Morphine vs fentanyl myocardial o2 demand

[medicsb]

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."

 

[Carlos Danger]

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.

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.

 

[MSDeltaFlt]

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.

 

[URI]

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.

 

[MSDeltaFlt]

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

 

[URI]

Thank you.

 

[morbusstrangularis]

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.

 

[TransportJockey]

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

 

[morbusstrangularis]

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.

 

[morbusstrangularis]

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

 

[morbusstrangularis]

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/

 

[mycrofft]

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.

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.

 

[URI]

Point taken mycrofft, well said.