requiring only center points to identify BM lesions in CT images.

Opioid Sparing Effect of Ketamine in Military Pre-Hospital Pain Management - A Retrospective Study

BACKGROUND

Opioids are the most commonly used analgesics in acute trauma, but are limited by slow onset and significant adverse effects. Ketamine is an effective and widely used analgesic. This study was aimed to evaluate the effectiveness and opioid-sparing effects of ketamine when utilized in pre-hospital military trauma setting.

METHODS

A retrospective analysis of a pre-hospital military trauma registry between 2014 - 2020. Inclusion criteria were age ≥ 16 years, ≥2 documented pain assessments, at least one indicating severe pain, and administration of opioids and/or low-dose ketamine. Joint hypothesis testing was used to compare casualties who received opioids only to those who received ketamine on outcomes of pain score reduction and opioid consumption.

RESULTS

Overall, 382 casualties were included. 91 (24%) received ketamine (21 as a single analgesic), with a mean dose of 29 mg (SD 11). Mean reduction in pain scores (on an 11-point scale) was not significantly different; 4.3-point (2.8) reduction in the ketamine group and 3.7-points (2.4) in the opioid-only group (p = 0.095). Casualties in the ketamine group received a median of 10 mg (IQR 3.5, 25) of morphine equivalents (ME) compared with a median of 20 ME (10, 20) in the opioid-only group. In a multivariable multinomial logistic regression, casualties in the ketamine group were significantly more likely to receive a low (1-10 ME) rather than a medium (11-20 ME) dose of opioids compared to the opioid-only group (OR 0.032, CI 0.14 - 0.75).

CONCLUSIONS

The use of ketamine in the pre-hospital military setting as part of a pain management protocol was associated with a low rather than medium dose of opioids in a multivariable analysis, while the mean reduction in pain scores was not significantly different between groups. Using ketamine as a first-line agent may further reduce opioid consumption with a similar analgesic effect.

LEVELS OF EVIDENCE

Level IV, therapeutic/care management.

Impact of In-Station Medication Automated Dispensing Systems On Prehospital Pain Medication Administration

Introduction: Medication automatic dispensing systems (ADS) have been implemented in many settings, including fire-based EMS stations. The aim of this study was to evaluate the impact of in-station ADSs on controlled substance administration rates and EMS response intervals.Methods: This study was a retrospective review of data from a single fire-based EMS agency. Medication administration rates and EMS response intervals were compared before ADS implementation (P1; 6/1/15 to 5/31/16) and after ADS implementation (P3; 6/1/17-5/31/19). Cases with missing data and during a one-year implementation period were excluded.Results: 4045 cases were identified in P1 and 8168 in P3. The odds of morphine or versed administration increased following ADS implementation: OR =1.77 (95% CI: 1.53, 2.03) and OR =1.53 (95%CI: 1.18, 2.00) respectively. There were statistically, but likely not operationally significant increases in median response interval and transport interval from P1 to P3 of 14 seconds, (p < 0.001) and 39 seconds (p< 0.001) respectively. Time at hospital for all calls decreased by more than 11 minutes for all transports, from a median of 34 minutes (IQR; 23.7, 45.5) to 22.7 minutes (IQR:18.5, 27.6) in P3, p < 0.001 and by 27.9 minutes for calls in which a controlled substance was given: P1 = 50.6 minutes (IQR: 34.6, 63.2), P3 = 22.7 minutes (IQR: 18.3, 27.4), p < 0.001.Conclusion: In this system, medication ADS implementation was associated with an increase in the rates of controlled substance administration and a decrease in the time units were at hospitals.

Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review

INTRODUCTION

Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies.

METHODS

The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method.

RESULTS

A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine.

CONCLUSIONS

Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.

Can ultrasound-guided infraclavicular block be an alternative option for forearm reduction in the emergency department? A prospective randomized study

Objective

Ultrasound-guided infraclavicular nerve block (IB) has become a well-established method in several outpatient procedures; however, its use in emergency departments (EDs) remains limited. The aim of this study was to compare procedural sedation and anlagesia (PSA) and IB in the pain management for patients who underwent forearm fracture reduction in the ED.

Methods

This prospective randomized study included 60 patients aged 18 to 65 years, who visited the ED with forearm fractures. They were randomly divided into two groups: Group PSA (n=30) and Group IB (n=30). The pain scores of patients were evaluated before and during the procedure with the visual analog scale. Complications and patient and operator satisfaction levels were recorded.

