Morphine and Fentanyl

[NPO]

We technically have morphine, fentanyl, Dilaudid and ketamine in our scope of practice, but we only carry fentanyl and ketamine regularly.

My most aggressive combination I've ever given was fentanyl potentiated by valium, with a ketamine kicker for good measure.

(Didn't help one bit)

 

[Djohnson]

We stopped carrying morphine in the box a few years ago, now we have both fentanyl and Toradol. In my personal experience, fentanyl has not had the same level of analgesia that morphine did. I've found that a higher loading dosevof fentanyl is usually required as well as more frequent redoing due to the shorter half life. Even then, I have not seen the same amount of analgesia compared to morphine. This can be an issue in the many parts of my region that are more rural.

 

[Brandon O]

We stopped carrying morphine in the box a few years ago, now we have both fentanyl and Toradol. In my personal experience, fentanyl has not had the same level of analgesia that morphine did. I've found that a higher loading dosevof fentanyl is usually required as well as more frequent redoing due to the shorter half life. Even then, I have not seen the same amount of analgesia compared to morphine. This can be an issue in the many parts of my region that are more rural.

What doses?

 

[NPO]

We stopped carrying morphine in the box a few years ago, now we have both fentanyl and Toradol. In my personal experience, fentanyl has not had the same level of analgesia that morphine did. I've found that a higher loading dosevof fentanyl is usually required as well as more frequent redoing due to the shorter half life. Even then, I have not seen the same amount of analgesia compared to morphine. This can be an issue in the many parts of my region that are more rural.

I've noticed the same thing. For significant trauma I'll skip fentanyl for ketamine because of the half life.

 

[Djohnson]

What doses?

In the rural areas it's about conservation. For most adults a loading dose of 100 to 150 mcg of fentanyl is best for me, but we only have 200 mcg in the box. If you're an hour out, increments of 50 mcg. If it's needed, we also have ketamine in the RSI box, but we have to call for orders.

 

[Brandon O]

In the rural areas it's about conservation. For most adults a loading dose of 100 to 150 mcg of fentanyl is best for me, but we only have 200 mcg in the box. If you're an hour out, increments of 50 mcg.

That's not a very heavy fentanyl dose. Your problem may be one of quantity. I presume you were giving 2mg or more of morphine at a time?

 

[Djohnson]

That's not a very heavy fentanyl dose. Your problem may be one of quantity. I presume you were giving 2mg or more of morphine at a time?

Yes, 2 to 4 mg. Technically, fentanyl dose is 1 to 3 mcg/kg of fentanyl, but we get a lot of flack if we go over 200 per dose. I was mistaken before as well, we have 400 mcg in the box. Either way though, in doses I've given in the 1 to 2 mcg/kg range, I haven't seen much decrease in pain in most patients. With that being said, I have had some grown men that were snowed with 50 mcg. It just seems much more inconsistent.

 

[Brandon O]

Yes, 2 to 4 mg. Technically, fentanyl dose is 1 to 3 mcg/kg of fentanyl, but we get a lot of flack if we go over 200 per dose. I was mistaken before as well, we have 400 mcg in the box. Either way though, in doses I've given in the 1 to 2 mcg/kg range, I haven't seen much decrease in pain in most patients. With that being said, I have had some grown men that were snowed with 50 mcg. It just seems much more inconsistent.

I would go by aliquots of 50 or so (less if they are really shocked, maybe more if they are stable but in severe pain) and continue to load them until they are happy. There is not much sense in saying that any opioid is more or less effective than other; their potencies differ, but so does the dosing, so you just titrate to effect. The only issue is if you run into side effects before achieving pain control, but that should be less likely with fentanyl (a cleaner agent), not more.

 

[E tank]

In the rural areas it's about conservation. For most adults a loading dose of 100 to 150 mcg of fentanyl is best for me, but we only have 200 mcg in the box. If you're an hour out, increments of 50 mcg. If it's needed, we also have ketamine in the RSI box, but we have to call for orders.

For most adults, those doses are modest sedation for anxiety, not analgesia. Add 10-20 of ketamine to that and you have something more approaching treatment for acute, moderate to severe pain. Something that has come into the collective anesthesia consciousness in the last 10 to 15 years or so is "multimodal" analgesia whereby you hit complimentary analgesia producing receptors with moderate doses of a couple or even three different agents/routes instead of a big whack (or not enough of) just one. Synergy with greater analgesia with less side effects are the objectives.

