# Morphine vs fentanyl myocardial o2 demand



## URI (Aug 21, 2013)

So I was wondering what you guys thought about the effects of Morphine vs. Fentanyl on myocardial O2 demands.
In Medic school they taught me the MONA acronym for remembering tx. of CHF.
(Morphine, O2, Nitro, ASA)  
My protocols specifically suggest using Morphine for CHF because it decreases preload and after load thus lowering O2 demand. (Which to me makes sense) however, It also states Fentanyl is not recommended in the tx. of CHF. 

My question is why? Why would fentanyl be a poor decision in the tx. Of CHF? 
I understand morphine would be a better choice, but why would fentanyl wrong? 
  Any thoughts?
Thanks.


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## SanDiegoEmt7 (Aug 21, 2013)

At typical dosages of fentanyl blood pressure is minimally affected, therefore maybe reducing chest pain but not reducing the workload of the heart.

My understanding.


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## truetiger (Aug 21, 2013)

If you have both, you're obviously going to want to use the morphine. If morphine is unavailable or the patient is allergic, use the fentanyl. While doesn't reduce the preload and after load as morphine does, it will help cut down myocardial oxygen demand by reducing sympathetic tone by reducing pain.


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## URI (Aug 21, 2013)

Ok so in other words its not that  Fentanyl is contraindicated then, just not preferred because of the mentioned benefits of Morphine.


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## truetiger (Aug 21, 2013)

Yup


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## URI (Aug 21, 2013)

Thanks for clarifying.


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## TransportJockey (Aug 21, 2013)

What about fent use in a CAD patient? I remember a while back talk about fent taking over in chest pain patients but I haven't seen too much on it lately.


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## truetiger (Aug 21, 2013)

I haven't heard of that. Here we have it in our protocols if morphine isn't an option.


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## TransportJockey (Aug 21, 2013)

truetiger said:


> I haven't heard of that. Here we have it in our protocols if morphine isn't an option.



Same here. Narcotics choice is all paramedic discretion here. I just want to do the best I can for my patients


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## VFlutter (Aug 21, 2013)

TransportJockey said:


> What about fent use in a CAD patient? I remember a while back talk about fent taking over in chest pain patients but I haven't seen too much on it lately.



We use Fentanyl pretty much exclusively in the Cardiac Cath lab for PCI and cardioversions. The vast majority of the patients have significant CAD.

They also like to use it during Endoscopy.


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## URI (Aug 21, 2013)

RI protocols state that Fentanyl is the preferred choice narcotic for chest pain when it's cardiac related. (Other than CHF)

So we discussed the benefits of Morphine, especially is CHF,but for CAD pts. is there added benefit to Fentanyl opposed to Morphine?


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## blindsideflank (Aug 21, 2013)

Morphine causes histamine release (basophils and mast cell degranulation) 
This is more significant in chf where I would say the most benefit you would see in CAD is from reduced anxiety (let's not get started on morphine and reduced pain affecting triage times)


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## URI (Aug 21, 2013)

Thanks blindside,  that was the answer I was looking for. That makes sense.


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## blindsideflank (Aug 21, 2013)

URI said:


> My protocols specifically suggest using Morphine for CHF because it decreases preload and after load thus lowering O2 demand. (Which to me makes sense) however, It also states Fentanyl is not recommended in the tx. of CHF.
> 
> My question is why? Why would fentanyl be a poor decision in the tx. Of CHF?
> I understand morphine would be a better choice, but why would fentanyl wrong?
> ...


 When you say that you understand, I think you are missing a bit of the differences in the pharmacology. Read a few quick studies on morphine vs fentanyl and histamine release (and the effects of peripheral vascular resistance.


Now if you are always giving morphine too fast and making patients sick, which has had your practice evolve to always giving gravol with it, how does that effect your therapeutic goal of the morphine (particularly in chf)

Gravol is an anticholinergic and an antihistamine...


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## Medic Tim (Aug 21, 2013)

blindsideflank said:


> When you say that you understand, I think you are missing a bit of the differences in the pharmacology. Read a few quick studies on morphine vs fentanyl and histamine release (and the effects of peripheral vascular resistance.
> 
> 
> Now if you are always giving morphine too fast and making patients sick, which has had your practice evolve to always giving gravol with it, how does that effect your therapeutic goal of the morphine (particularly in chf)
> ...



