Fentanyl

[18C/GS 0602]

Annals of Emergency Medicine
Volume 44(2) August 2004 p 121–127
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A Novel Pain Management Strategy for Combat Casualty Care

Kotwal, Russ S. MD, MPH; O'Connor, Kevin C. DO; Johnson, Troy R. MD; Mosely, Dan S. MD; Meyer, David E. MS, PT; Holcomb, John B. MD

Abstract

Study objective: Pain control in trauma patients should be an integral part of the continuum of care, beginning at the scene with out-of-hospital trauma management, sustained through the evacuation process, and optimized during hospitalization. This study evaluates the effectiveness of a novel application of a pain control medication, currently indicated for the management of chronic and breakthrough cancer pain, in the reduction of acute pain for wounded Special Operations soldiers in an austere combat environment.

Methods: Doses (1,600 µg) of oral transmucosal fentanyl citrate were administered by medical personnel during missions executed in support of Operation Iraqi Freedom from March 3, 2003, to May 3, 2003. Hemodynamically stable casualties presenting with isolated, uncomplicated orthopedic injuries or extremity wounds who would not have otherwise required an intravenous catheter were eligible for treatment and evaluation. Pretreatment, 15-minute posttreatment, and 5-hour posttreatment pain intensities were quantified by the verbal 0-to-10 numeric rating scale.

Results: A total of 22 patients, aged 21 to 37 years, met the study criterion. The mean difference in verbal pain scores (5.77; 95% confidence interval [CI] 5.18 to 6.37) was found to be statistically significant between the mean pain rating at 0 minutes and the rating at 15 minutes. However, the mean difference (0.39; 95% CI -0.18 to 0.96) was not statistically significant between 15 minutes and 5 hours, indicating the sustained action of the intervention without the need for redosing. One patient experienced an episode of hypoventilation that resolved readily with administration of naloxone. Other documented adverse effects were minor and included pruritus (22.7%), nausea (13.6%), emesis (9.1%), and lightheadedness (9.1%).

Conclusion: Oral transmucosal fentanyl citrate can provide an alternative means of delivering effective, rapid-onset, and noninvasive pain management in an out-of-hospital, combat, or austere environment.

[SwedeGlocker]

What level of training is recuired to give Fentanyl in you armed forces? I can see several resons why its a great tool but i feel that anyone giving it should have more training than if they where giving MS or ketamine.

[The Reaper]

The Fentanyl patch is patient self-administered.

I was put under last year for a minor procedure with what I seem to recall was Fentanyl, it was a very nice ride. Much better then some of the previous anesthesias I have received.

TR

[ccrn]

Originally posted by The Reaper
Much better then some of the previous anesthesias I have received.

TR


Fentanyl works very well along with a sedative like Versed (midazolam) for conscience sedation.

Im not sure what level of training medics etc are getting for fentanyl administration so I cannot help you there.

I have read that they are using the fentanyl lozenges on wounded in the field. I think this would work very well from my experience with hospice pt's. They and their families were able to manage the lozenges easily even with the risks the most common (and dangerous) being respiratory depression. A pt can mostly self medicate although they need to be observed at least in some degree.

The ones available to us had little lolipop sticks in them making them easy to handle and hard to accidently swallow.

Personaly I would think that ketamine would be more difficult to manage in the field mostly because of its route-

ccrn

[SwedeGlocker]

Why do you find ketamine more difficult to manage in field. Or do you mean that it takes more training giving meds IV/IM. There is a military project with nasal ketamine as we speak.

[ccrn]

Originally posted by SwedeGlocker
Or do you mean that it takes more training giving meds IV/IM


Correct although those routes are certainly within the capability of any IV certified personel.

Also the indication for ketamine ie general anesthetic which has more inherent risk than pain control. Personel would have to be trained in at least simple anesthesia to use it safely-

[SwedeGlocker]

If i only had one choice for pain control i would without any hesitation pick ketamine as my number one choice. As a bonus it can also be used as a general anesthestic. Either as a plain ketamine drip or as tiva with Versed and Norcuron.