Results

There was no difference between the two groups in terms of demographic characteristics. The median (interquartile range) pain scores observed during the procedures were significantly higher in Group PSA than in Group IB (4 [4–6] vs. 2 [0–2], respectively; P<0.001). Patient and operator satisfaction levels were significantly higher in Group IB (P<0.001). Oxygen desaturation was statistically higher in Group PSA than in Group IB (40.00% vs. 3.33%, respectively; P=0.002).

Conclusion

IB was an effective alternative for reducing pain and increasing patient satisfaction in ED patients undergoing forearm fracture reduction.

Methoxyflurane in Non-Life-Threatening Traumatic Pain-A Retrospective Observational Study

Pain management is a key issue in prehospital trauma. In Switzerland, paramedics have a large panel of analgesic options. Methoxyflurane was recently introduced into Switzerland, and the goal of this study was to describe both the effect of this medication and the satisfaction of its use. This was a retrospective cohort study, performed in one emergency ambulance service. It included adult patients with traumatic pain and a self-assessment of 3 or more on the visual analogue scale or verbal numerical rating scale. The primary outcome was the reduction in pain between the start of the care and the arrival at the hospital. Secondary outcomes included successful analgesia and staff satisfaction. From December 2018 to 4 June to October 2020, 263 patients were included in the study. Most patients had a low prehospital severity score. The median pain at arrival on site was 8 and the overall decrease in pain observed was 4.2 (95% CI 3.9–4.5). Regarding secondary outcomes, almost 60% had a successful analgesia, and over 70% of paramedics felt satisfied. This study shows a reduction in pain, following methoxyflurane, similar to outcomes in other countries, as well as the attainment of a satisfactory level of pain reduction, according to paramedics, with the advantage of including patients in their own care.

Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes?

BACKGROUND

Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients.

METHODS

We performed a 2 year (2016-2017) retrospective analysis of our Level-I trauma center database. We included all adult trauma patients (age > 18y) who received pre-hospital opioids (Fentanyl (F) or Morphine-Sulfate (MS)). Outcome measures were emergency-department (ED) hypotension (SPB < 90 mmHg), ED intubation, prescription opioid medication upon discharge, and mortality. Multivariate logistic regression was performed.

RESULTS

In total, 709 patients were included in the analysis. Cutoff values of 200 mcg F and 15 mg MS were significantly associated with adverse outcomes. Overall, the ED hypotension rate was 14.4%, ED intubation rate was 6%, and ED mortality rate was 3.1%. On regression analysis, higher dosages of both pre-hospital F and pre-hospital MS were independently associated with increased odds of ED hypotension, ED intubation, and discharge on opioid medications, but not with ED mortality.

CONCLUSION

Pre-hospital administration of high dose opioids is associated with increased odds of adverse outcomes. Collaborative efforts to standardize and control the overuse of opioids should target the pre-hospital setting to limit opioid associated adverse effects.

Pitch-side Acute Severe Pain Management Decisions in European Elite football

This is the first study on acute severe pain management involving sport and exercise medicine Doctors who are leaders in football medicine in their respective countries. An online survey was designed describing the management of acute severe pain in this expert cohort. The survey captured participant sex, age, years working in sports medicine, core specialty and use of clinical practice guidelines (CPGs). Finally, three clinical vignettes exploring the management of acute pain were presented. Forty-four senior team doctors across 55 European countries completed the survey. There were no consistent guidelines proposed, with 33 (75%) participants indicating they did not use any. Methoxyflurane was proposed by 14 (32%) and 13 (30%) participants for female anterior cruciate ligament rupture and male ankle fracture, respectively. Strong opioids were not used in 17 (39%) and 6 (14%) participants regarding female cruciate injuries and male fractures, respectively. Despite 75% of participants having paediatric life support training, eight (18%) participants expressed uncertainty administering medications in this population, and 15 (34%) would avoid using strong opioids altogether. There is a tendency to undertreat pain and avoid strong opioids for reasons including lack of monitoring equipment, anti-doping concerns and lack of comfort treating paediatric patients with opioids.

Impact of Intrathecal Fentanyl on Hospital Outcomes for Patients Undergoing Primary Total Hip Arthroplasty With Neuraxial Anesthesia

BACKGROUND

Intrathecal opioids have been used to reduce pain after total joint arthroplasty; however, the utility of these drugs is disputed. We examined the impact of eliminating intrathecal fentanyl on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA).

