Morphine vs fentanyl myocardial o2 demand

[URI]

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.

 

[SanDiegoEmt7]

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.

 

[truetiger]

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.

 

[URI]

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

 

[truetiger]

Yup

 

[URI]

Thanks for clarifying.

 

[TransportJockey]

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.

 

[truetiger]

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

 

[TransportJockey]

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

 

[VFlutter]

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.

 

[URI]

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?

 

[blindsideflank]

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)

 

[URI]

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

 

[blindsideflank]

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.

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...

 

[Medic Tim]

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...

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

 

[blindsideflank]

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

 

[Medic Tim]

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.

 

[Carlos Danger]

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.

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.

 

[Christopher]

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.

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.

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.

 

[Milla3P]

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.