Ive never seen or heard of gravol being used outside of Canada in the prehospital setting.


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## blindsideflank (Aug 21, 2013)

We also carry maxeran and zofran. What is used worldwide? Domperidone?


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## Medic Tim (Aug 21, 2013)

blindsideflank said:


> We also carry maxeran and zofran. What is used worldwide? Domperidone?


I carry Zofran, maxeran and gravol where I currently work in AB. What I see/have seen in the US is Maxeran, Compazine, promethazine and Zofran.


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## Carlos Danger (Aug 21, 2013)

URI said:


> So I was wondering what you guys thought about the effects of Morphine vs. Fentanyl on myocardial O2 demands.
> In Medic school they taught me the MONA acronym for remembering tx. of CHF.
> (Morphine, O2, Nitro, ASA)
> My protocols specifically suggest using *Morphine for CHF because it decreases preload *and after load thus lowering O2 demand. (Which to me makes sense) however, It also states Fentanyl is not recommended in the tx. of CHF.
> ...



I don't think there is any proof that morphine is better than fentanyl for cardiac pain or CHF, or that opioids really do anything at all in those settings, aside from make the patient more comfortable.

It never made much sense to me to use morphine as a preload reducer. That is what nitro is for, and nitro is much better at it than morphine is.

Fentanyl is a much better drug in general, IMO. It reaches peak effect much quicker than morphine, which means it is easier to titrate and safer to re-dose. It is more hemodynamically stable, thanks to its lack of histamine release. It has fewer side effects (itching, etc.). It probably does a better job of blunting the SNS, though maybe not in the doses that are typically used prehospital.

My guess is that fentanyl is actually a better drug for cardiac pain. This is because the first line drug for cardiac chest pain really should be nitro, but if you've given nitro until you can't give any more because the BP has dropped but the patient is still having pain, then fentanyl is likely to have less of an effect at reducing BP further.


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## Christopher (Aug 22, 2013)

URI said:


> So I was wondering what you guys thought about the effects of Morphine vs. Fentanyl on myocardial O2 demands.
> In Medic school they taught me the MONA acronym for remembering tx. of CHF.
> (Morphine, O2, Nitro, ASA)
> My protocols specifically suggest using Morphine for CHF because it decreases preload and after load thus lowering O2 demand. (Which to me makes sense) however, It also states Fentanyl is not recommended in the tx. of CHF.
> ...



Morphine is not indicated for an exacerbation of CHF and should *not* be routinely given for CHF. There is no known benefit and potentially causal harm from morphine during CHF. This is no longer part of the standard of care since around 2007-ish.

Nitro and CPAP are your two, and really only two, solid options for exacerbations of CHF.

Did you instead mean morphine vs fentanyl for patients experiencing the signs and symptoms of an acute coronary syndrome / ischemia?

There is limited evidence to suggest benefit from morphine for ACS. There is limited evidence to suggest harm from morphine for ACS. Basically, there is insufficient evidence to suggest that you should favor morphine as your opiate during ACS.



URI said:


> Ok so in other words its not that  Fentanyl is contraindicated then, just not preferred because of the mentioned benefits of Morphine.



There is not a known statistically significant (nor clinically significant) reduction in preload or afterload from the administration of morphine for ACS or CHF.

For CHF if you need anxiolysis then fentanyl is a reasonable option (or small doses of lorazepam).

For ACS if you need anxiolysis or pain control, fentanyl is non-inferior to morphine and has a much more favorable hemodynamic profile making it ideal for the prehospital treatment of chest pain patients refractory to NTG.


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## Milla3P (Aug 22, 2013)

URI said:


> RI protocols state that Fentanyl is the preferred choice narcotic for chest pain when it's cardiac related. (Other than CHF)
> 
> So we discussed the benefits of Morphine, especially is CHF,but for CAD pts. is there added benefit to Fentanyl opposed to Morphine?



The RI protocol update came out while the belief that morphine's reduction in preload was beneficial for an acute CHF exacerbation. Shortly afterwards the general consensus became that the administration was an overall bad idea and borderline negligent as there is a good chance you're going to do more harm than good. 