Fenatyl(IV) is a great choice when one need a fast acting, short duration stuff but not as an allround pain control metod.

[rogerabn]

Sorry for spelling and grammar, I am writing this on a break during a case.
Due to the low molecular weight, Fentanyl can be adminstered both transdermal,and submucosal (both oral and nasal). It is approximetly 250 times more potent than Morphine (the gold standard for opiods).
We use it almost exculsively in anesthesia due to the low incidence of side effects; no histiamine release, allergic RXN's and negative GI effects.
The nice thing about Fentanly is that peak analgesia is reached within 5 mins. after IV adminstration. (Morphine does not reach peak analgesic efficency for 20 to 25 mins after IV adminstration. Although there is of course some immediate affects noted.)
The theraputic half-life is short so it is very perdicatable.
The down side of using Fentanyl is it's potency. This is a drug used by anesthesia providers with the ablity to maintain airways.
Ridged Chest is seen with rapid IV adminstration along with resp. depression. If you use it, you better have airway adjunts avalible.
Adminstering Fentanyl submucosal or transdermally is sometimes a crap shoot due to the varialble absorbtion rates. so under and overdoseage is possible.
I use the stuff everyday and love it. But in settings other than a controlled enviorment I would be hesitent about using it. ie in a field enviorment. Roger Coleman, CRNA

[The Reaper]

It is used transdermally for pain control in cancer patients.

TR

[Sacamuelas]

A few of the patients that I see on rounds in the long term care and hospice areas are on transdermal fentanyl patches. Very effective long term pain management and especially good for patient compliance issues.

[greg c]

Does causing nearly 1 out of 10 patients to puke seem a little high to anyone else?

[ccrn]

Originally posted by SwedeGlocker
If i only had one choice for pain control i would without any hesitation pick ketamine as my number one choice. As a bonus it can also be used as a general anesthestic. Either as a plain ketamine drip or as tiva with Versed and Norcuron.

Fenatyl(IV) is a great choice when one need a fast acting, short duration stuff but not as an allround pain control metod.

Personaly, from what Ive read and been told I hope that I am not treated with ketamine unless nothing else is available period. It is used as animal tranquilizer over here for the most part. I believe it does have a role in OR or PEDS but Ive never seen it used in any of the ICU,s or ER's Ive worked in.

From what Ive read there are studies being done here for a role as an adjunct to analgesia.

Ive not heard of field medics using a long acting paralytic such as norcuron-

ccrn

PS
I would like to add that anesthesia and paralysis are not pain control. Just because they are not moving or canoot communicate with you does not mean they are not suffering. Have mercy on your patients.

[SwedeGlocker]

Ketamine have been used under austere/primitive medicine for long time and have the best saftey profile both as a low dose analgetica or as a general anesthestic in high doses. Not even propofol is near when it comes to safety. Acording to some SOCOM medics is ketamine issue for both 91W and 18D.

I agree that Norcuron shouldnt be used in "field" but during surgery att company/batalion level that demands muscle relaxition its a great real world tested choice.

ccrn: I cant find anywhere in this post where i suggested that anesthesia or paralysis is pain control. Ketamine is the only common general anesthestic that also act as a pain control.

Please note that i have posted a thread about TIVA. We should perhaps discuss some of this in that post.

[ccrn]

Originally posted by SwedeGlocker
Not even propofol is near when it comes to safety


I would disagree. I use propofol daily for both bedside procedures and long sedation sedation. I also use versed, ativan, and precedex for sedative drips on ICU pt's.

While I readily admit that I am not that familiar with ketamine if what you say is true then I would be using ketamine for sedation and pain control rather than propofol , MS, dilauded, and fentanyl.

But then again the EU and Cananda all know U.S pharmacutical companies are evil.