METHODS

Retrospective review of 376 THA patients from a single institution was conducted. Univariate analysis was used to compare intraoperative medication usage and postoperative outcomes for THA patients receiving intrathecal fentanyl compared with those who did not receive intrathecal fentanyl.

RESULTS

Recovery room pain scores were significantly lower for patients who received intrathecal fentanyl (intrathecal fentanyl 1.4 vs no 2.2, P = .001), but no difference in opioid consumption was observed (intrathecal fentanyl 9.3 milligram morphine equivalent vs no 10.5 milligram morphine equivalent, P = .200). Intraoperative use and dose of intravenous morphine, hydromorphone, and dexamethasone did not differ significantly between groups. There were no significant differences in length of stay between the groups (intrathecal fentanyl 1.1 days vs 1.1 days, P = .973), 90-day readmission, or recatherization rates between groups (readmission, intrathecal fentanyl 4.8% vs no 5.8%, P = .709; recatherization, intrathecal fentanyl 0% vs no 0.7%, P = 1.00).

CONCLUSION

The administration of intrathecal fentanyl does not have a significant effect on early postoperative narcotic consumption, length of stay, 90-day readmissions, or recatheterization after THA with neuraxial anesthesia. Intrathecal fentanyl does not appear to improve outcomes and should not be included as a standard element of THA rapid recovery protocols.

Evaluation of a clinical protocol using intranasal fentanyl for treatment of vaso-occlusive crisis in sickle cell patients in the emergency department

BACKGROUND

Vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visits and admission in children with sickle cell disease (SCD).

OBJECTIVES

This study aims to evaluate whether the use of a new pain management pathway using intranasal (IN) fentanyl from triage leads to improved care, translated by a decrease in time to first opiate dose.

METHODS

We performed a retrospective chart review of patients with SCD who presented to the emergency department (ED) with VOC, in the period pre- (52 patients) and post- (44 patients) implementation period of the protocol. Time to first opiate was the primary outcome and was evaluated pre- and postimplementation. Patients received a first opiate dose within 52.3 minutes of registration (interquantile range [IQR] 30.6, 74.6), corresponding to a 41.4-minute reduction in the opiate administration time (95% confidence interval [CI] -56.1, -27.9). There was also a 43% increase in the number of patients treated with a nonintravenous (IV) opiate as first opiate dose (95% CI 26, 57). In patients who were discharged from the ED, there was a 49% decrease in the number of IV line insertions (95% CI -67, -22). There was no difference in the hospitalization rates (difference of 6 [95% CI -13, 25]).

CONCLUSIONS

This study validates the use of our protocol using IN fentanyl as first treatment of VOC in the ED by significantly reducing the time to first opiate dose and the number of IVs.

Analgesia in acute ischemic chest pain

Analgesics, particularly opioids, have been routinely used in the emergency treatment of ischemic chest pain for a long time. In the past two decades; however, several studies have raised the possibility of the harmful effects of opioid administration. In 2014, the American Heart Association (AHA)/American College of Cardiology Foundation (ACCF) changed the guidelines regarding the use of opioids from class IC to class IIb for non-ST elevation acute coronary syndrome. And in 2015, the European Society of Cardiology (ESC) guidelines incidentally noted the side effects of opioids. In ST-segment elevation myocardial infarction, both ESC and AHA/ACCF still recommend the use of opioids. Given the need for adequate pain relief in ischemic chest pain in the emergency setting, it is necessary to understand the adverse effects of analgesia, while still providing sufficiently potent options for analgesia. The primary purpose of this review is to quantify the effects of analgesics commonly used in the prehospital and emergency department in patients with ischemic chest pain.

Assessment of Pain Management During Interfacility Air Medical Transport of Intubated Patients

OBJECTIVE

The management of pain is an important component of care in the prehospital and transport setting. However, recent evidence suggests that pain control is infrequently achieved in these settings. The objective of the current study was to determine the proportion and frequency of opioid analgesia provided to intubated patients during interfacility transport by an air medical transport system.

METHODS

This was a health records review examining electronic records of intubated patients transported by Ornge from July 2015 to November 2015. Cases were identified using Ornge database, and intubated patients were selected based on the inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was whether analgesia was provided. Secondary outcomes included the frequency of administration and dose adequacy of an opioid analgesia; the analgesic used; adverse events; and the impact of age, sex, past medical history of chronic pain, or reason for transfer on pain management.