If your medic instructor is teaching MONA in a medic class then he (or she) is doing a hack job and throwing cookbook Cardiac sayings into his class. They should be teaching to the NR standards and not to the RI protocols. 

If you're in a Cardiac class on the other hand; don't worry. Fent is out the window anyways.


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## medicsb (Aug 22, 2013)

If you want to treat anxiety, use a benzo.

As far as pain management for ACS, in the prehospital phase, take your pick.  The reason morphine has been questioned is due to one study from Duke (?), which was retrospective and also demonstrated quite well that the patients that received morphine were much more sick than the ones who didn't.  

In the context of pain management in general, I can't think of a case where a patient's BP tanked or where the patient suffered an adverse reaction from morphine.  

The benefits of fentanyl are overblown as are the risks of morphine.  As far as I know, there hasn't been a study that undeniably demonstrates superiority of fentanyl over morphine or vice versa.  It's all hypothetical.  I admit that I prefer to use fentanyl if the patient is exhibiting mild hemodynamic instability (anything more than that and I'm less concerned about pain and more concerned about getting them stable), but morphine might work just fine for those patient, too.

Example:
J Emerg Med. 2012 Jul;43(1):69-75. 
The effectiveness and adverse events of morphine versus fentanyl on a physician-staffed helicopter.
"CONCLUSION:  In our study, there was not a significant difference in analgesic effectiveness between morphine and fentanyl. There was no significant difference in the incidence of adverse effects between the two drugs."


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## Carlos Danger (Aug 22, 2013)

medicsb said:


> J Emerg Med. 2012 Jul;43(1):69-75.
> The effectiveness and adverse events of morphine versus fentanyl on a physician-staffed helicopter.
> "CONCLUSION:  In our study, there was not a significant difference in analgesic effectiveness between morphine and fentanyl. There was no significant difference in the incidence of adverse effects between the two drugs."



Here's another one that showed similar results. Retrospective, but pretty well done: Effectiveness and safety of fentanyl compared with morphine for out-of-hospital analgesia. PEC 2010;14:167–175

Both studies had pretty significant limitations, IMO. Both used low total doses of drug (well below 10 mg of morphine or equivalent), and neither really achieved good analgesia, with both having mean starting pain scores of about 8 and only dropping those scores an average of less than 3 points. It sounds as though in the first study, the protocol was not followed closely as far as endpoints.

One challenge in comparing these two drugs head-to-head in a prospective trial is the significant difference in onset times. Fentanyl is much faster in onset, owing to its much higher lipid solubility. Morphine is slow enough to peak onset that it is potentially unsafe to dose it every 5 minutes: with a peak effect of 15-25 minutes, you could potentially give your 4th dose before the first dose has even taken full effect.  Surely the flight physicians in the first study were aware of this difference and it may have had an impact on their behavior, in fact it may explain the reason why they simply stopped giving the meds after just a couple doses, despite not yet meeting the endpoints required by the study protocol.



medicsb said:


> *The benefits of fentanyl are overblown as are the risks of morphine. * As far as I know, there hasn't been a study that undeniably demonstrates superiority of fentanyl over morphine or vice versa.  *It's all hypothetical.*  I admit that I prefer to use fentanyl if the patient is exhibiting mild hemodynamic instability (anything more than that and I'm less concerned about pain and more concerned about getting them stable), but morphine might work just fine for those patient, too.



I would agree that the risks of morphine (as far as the likelihood of it causing respiratory or hemodynamic depression) are generally quite overblown. I would also agree that in the small doses generally used prehospital (<10mg of morphine or equivalent), any adverse effects are unlikely no matter which opioid you use. So if your protocols are going to call for very conservative dosing regimens, it probably doesn't matter which drug you use.

That doesn't mean that fentanyl's advantages are hypothetical, though. The pharmacodynamics of the drugs are what they are. Not everyone sticks to 20 mcg boluses, or uses it just for analgesia. It just means that when using a small dose of drug, adverse effects are less likely.