Perhaps Roger or Doc T could expand on ketamine and its pros and cons-

ccrn

Glock are you by chance a drug rep?

[Doc T]

My experience with ketamine has all been good.

we premedicate with an amnestic agent so patients don't recall if they have "nightmares" which are reportedly pretty common.

We tend not to use it in patients with traumatic brain injuries because of experimental rises in ICPs in some animals (I believe they were all obstructed but I cannot remember offhand)...it is controversial but many do still use it with TBI patients.


The risk of severe laryngospasm is a bigger concern. It occurs rarely but when it does can be devastating as the patients typically do not have an airway. I have not seen it...alot of the patients tend to snore loudly but that is neither here nor there. One of my partners had to cric someone as they were unable to intubate when it occurred... so its real and you need to be prepared for it.

Overall, patients tolerate it well...

doc t.

[greg c]

Originally posted by ccrn


PS
I would like to add that anesthesia and paralysis are not pain control.

While I readily admit that I am not that familiar with ketamine if what you say is true then I would be using ketamine for sedation and pain control rather than propofol , MS, dilauded, and fentanyl.

Glock are you by chance a drug rep?

I am distressed to find here the staements "I've never seen it used" and "I am not familiar with ketamine, [but] if what you say is true I would be using [it as opposed to what I do now]- the sentiment behind these statements that experience is a substitute for knowledge or continued learning is one that has classically stood in the way of medical progress- from sterile fields to use of pulse oximetry.

Here is what I know about ketamine:

It is a bronchial smooth muscle relaxant. I've used it in the ED and ICU when intubating asthmatics with bronchospasm. It has BOTH analgesic and anesthetic properties.

Is it safer than propofol? Lets look at the side effects of both:

Propofol:
respiratory depression

High dose use can result in clinically significant hypertriglyceridemia due to lipid content- allthough this is controversial in my mind

Can have contamination of the lipid by unusual infectious organisms (Post-operative infections traced to contamination of an intravenous anesthetic, propofol. NEJM 1995; 333: 147-54)
(this is why we need to change bottles and tubing so frequently with this medication!)

During maintenance of anesthesia with a propofol infusion, systolic pressure remains between 20 and 30 percent below preinduction levels. (Miller, Anesthesia) All I know is that clinically I have a LOT of patients who don't get this drug either due to predicted need for long term sedation or sepsis with hypotension

Ketamine:
very little respiratory depression

As noted, funky emergence dreams

increases intracranial pressure

increases blood pressure

excessive secretions

Both drugs have significant potential problems.

My bottom line is that I don't use ketamine for long term sedation, and only rarely for induction, but my limited experience does NOT translate into ketamine being a poor medication. Nor does it make everyone who proposes its use a drug rep. :rolleyes:

[ccrn]

Originally posted by greg c
the sentiment behind these statements that experience is a substitute for knowledge or continued learning



Experience is knowledge.

As a registered nurse licensed to practice in three states CEU has become a part time job. Some of it is good, some interesting, some applicable. All of it makes me a better nurse, that is my experience.

In assisting in hundreds of intubations I have only seen atomidate, versed, and a short acting paralytic such as succinylcholine or intermediate acting such as cisatracurium used for the most part including pt's with bronchospasm. That is also my experience.

I stand by my statement that ketamine has a role (based upon my experience in hospital and reading) in OR and PEDS for the most part again. If it were otherwise it would be used all over by qualified providers for IV sedation and analgesia according to your statements. I dont see large groups of investors rushing out to buy stock in katamine but now that the cat is out of the bag Im sure to.

I dont what your qualifications or background are greg as your profile isnt really filled out but lets say you are an MD based on your assertions for the sake of this conversation.