 

[Djohnson]

For most adults, those doses are modest sedation for anxiety, not analgesia. Add 10-20 of ketamine to that and you have something more approaching treatment for acute, moderate to severe pain. Something that has come into the collective anesthesia consciousness in the last 10 to 15 years or so is "multimodal" analgesia whereby you hit complimentary analgesia producing receptors with moderate doses of a couple or even three different agents/routes instead of a big whack (or not enough of) just one. Synergy with greater analgesia with less side effects are the objectives.

I like that, I'll keep that in mind for next time.

 

[RocketMedic]

I really like 1-2mcg/kg of fentanyl and 0.25mg/kg of ketamine for potentiation and edutainment of analgesia. Ketamine has cut my fentanyl use considerably.

 

[TrueNorthMedic]

For those using Ketamine along with Fentanyl, or just Ketamine alone, do you find that this causes any sedation or decreased LOC in the patient, or do you just get pain relief with the pt remaining fully alert?

The one opportunity I've had to use this combo, the pt was completely pain free and appeared to be asleep but would open her eyes and converse normally with you as soon as you talked to her. I think I gave 100mcg of Fent and 25 mg Ketamine.

 

[Djohnson]

We technically have morphine, fentanyl, Dilaudid and ketamine in our scope of practice, but we only carry fentanyl and ketamine regularly.

My most aggressive combination I've ever given was fentanyl potentiated by valium, with a ketamine kicker for good measure.

(Didn't help one bit)

I'm guessing this was a pretty severe trauma? What happened?

 

[RocketMedic]

For those using Ketamine along with Fentanyl, or just Ketamine alone, do you find that this causes any sedation or decreased LOC in the patient, or do you just get pain relief with the pt remaining fully alert?

The one opportunity I've had to use this combo, the pt was completely pain free and appeared to be asleep but would open her eyes and converse normally with you as soon as you talked to her. I think I gave 100mcg of Fent and 25 mg Ketamine.

Pretty much this.

 

[NPO]

I'm guessing this was a pretty severe trauma? What happened?

The patient had a spinal nerve stimulator surgically placed a few hours prior for chronic back pain. The nerve stimulator malfunctioned and caused significant pain directly to the spinal cord.

 

[E tank]

The patient had a spinal nerve stimulator surgically placed a few hours prior for chronic back pain. The nerve stimulator malfunctioned and caused significant pain directly to the spinal cord.

Chronic narcotic use? Enough Ketamine would have worked eventually...narcotic, not so much.

 

[NPO]

Chronic narcotic use? Enough Ketamine would have worked eventually...narcotic, not so much.

I'm sure he had a history of pain meds due to his chronic back pain, escalating to surgical intervention.

This was a 35 year old, 250lbs, corn fed, back woods male.

 

[Carlos Danger]

For those using Ketamine along with Fentanyl, or just Ketamine alone, do you find that this causes any sedation or decreased LOC in the patient, or do you just get pain relief with the pt remaining fully alert?

The one opportunity I've had to use this combo, the pt was completely pain free and appeared to be asleep but would open her eyes and converse normally with you as soon as you talked to her. I think I gave 100mcg of Fent and 25 mg Ketamine.

There are so many variables that go into a patients reaction to any given medication or dose. You can give the same thing to 10 different patients of similar weight and who appear to be in a similar amount of pain, and you'll get at least 5 different results.

 

[Carlos Danger]

The patient had a spinal nerve stimulator surgically placed a few hours prior for chronic back pain. The nerve stimulator malfunctioned and caused significant pain directly to the spinal cord.

Chronic opioid users (which anyone with a SCS will be) in acute pain can be really difficult. Opioids will usually work eventually but you need massive doses, to the point that the side effects become prohibitive. These folks generally have high levels of anxiety and very poor pain tolerances. They'll sometimes stop breathing before they get comfortable. These are pretty much the only cases where ketamine is the first thing I'll reach for.

 

[NPO]

Chronic opioid users (which anyone with a SCS will be) in acute pain can be really difficult. Opioids will usually work eventually but you need massive doses, to the point that the side effects become prohibitive. These folks generally have high levels of anxiety and very poor pain tolerances. They'll sometimes stop breathing before they get comfortable. These are pretty much the only cases where ketamine is the first thing I'll reach for.

I've seen very few "true" 10/10 pain patients.

Looking at him made ME hurt.