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## MSDeltaFlt (Aug 22, 2013)

As above.  Fentanyl vs Morphine?  6 to one.  Half a dozen to the other.  The reason why protocols place one narcotic higher in the option list is due to off-line Med Control preference (the dude(s)/dudette(s) authorizing your protocols).  The ultimate goal is to get your patient's cardiac related chest pain as close to 0/10 as feasible.


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## URI (Aug 23, 2013)

I just wanted to say thank you to everyone who chimed in. I have a ton of research to do. 
 I am a new paramedic and as Milla stated, I may not have had the best training.  (Still a poor excuse) 

Does anyone have any suggestions/websites that they go to to stay abreast on the National standards? 
I'm not asking out of laziness as I will do my own research. I just want the best for my patients, as do all of you. 
Thanks.


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## MSDeltaFlt (Aug 23, 2013)

You can start with websites like this one.  It just depends on your search criteria.

http://m.circ.ahajournals.org/content/102/10/1193.full


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## URI (Aug 23, 2013)

Thank you.


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## morbusstrangularis (Sep 8, 2013)

Good discussion. With everything that I've read, it doesn't really matter which opiate you use for ACS/cardiac-ischemic chest pain. It boils down to provider's discretion, and this is where really knowing your pharmacology comes in. Most of my experience with pain control is intra- and post-operative, but I've found that I detest morphine for most indications. I don't like the hemodynamic instability, long time to onset, or rate of unpleasant side effects. I prefer fentanyl and dilaudid, situation dependant. As it has been noted previously, the hemodynamic effects of morphine are not the goal, its a reduction in anxiety.

On an interesting side note, in a large, multicenter study morphine was found to be an independent predictor of mortality in CHF. It should no longer be used. Unfortunately I'm on my phone in the rig right now, but if anyone is interested in the study, let me know and I'll post it later.


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## TransportJockey (Sep 8, 2013)

morbusstrangularis said:


> Good discussion. With everything that I've read, it doesn't really matter which opiate you use for ACS/cardiac-ischemic chest pain. It boils down to provider's discretion, and this is where really knowing your pharmacology comes in. Most of my experience with pain control is intra- and post-operative, but I've found that I detest morphine for most indications. I don't like the hemodynamic instability, long time to onset, or rate of unpleasant side effects. I prefer fentanyl and dilaudid, situation dependant. As it has been noted previously, the hemodynamic effects of morphine are not the goal, its a reduction in anxiety.
> 
> On an interesting side note, in a large, multicenter study morphine was found to be an independent predictor of mortality in CHF. It should no longer be used. Unfortunately I'm on my phone in the rig right now, but if anyone is interested in the study, let me know and I'll post it later.



I'm interested in that study. I haven't been able to find it yet


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## morbusstrangularis (Sep 8, 2013)

TransportJockey said:


> I'm interested in that study. I haven't been able to find it yet



For a great blog post by an er doc, google socmob lmnop, It's the first article talking about changing mnemonics. Apparently I can't post links until I have 5+ posts under my belt, can someone post it for me?

The data came from the ADHERE registry data as cited above, still searching for a link to.the actual article. Still on the phone as well, not very proficient at typing or researching through it.


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## morbusstrangularis (Sep 8, 2013)

Also, my bad, I recognize the difference between a retrospective analysis and controlled trial, my bad for my initial description.


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## morbusstrangularis (Sep 8, 2013)

And that was my fifth! Sorry for so many posts, but now I can bring you this: http://socmob.org/2013/04/evidence-based-management-of-acute-heart-failure-forget-lmnop-think-pond/


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## mycrofft (Sep 9, 2013)

URI said:


> I just wanted to say thank you to everyone who chimed in. I have a ton of research to do.
> I am a new paramedic and as Milla stated, I may not have had the best training.  (Still a poor excuse)
> 
> Does anyone have any suggestions/websites that they go to to stay abreast on the National standards?
> ...



Any health professional who stops learning or isn't getting anything new from their reading needs better subscriptions  and a kick in the pants. Then bring it to your bosses' attentions. Learning new stuff and discovering controversy means you're an active and potentially valuable provider who ought to consider better paying aspects of the field once the "yahoo" gene has been satisfied.


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## URI (Sep 10, 2013)

Point taken mycrofft, well said.


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