RESULTS

Of the 500 potential patient transports, 448 met our inclusion criteria. Among the 448 patients, 295 (65.8%) were men, 327 (73.0%) received analgesia, and 211 (64.3%) received more than 1 dose during transport (median frequency of 2 doses, interquartile range = 1 to 3). The average transport time was 135 minutes, and repeated dosing (> 1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.9%), and the most common dose was 50 µg (51.8%). Adverse events occurred in 8 patients (2.5%), most commonly new hypotension (mean arterial pressure < 65 mm Hg, n = 5). There was no significant difference in the administration of analgesia based on the patient's age or sex (68.0% of female patients and 75.6% of male patients received analgesia). Interestingly, only 30.8% of patients repatriated to their originating hospital received analgesia compared with 72.3% of patients undergoing their initial transfer to a higher level of care.

CONCLUSION

Seventy-three percent of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex, past medical history of chronic pain, or reason for transfer other than repatriation to the originating hospital.

Intranasal sufentanil versus intravenous morphine for acute severe trauma pain: A double-blind randomized non-inferiority study

BACKGROUND

Intravenous morphine (IVM) is the most common strong analgesic used in trauma, but is associated with a clear time limitation related to the need to obtain an access route. The intranasal (IN) route provides easy administration with a fast peak action time due to high vascularization and the absence of first-pass metabolism. We aimed to determine whether IN sufentanil (INS) for patients presenting to an emergency department with acute severe traumatic pain results in a reduction in pain intensity non-inferior to IVM.

METHODS AND FINDINGS

In a prospective, randomized, multicenter non-inferiority trial conducted in the emergency departments of 6 hospitals across France, patients were randomized 1:1 to INS titration (0.3 μg/kg and additional doses of 0.15 μg/kg at 10 minutes and 20 minutes if numerical pain rating scale [NRS] > 3) and intravenous placebo, or to IVM (0.1 mg/kg and additional doses of 0.05 mg/kg at 10 minutes and 20 minutes if NRS > 3) and IN placebo. Patients, clinical staff, and research staff were blinded to the treatment allocation. The primary endpoint was the total decrease on NRS at 30 minutes after first administration. The prespecified non-inferiority margin was -1.3 on the NRS. The primary outcome was analyzed per protocol. Adverse events were prospectively recorded during 4 hours. Among the 194 patients enrolled in the emergency department cohort between November 4, 2013, and April 10, 2016, 157 were randomized, and the protocol was correctly administered in 136 (69 IVM group, 67 INS group, per protocol population, 76% men, median age 40 [IQR 29 to 54] years). The mean difference between NRS at first administration and NRS at 30 minutes was -4.1 (97.5% CI -4.6 to -3.6) in the IVM group and -5.2 (97.5% CI -5.7 to -4.6) in the INS group. Non-inferiority was demonstrated (p < 0.001 with 1-sided mean-equivalence t test), as the lower 97.5% confidence interval of 0.29 (97.5% CI 0.29 to 1.93) was above the prespecified margin of -1.3. INS was superior to IVM (intention to treat analysis: p = 0.034), but without a clinically significant difference in mean NRS between groups. Six severe adverse events were observed in the INS group and 2 in the IVM group (number needed to harm: 17), including an apparent imbalance for hypoxemia (3 in the INS group versus 1 in the IVM group) and for bradypnea (2 in the INS group versus 0 in the IVM group). The main limitation of the study was that the choice of concomitant analgesics, when they were used, was left to the discretion of the physician in charge, and co-analgesia was more often used in the IVM group. Moreover, the size of the study did not allow us to conclude with certainty about the safety of INS in emergency settings.

CONCLUSIONS

We confirm the non-inferiority of INS compared to IVM for pain reduction at 30 minutes after administration in patients with severe traumatic pain presenting to an emergency department. The IN route, with no need to obtain a venous route, may allow early and effective analgesia in emergency settings and in difficult situations. Confirmation of the safety profile of INS will require further larger studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02095366. EudraCT 2013-001665-16.

Prehospital intravenous fentanyl administered by ambulance personnel: a cluster-randomised comparison of two treatment protocols

Background

Prehospital acute pain is a frequent symptom that is often inadequately managed. The concerns of opioid induced side effects are well-founded. To ensure patient safety, ambulance personnel are therefore provided with treatment protocols with dosing restrictions, however, with the concomitant risk of insufficient pain treatment of the patients. The aim of this study was to investigate the impact of a liberal intravenous fentanyl treatment protocol on efficacy and safety measures.

