Add a benzo to morphine for better analgesia?

[mycrofft]

Mycrofft, somewhat personal so you don't have to answer if you don't want but were both your cardioversions done with propofol?

We are only allowed to sedate for cardioversion, I've brought it up a few times about concurrent pain and sedation during cardioversion.

Yeah, I believe they were done with propofol. (Which my auto speller keeps changing to "proposal"). I was out and woke up in a recovery section. The colonoscopy was also done with it and they had trouble waking me up.

When we did colonoscopies (few) at the doc in a box I worked at in 1986-87, we used I.V. valium and hydrazine with ok effect; sedated and didn't care when they experienced discomfort…sort of like Demerol used to be ("Go on, cut off my other leg, what's for supper?").

 

[Carlos Danger]

Yeah, I believe they were done with propofol. (Which my auto speller keeps changing to "proposal"). I was out and woke up in a recovery section. The colonoscopy was also done with it and they had trouble waking me up.

That is quite unusual. The primary reason propofol has become so popular for those procedures is precisely because people wake up so quickly and completely, and usually feel perfectly normal afterwards. In contrast to sedation techniques using opioids and benzos, where some people say they don't feel right for a whole day or two.

 

[mycrofft]

Well, maybe they slipped me a mickey?

"Easily woken" can be like "Minor office procedure"; try it yourself once. Sternal bruising is not a sign for me that it was easy.

BUT we digress….

 

[Carlos Danger]

Dr. Walsh was kind enough to send me the paper, and since I have today off, I was able to read it this morning.

I think there are some problems with the protocol used in the study:

1. Morphine vs. fentanyl is a matter of personal preference in most cases, but fentanyl is objectively faster in onset, time to peak effect, and offset, which I think makes it a fair claim to say it is a better choice anytime you are trying to "titrate" your doses so that you get a satisfactory effect with the smallest dose possible. Also, being devoid of histamine release makes fentanyl a "cleaner" drug, which becomes important, I think, when you are trying to discern the effects of several drugs given at once. Anecdotally I think these properties make fentanyl just "work" better adjunctively with benzos.
   
   
2. I hate to belabor the point about the time-to-peak effect, but it is of critical importance in this setting. Onset time for morphine is anywhere from 2-10 minutes depending where you look, but time to peak effect is much more important when you are repeating doses, and it is up to 30 minutes according to some references. 5 minutes is simply not enough time between doses of morphine to reliably assess how well your previous dose(s) worked, and therefore how much more you should give. This doesn't matter as much with the smallish doses that are often used in EMS and in some ED's, but if you are giving more substantial doses, then it could definitely become an issue as your first 1 or 2 doses are just taking full effect as you are pushing your 3rd or 4th dose. I don't question the statistical analysis which showed no difference in opioid requirements between the versed and placebo groups, but I can't help but think that the fairly rapid administration of substantial repeat doses of morphine blurred the picture to a degree.
   
   
3. Unless I am misunderstanding the paper, the versed or placebo was given prior to the morphine ("only one dose at baseline"). Whether it was given first or second doesn't really matter though, the important thing is that it was given automatically without any assessment as to whether it was indicated....certainly not everyone in pain needs or is a good candidate for the adjunctive use of a benzo. If we go around giving a drug to everyone we encounter without assessing whether it is indicated or even whether the patient will tolerate it, we shan't be surprised to see a large number of untoward effects associated with the drug.
   
   
4. The dose of versed they used (0.04mg/kg) is a fairly hefty dose. That's 3.2 mg in an 80kg patient, which is not a lot of versed if given alone, but in combination with a good dose of morphine (8 mg for that same 80kg patient....followed at least once by another 3mg dose, and then possible by more 3mg doses), it is far more than I would give without closely assessing the need. The total morphine dose for the versed group was 14mg, which again, is quite a bit to give over a short period of time in addition to versed....it's really not surprising that they had more problems with sedation and resp depression in that group.

I think the only thing we can reliably take from this study is that we should not give versed with opioids without first assessing the need, and that the versed/morphine combo is not a great one. If the study was repeated with fentanyl and the versed was only given if an adjunct was needed after the opioid, then I think we might see quite different results.

Once the patient is comfortable, then longer-acting opioids such as dilaudid or morphine work well to maintain the state of comfort. But knocking out that initial anxious "wound up" state that some are in is much easier to do with a faster opioid, and sometimes with some benzo added.

 

[mycrofft]

Great reply.

As an aside to the entire thread, with how long a treatment-plus-transport time would this be useful? How would receiving such a patient affect handoff to the ED? Or to a home hospice caregiver, etc? (Yes, people go home in extreme pain, too).

 

[EMTelite]

I have seen posts on tbis before but I have also done some research your benzo wil offer an anesthetic property which seems to lead to the belief it potentiates the effect of your analgesic. An anti inflammatory will do more to potentiate the effects of your analgesic

Just my opinion

 

[ChrisV]

Never tried this approach as protocol didn't allow it. Frankly it seems like an excellent idea. Had a patient with a compound fracture, that I was blessed to witness said fracturing event, have an allergy to morphine (Fentynal was backordered) which was the only pharmaceutical available at the time. A healthy dose of Versed and quality splinting was enough to eliminate the pain until arrival at definitive care. Furthermore, the patient didn't remember the painful splinting and transferring. The combination of the benzo and the opiod seems like a fantastic idea. Thanks for the link to the study.

 

[the_negro_puppy]

Our protocols allow Intensive Care Medics to use Midazolam for severe pain (burns, bad fractures) after Morphine (0.1 / 0.2mg/kg) have been given. I have seen this done once with a fractured femur, I believe 2 x 1mg IV dosages were given after approx 15mg of Morphine.

However Ketamine is given far more often if extra analgesia is required.

 

[FiremanMike]

At the FD we were just given the ability to use versed for severe pain after exhausting our fent. Where I do CCT we generally alternate 2.5 of versed and 50 of fent every 5 or so, but that's really for sedation and not pain.

 

[KellyBracket]

At the FD we were just given the ability to use versed for severe pain after exhausting our fent. Where I do CCT we generally alternate 2.5 of versed and 50 of fent every 5 or so, but that's really for sedation and not pain.

Important distinction!

 

[Handsome Robb]

At the FD we were just given the ability to use versed for severe pain after exhausting our fent. Where I do CCT we generally alternate 2.5 of versed and 50 of fent every 5 or so, but that's really for sedation and not pain.

Sounds like post intubation sedation maintenance blouses. Glad to know that there's agencies out there doing it right though! Cause we sure don't