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Three Part Question

In [adults presenting with pain] is [intranasal fentanyl superior to intravenous morphine] at [reducing pain]?

Clinical Scenario

It's 7:45am and you are just winding down with a coffee before the end of a shift and the doors to emergency department burst open. Lying on a stretcher is a young, obese lady who is screaming in agony. She has an obvious fracture dislocation of the ankle. Just when you thought things couldn't get any worse she is presented to you by the paraamedics as the renowned Vera No-veins. While you evaluate your options of escape you ask yourself the question: "Would intranasal fentanyl be as efficacious as intravenous morphine in the reduction of pain from this broken ankle"?

Search Strategy

Medline 1950 - November week 1 2009 using the OvidSP
{(fentanyl.mp. OR exp Fentanyl/) AND (exp Administration, Intranasal/ OR intranasal.mp.)} AND {(morphine.mp. OR exp Morphine/ OR exp Morphine Derivatives/) AND (exp Infusions, Intravenous/ OR intravenous.mp. OR exp Injections, Intravenous/)} AND {pain.mp. or exp Pain/}
LIMIT to Human, "all adult (19 plus years)" and English Language

The Cochrane database of systematic reviews. Accessed via Wiley InterScience through Athens
Search re-ran Jan 2010 no new relevancies

Search Outcome

This MEDLINE search returned four papers of which one answered my three part question.

The Cochrane database of systematic reviews did not return any reviews

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rickard, C., et al 27/02/2007 Austrailia	258 patients presenting with pain in the pre-hospital setting	Prospective, multi-centred, open-labelled, RCT consisting of two treatment arms with patients receiving either INF or IVM at time 0, and further doses at 5 min intervals if required.	Verbal rating scores (VRS) at baseline, before each dose of analgesia and at destination (T0, T1, T2 and Td)	No significant difference in VRS at any time point (T0, T1, T2 or T3)	Imitial sample size estimates of 200 per arm not met (400 total) therefor strong potential for type 2 error. Open-labelled design may have resulted in operator bias. No comment why different inclusion VRS scores were required for chest pain (>5) as opposed to non-cardiac pain (>2).

Comment(s)

Severe pain is a common presenting complaint why patients attend the emergency department. The traditional "gold standard" of analgesic agent is intravenous morphine. Unfortunately this is not without its complications. Failure to cannulate, pain and fear of cannulation and the risk of infection are all important considerations. INF could be perceived as a more beneficial agent to morphine due to its ease of administration, rapid onset, shorter duration and lack of histamine release (Braude D, and Richards M. Prehosp Emerg Care 2004;8:441-2). The effectiveness of paediatric INF administation has been demonstrated in the ED (Borland M.l., et al. Emerg Med 2002;14:275-80) and for reducing both post-operative pain and anxiety for children undergoing ENT surgery (Galinkin J.L., et al. Anesthesiology 2000;93:1378-83). Despite the lack evidence that directly compares the efficacy of INF to IVM as a means of providing analgesia in the ED, I believe the conclusions of this paper, albeit performed in a pre-hospital setting, could be extrapolated to encompass the ED.

Editor Comment

RB

Clinical Bottom Line

In conclusion, it appears that INF is an effective alternative to IVM for use in adults with pain. Of particular value is the option to provide rapid analgesia to patients where cannulation is undesirable or impossible. However a larger study would lend more weight in support of this conclusion

References

1. Rickard, C., et al A randomized controlled trial of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting American Journal of Emergency Medicine (2007) 25, 911– 917