Methods

A two-armed, cluster-randomised trial was conducted in the Central Denmark Region over a 1-year period. Ambulance stations (stratified according to size) were randomised to follow either a liberal treatment protocol (3 μg/kg) or a standard treatment protocol (2 μg/kg). The primary outcome was the proportion of patients with sufficient pan relief (numeric rating scale (NRS, 0–10) < 3) at hospital arrival. Secondary outcomes included abnormal vital parameters as proxy measures of safety. A multi-level mixed effect logistic regression model was applied.

Results

In total, 5278 patients were included. Ambulance personnel following the liberal protocol administered higher doses of fentanyl [117.7 μg (95% CI 116.7–118.6)] than ambulance personnel following the standard protocol [111.5 μg (95% CI 110.7–112.4), P = 0.0001]. The number of patient with sufficient pain relief at hospital arrival was higher in the liberal treatment group than the standard treatment group [44.0% (95% CI 41.8–46.1) vs. 37.4% (95% CI 35.2–39.6), adjusted odds ratio 1.47 (95% CI 1.17–1.84)]. The relative decrease in NRS scores during transport was less evident [adjusted odds ratio 1.18 (95% CI 0.95–1.48)]. The occurrences of abnormal vital parameters were similar in both groups.

Conclusions

Liberalising an intravenous fentanyl treatment protocol applied by ambulance personnel slightly increased the number of patients with sufficient pain relief at hospital arrival without compromising patient safety. Future efforts of training ambulance personnel are needed to further improve protocol adherence and quality of treatment.

Trial registration

ClinicalTrials.gov (NCT02914678). Date of registration: 26th September, 2016.

Rapid sequence induction (RSI) in trauma patients: Insights from healthcare providers

BACKGROUND

We aimed to describe the current practice of emergency physicians and anaesthesiologists in the selection of drugs for rapid-sequence induction (RSI) among trauma patients.

METHODS

A prospective survey audit was conducted based on a self-administered questionnaire among two intubating specialties. The preferred type and dose of hypnotics, opioids, and muscle relaxants used for RSI in trauma patients were sought in the questionnaire. Data were compared for the use of induction agent, opioid use and muscle relaxant among stable and unstable trauma patients by the intubating specialties.

RESULTS

A total of 102 participants were included; 47 were anaesthetists and 55 were emergency physicians. Propofol (74.5%) and Etomidate (50.0%) were the most frequently used induction agents. Significantly higher proportion of anesthesiologist used Propofol whereas, Etomidate was commonly used by emergency physicians in stable patients (P=0.001). Emergency physicians preferred Etomidate (63.6%) and Ketamine (20.0%) in unstable patients. The two groups were comparable for opioid use for stable patients. In unstable patients, use of opioid differed significantly by intubating specialties. The relation between rocuronium and suxamethonium use did change among the anaesthetists. Emergency physicians used more suxamethonium (55.6% vs. 27.7%, P=0.01) in stable as well as unstable (43.4 % vs. 27.7%, P=0.08) patients.

CONCLUSION

There is variability in the use of drugs for RSI in trauma patients amongst emergency physicians and anaesthesiologists. There is a need to develop an RSI protocol using standardized types and dose of these agents to deliver an effective airway management for trauma patients.

Treatment of pain with intranasal fentanyl in pediatric patients in an acute care setting: a systematic review

AIM

The primary objective of this review is to provide an updated, comprehensive overview on the efficacy of intranasal fentanyl (INF) for acute pain relief in the pediatric population.

METHODS

Utilizing the Preferred Reporting Instructions for Systematic Reviews and Meta-Analyses (PRISMA), we were able to screen articles based on key words to reach a final number of 10 studies.

RESULTS

All but one study showed that INF was efficacious for pain relief in this select pediatric population.

CONCLUSION

It is evident that INF is efficacious for analgesia, but other agents should also be considered in this patient population. As a result, further research is needed to investigate the clinically efficacy of INF in an acute care setting for pediatric patients.

Administration of intravenous morphine for acute pain in the emergency department inflicts an economic burden in Europe

BACKGROUND

Acute pain is among the leading causes of referral to the emergency department (ED) in industrialized countries. Its management mainly depends on intensity. Moderate-to-severe pain is treated with intravenous (IV) administered opioids, of which morphine is the most commonly used in the ED. We have estimated the burden of IV administration of morphine in the five key European countries (EU5) using a micro-costing approach.