Of course you dont use ketamine for long term sedation, and your experience with it is "limited" for a reason isnt it?

ccrn

BTW, the "drug rep" comment was supposed to be a joke

[rogerabn]

Analgesia or anesthesia, Ketaimine can perform both roles. For deep skeletal muscle analgesia it works great, but for abdominal injury/surgery not so great. In crash C-Section’s we use it when unable to obtain a spinal/epidural. (generally have tried for the spinal and the pt. is now on the table and you are looking at a horrible airway.) I have used high dose ketamine with the surgeon injecting local as they cut through each layer. This was one of the more extreme use’s. And it certainly sucked for that patient.

The nice thing about ketamine is the fact that it is not a respiratory depressant. If used in an induction of general anesthesia it can buy you some time and not put the patient into too much of harms way. Precedex has been used more and more lately in that role, and I have found it useful during difficult airways.

Now to fentanyl; this drug is highly potent, unless the patient is on a monitor it should never be administered IV. Also I have heard of overdoses with the transdermal patch when the patient used a hot pad over the site, And in Florida a couple of years ago a Dentist prescribed it too a 16 year old. He put it on and went too sleep on a heated water bed. He subsequently overdosed and died.
And then there is the drug addicts who cut them open and eat the gel. This has helped more than a few addicts too finally get that :�big sleep� that they seem to be looking for

[DoctorDoom]

x

[ccrn]

I didn't think too much of this because of the small study population of 22 patients..


I agree, and from practical experience on the floor MS04 has quite a bit higher incident of N,V than either fentahyl or dilauded especialy in post surgical pts. We hardly ever use demerol anymore accept for post anesthesia shakes (and drug seekers and migraines) for which they work wonderful-

Making rounds again DD?

[DoctorDoom]

x

[Doc]

But then again the EU and Cananda all know U.S pharmacutical companies are evil.

Glock are you by chance a drug rep?

Hijack in progress. Sorry.

ccrn,

Could you expand on your comments for me? I'm thinking they are just good natured humor, but I just want to make sure.

Check out mine and wally's profile when you get the chance.

Doc

[Sacamuelas]

LOL... if he answers that one wrong Doc, we will have to split the thread. NO KILLING in the medical tent. haha
:munchin

[Doc]

LOL... if he answers that one wrong Doc, we will have to split the thread. NO KILLING in the medical tent. haha
:munchin

I hear you Sacamuelas. If it goes to debate ccrn or I will start another thread so we don't disturb this thread already in progress. ;)

Please excuse me while I get ready. :lifter

Thanks,

Doc

[ccrn]

BTW, the "drug rep" comment was supposed to be a joke



...as previously stated...

[brewmonkey]

The Fentanyl patch is patient self-administered.

I was put under last year for a minor procedure with what I seem to recall was Fentanyl, it was a very nice ride. Much better then some of the previous anesthesias I have received.

TR


Was it duragesic?

[The Reaper]

Was it duragesic?

Don't know, I was out quickly after they started it, softly, and came back the same way, floating. No pain, no worries, only a few recollections of the procedure.

Some of the other stuff will give you some real horror stories.

TR

[Razor]

That's the truth. Morphine may take the pain away, but after a week I just couldn't handle the freakish dreams meshing with reality anymore.

[DoctorDoom]

x

[TF Kilo]

Wow, Doc Kotwal made a study about it! Cool!

The Fentanyl was lollypop form. The standard dosage procedure was for one lollypop to be administered to a patient requiring pain management. Administration was time based for ease of use, The Medic administering the lollypop would set a timer or keep track of the time. 10 min in the mouth, 10 off, 9 in, 9 out, until it was gone. It definately did an awesome job. One PT was a full blowout of the knee, all tendons and ligaments ruptured (ankle brace caught in suspension lines, landed on one leg w/ injured leg's foot at eye level on casualty) and when he was given the 'pop he was on cloud 9. Did an awesome job on every casualty it was administered on, but the dosage for the lollypops was recommended by everyone to be lowered due to it being significantly greater than required. Some less severe casualties that recieved pain management via lollypop were turned loopy and generally everyone became a litter patient due to inability to stand from effects of the drug.