SCOPE

A structured literature review was conducted to identify clinical guidelines for acute pain management in EU5 and clinical studies conducted in the ED setting. The data identified in this literature review constituted the source for all model input parameters, which were clustered as analgesic (morphine), material used for IV morphine administration, nurse workforce time and management of morphine-related adverse events and IV-related complications.

FINDINGS

The cost per patient of IV morphine administration in the ED ranges between €18.31 in Spain and €28.38 in Germany. If costs associated with the management of morphine-related adverse events and IV-related complications are also considered, the total costs amount to €121.13-€132.43. The main driver of those total costs is the management of IV-related complications (phlebitis, extravasation and IV prescription errors; 73% of all costs) followed by workforce time (14%).

CONCLUSIONS

IV morphine provides effective pain relief in the ED, but the costs associated with the IV administration inflict an economic burden on the respective national health services in EU5. An equally rapid-onset and efficacious analgesic that does not require IV administration could reduce this burden.

Battlefield Analgesia in Tactical Combat Casualty Care

At the start of the Afghanistan conflict, battlefield analgesia for US military casualties was achieved primarily through the use of intramuscular (IM) morphine. This is a suboptimal choice, since IM morphine is slow-acting, leading to delays in effective pain relief and the risk of overdose and death when dosing is repeated in order to hasten the onset of analgesia. Advances in battlefield analgesia, pioneered initially by Tactical Combat Casualty Care (TCCC), and the Army's 75th Ranger Regiment, have now been incorporated into the Triple-Option Analgesia approach. This novel strategy has gained wide acceptance in the US military. It calls for battlefield analgesia to be achieved using 1 or more of 3 options depending on the casualty's status: 1) the meloxicam and acetaminophen in the combat wound medication pack (CWMP) for casualties with relatively minor pain that are still able to function effectively as combatants if their sensorium is not altered by analgesic medications; 2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress, and are not at significant risk for developing either condition; or 3) ketamine for casualties who have moderate to severe pain, but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioid medication. The present paper outlines the evolution and evidence base for battlefield analgesia as currently recommended by TCCC. It is not intended to be a comprehensive review of all prehospital analgesic options.

Sedation and analgesia for procedures in the pediatric emergency room

OBJECTIVE

Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area.

DATA SOURCES

Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included.

DATA SYNTHESIS

Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented.

CONCLUSIONS

The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.

Sedation and Analgesia in Transportation of Acutely and Critically Ill Patients

Transportation of acutely or critically ill patients is a challenge for health care providers. Among the difficulties that providers face is the balance between adequate sedation and analgesia for the transportation event and maintaining acceptable respiratory and physiologic parameters of the patient. This article describes common challenges in providing sedation and analgesia during various phases of transport.

Cost of Intravenous Analgesia for the Management of Acute Pain in the Emergency Department is Substantial in the United States

Background: Pain is a leading cause of admission to the emergency department (ED) and moderate-to-severe acute pain in medically supervised settings is often treated with intravenous (IV) opioids. With novel noninvasive analgesic products in development for this indication, it is important to assess the costs associated with IV administration of opioids. Materials and Methods: A retrospective observational study of data derived from the Premier database was conducted. All ED encounters of adult patients treated with IV opioids during a 2-year time period, who were charged for at least one IV opioid administration in the ED were included. Hospital reported costs were used to estimate the costs to administer IV opioids. Results: Over a 24 month-period, 7.3 million encounters, which included the administration of IV opioids took place in 614 US EDs. The mean cost per encounter of IV administration of an initial dose of the three most frequently prescribed opioids were: morphine $145, hydromorphone $146, and fentanyl $147. The main driver of the total costs is the cost of nursing time and equipment cost to set up and maintain an IV infusion ($140 ± 60). Adding a second dose of opioid, brings the average costs to $151-$154. If costs associated with the management of opioid-related adverse events and IV-related complications are also added, the total costs can amount to $269-$273. Of these 7.3 million encounters, 4.3 million (58%) did not lead to hospital admission of the patient and, therefore, the patient may have only required an IV catheter for opioid administration. Conclusions: IV opioid use in the ED is indicated for moderate-to-severe pain but is associated with significant costs. In subjects who are discharged from the ED and may not have required an IV for reasons other than opioid administration, rapid-onset analgesics for moderate-to-severe pain that do not require IV administration could lead to direct cost reductions and improved care.

Efficacy and safety of intravenous fentanyl administered by ambulance personnel

BACKGROUND

Management of pain in the pre-hospital setting is often inadequate. In 2011, ambulance personnel were authorized to administer intravenous fentanyl in the Central Denmark Region. The aim of this study was to evaluate the efficacy and safety of intravenous fentanyl administered by ambulance personnel.

METHODS

Pre-hospital medical charts from 2348 adults treated with intravenous fentanyl by ambulance personnel during a 6-month period were reviewed. The primary outcome was the change in pain intensity on a numeric rating scale (NRS) from before fentanyl treatment to hospital arrival. Secondary outcomes included the number of patients with reduction in pain intensity during transport (NRS ≥ 2), the number of patients with NRS > 3 at hospital arrival, and potential fentanyl-related side effects.

RESULTS

Fentanyl reduced pain from before treatment (8, IQR 7-9) to hospital arrival (4, IQR 3-6) (NRS reduction: 3, IQR 2-5; P = 0.001), 79.3% of all patients had a reduction in > 2 on the NRS during transport, and 58.4% of patients experienced pain at hospital arrival (NRS > 3). Twenty-one patients (0.9%) had oxygen saturation < 90%. A decrease in Glasgow Coma Scale was seen in 31 patients (1.3%) and hypotension observed in 71 patients (3.0%).

CONCLUSION

Intravenous fentanyl caused clinically meaningful pain reduction in most patients and was safe in the hands of ambulance personnel. Many patients had moderate to severe pain at hospital arrival. As the protocol allowed higher doses of fentanyl, feedback on effect and safety should be part of continuous education of ambulance personnel.

Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain

In the treatment of acute coronary syndromes, reduction of sympathetic stress and catecholamine release is an important therapeutic goal. One method used to achieve this goal is pain reduction through the systemic administration of analgesia. Historically, morphine has been the analgesic of choice in ischemic cardiac pain. This randomized double-blind controlled trial seeks to prove the utility of fentanyl as an alternate first-line analgesic for ischemic-type chest pain in the prehospital setting. Successive patients who were treated for suspected ischemic chest pain in the emergency medical services system were considered eligible. Once chest pain was confirmed, patients received oxygen, aspirin, and nitroglycerin therapy. If the ischemic-type chest pain continued the patient was randomized in a double-blinded fashion to treatment with either morphine or fentanyl. Pain scale scores, necessity for additional dosing, and rate of adverse events between the groups were assessed every 5 minutes and were compared using t-testing, Fisher's Exact test, or Analysis of Variance (ANOVA) where appropriate. The primary outcome of the study was incidence of hypotension and the secondary outcome was pain reduction as measured by the visual analog score and numeric rating score. A total of 207 patients were randomized with 187 patients included in the final analysis. Of the 187 patients, 99 were in the morphine group and 88 in the fentanyl group. No statistically significant difference between the two groups with respect to hypotension was found (morphine 5.1% vs. fentanyl 0%, p = 0.06). Baseline characteristics, necessity for additional dosing, and other adverse events between the two groups were not statistically different. There were no significant differences between the changes in visual analog scores and numeric rating scale scores for pain between the two groups (p = 0.16 and p = 0.15, respectively). This study supports that fentanyl and morphine are comparable in providing analgesia for ischemic-type chest pain. Fentanyl appears to be a safe and effective alternative to morphine for the management of chest pain in the prehospital setting.

Safety of intranasal fentanyl in the out-of-hospital setting: a prospective observational study

STUDY OBJECTIVE

Initial out-of-hospital analgesia is sometimes hampered by difficulties in achieving intravenous access or lack of skills in administering intravenous opioids. We study the safety profile and apparent analgesic effect of intranasal fentanyl in the out-of-hospital setting.

METHODS

In this prospective observational study, we administered intranasal fentanyl in the out-of-hospital setting to adults and children older than 8 years with severe pain resulting from orthopedic conditions, abdominal pain, or acute coronary syndrome refractory to nitroglycerin spray. Patients received 1 to 3 doses of either 50 or 100 μg, and the ambulance crew recorded adverse effects and numeric rating scale (0 to 10) pain scores before and after treatment.

RESULTS

Our 903 evaluable patients received a mean cumulative fentanyl dose of 114 μg (range 50 to 300 μg). There were no serious adverse effects and no use of naloxone. Thirty-six patients (4%) experienced mild adverse effects: mild hypotension, nausea, vomiting, vertigo, abdominal pain, rash, or decrease of Glasgow Coma Scale score to 14. The median reduction in pain score was 3 (interquartile range 2 to 5) after fentanyl administration.

CONCLUSION

The out-of-hospital administration of intranasal fentanyl in doses of 50 to 100 μg is safe and appears effective.

Randomized clinical trial of efficacy and safety of a single 2-mg intravenous dose of hydromorphone versus usual care in the management of acute pain

OBJECTIVES

The objective was to test the efficacy and safety of 2 mg of intravenous (IV) hydromorphone (Dilaudid) against "usual care" in emergency department (ED) patients with acute severe pain.

METHODS

This was a randomized clinical trial. Patients allocated to 2 mg of IV hydromorphone received their medication in a single dose. Those randomized to usual care received any IV opioid, with type, dose, and frequency chosen by the ED attending. All patients received 2 L/min. nasal cannula oxygen. The primary outcome was the difference in the proportion of patients who achieved clinically satisfactory analgesia by 30 minutes. This was defined as the patient declining additional analgesia when asked the question, "Do you want more pain medicine?" A 10% absolute difference was chosen a priori as the minimum difference considered clinically significant.

RESULTS

Of 175 subjects randomized to each group, 164 in the 2 mg hydromorphone group and 161 in the usual care group had sufficient data for analysis. Additional pain medication was declined by 77.4% of patients in the 2 mg hydromorphone group at 30 minutes, compared to 65.8% in the usual care group. This difference of 11.6% was statistically and clinically significant (95% confidence interval [CI] = 1.8% to 21.1%). Safety profiles were similar and no patient required naloxone. There was more pruritus in the hydromorphone group (18.3% vs. 8.7%; difference = 9.6%, 95% CI = 2.6% to 16.6%).

CONCLUSIONS

Using a simple dichotomous patient-centered endpoint in which a difference of 10% in proportion obtaining adequate analgesia was considered clinically significant, 2 mg of hydromorphone in a single IV dose is clinically and statistically more efficacious when compared to usual care for acute pain management in the ED.

Use of Intravenous Fentanyl Against Morphine Tolerance in Breakthrough Cancer Pain

Palliative care physicians are accustomed to using transdermal fentanyl patch for cancer pain control but not so familiar with its intravenous administration. Historically, fentanyl has been used to treat breakthrough pain because it is a very potent analgesic with a rapid onset and short duration of action. Although several formulations of fentanyl have been recently developed for breakthrough cancer pain, these are unavailable or too expensive in some countries. Also, all opioids can induce tolerance potentially and different opioids cause significantly different degrees of tolerance. Therefore, sequential opioid trials may be a reasonable approach in patients with poor analgesic effect after dose escalation. Here, we present 2 morphine-tolerant patients with cancer in whom the intravenous fentanyl was effectively used for their refractory breakthrough pain.

Prehospital nausea and vomiting after trauma: Prevalence, risk factors, and development of a predictive scoring system

BACKGROUND

Nausea and vomiting are common problems in trauma patients and potentially dangerous during trauma resuscitation. These symptoms are present in up to 10% of ambulance patients, but their prevalence in trauma patients is largely unknown. The aim of this study was to determine the prevalence of prehospital nausea and vomiting in trauma patients and evaluate antiemetic usage.

METHODS

Prospective, cohort study of trauma resuscitation patients transported by ambulance to a major trauma centre. Patients with hemodynamic instability (systolic blood pressure <90, heart rate >120) or Glasgow Coma Scale score <14 on arrival were excluded. Nausea, vomiting, and antiemetic use were recorded.

RESULTS

Convenience sample of 196 trauma resuscitation patients (68% men; age, 42 ± 18 years, mean Injury Severity Score 8 ± 7) were interviewed over the 5-month study period, of a total 369 admitted trauma patients (53%). Seventy-five (38%) patients reported some degree of nausea, 57 (29%) moderate or severe nausea, and 15 (8%) vomited. Older age and female gender were associated with vomiting (p < 0.01). Seventy-nine patients (40%) received a prophylactic antiemetic. Of these, four became nauseous (5%), compared with 71 of 117 (61%) for patients not given an antiemetic (p < 0.0001).

CONCLUSIONS

Prehospital nausea and vomiting are more common in our cohort of trauma patients than the reported rates in the literature for nontrauma patients transported to hospital by ambulance. Only 40% of patients receive prophylactic antiemetics, but those patients are less likely to develop symptoms.

LEVEL OF EVIDENCE

V, epidemiological study.

Intravenous Opioids for Severe Acute Pain in the Emergency Department

Objective:

To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy.

Data Sources:

Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department.

Study Selection and Data Extraction:

The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED.

Data Synthesis:

At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction.

Conclusions:

Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.