Fentanyl with MI

[fiznat]

Just to nitpick, that paper isn't really research per-se. It is a retrospective, non-randomized analysis of data taken from another larger study. It raises some questions, no doubt, but it's scientific relevance pretty much stops at identifying the need for further research.

It is a good thing to keep in mind though... In general I don't give morphine to my ACS patients at all, but that probably has more to do with the fact that it is locked up behind two keys in the safe and takes too long to set up + administer.

[UMSTUDENT]

Just to nitpick, that paper isn't really research per-se. It is a retrospective, non-randomized analysis of data taken from another larger study. It raises some questions, no doubt, but it's scientific relevance pretty much stops at identifying the need for further research.

It is a good thing to keep in mind though... In general I don't give morphine to my ACS patients at all, but that probably has more to do with the fact that it is locked up behind two keys in the safe and takes too long to set up + administer.

True, good catch. No true "controls," experimental parameters, or randomization to speak of. Like I said, there are limitations to the study, but it is important to consider. I think the recent information regarding the role of inflammation definitely calls for additional study.

[ccmedoc]

True, good catch. No true "controls" or experimental parameters to speak of. Like I said, there are limitations to the study, but it is important to consider. I think the recent information regarding the role of inflammation definitely calls for additional study.

Yep..I didn't think too much new came from this. There has been evidence for a while that inflammation played a huge part in AMI. We have been teaching, against convention, that reproducible chest pain does not preclude AMI. Simply because of this fact that inflammation is present. I would like to see more studies, any studies for that matter, about the efficacy of different analgesics in AMI, and the roles they play in outcome to discharge.

You have brought up some good points, guys..I wish it would rub off on some others :roll:

[chbare]

Agree, the safety and side effect profile of demerol can be concerning. Again, I still think fentanyl is a good alternative to morphine.

Take care,

chbare.

[Dustdevil]

Not to stray too far from the OP, but am I the only one here who simply is not terribly impressed with Morphine as an analgesic? Seriously. As much Morphine as I have given in the last thirty-five years, I sometimes feel like I have taken almost half that much myself, through various injuries, including the most recent one. It just doesn't do shit for me, pain wise. And I have had way too many patients tell me the very same thing over the years. I have always enjoyed much faster and better pain relief from Demerol than from Morphine. And Fentanyl simply blows them both away.

Morphine has never even been good as an anxiolytic or sedative for me. Doesn't even make me drowsy. Demerol and Fentanyl hit the spot quickly. And again, in my experience, they seem to do the same with most of my patients.

Of course, there is no doubt in my mind that much of the ineffectiveness we see with Morphine is the result of the monkey practice of dribbling it in by 2mg increments instead of just slamming it. That is cruel and ignorant. If your patient is in enough pain that you notice it, go big or go home.

[ccmedoc]

I see the point, MS doesn't help me either..I use the morphine mostly for kids and elderly. I also think the 2mg increment is ludicrous. Everyone is concerned about the respiratory issue, this is a bit ridiculous for most people.

4mg - 6mg to start is good in my opinion. If you go by the 0.1 mg/kg formula, 2mg doesn't even enter the picture except for kids.. 8)

I think if you stray from the MS or fentanyl, dilaudid is the next down the line....I like this stuff

Back to the program.........

[Dustdevil]

I honestly miss Stadol. I had wonderful luck with that stuff. You could practically RSI someone with 4mg IV of Stadol! First time I ever gave anyone 4mg, it was a 80ish lady who broke her hip in the middle of the night. She was in excruciating pain, and there wasn't a chance I was going to try to move her until I got her some relief. And, of course, she was allergic to Morphine and Demerol, so that left me with Stadol and Nubain to choose from at the time. I gave her 2mg IV, and she got significant relief quickly, but was still quite anxious, making it hard to handle her. And the movement to the cot exacerbated her pain. We were over thirty minutes from the ER, so I gave her another 2mg IV. Within five minutes, she was happy, laughing, and feeling no pain. Within fifteen minutes, she was drowsy and beginning to nod off. Within 25 minutes, she was sound asleep. By the time we got to the ER, she was snoring and completely unarousable by any means! I thought for sure the ER doc was going to be pissed. When he couldn't wake her up, he looked over at me and saw me looking for a place to hide my face. He said, "What'd you give her?" I told him 4mg of Stadol IVP. He just chuckled and said, "Good stuff! Nice job!" God, I miss ER docs like that!

[ERDoc]

If I had a crew bring in an MI pt that they had given fentanyl to and given me the reasons that the OP gave, I would be pretty impressed. They thought outside of the box and didn't just focus on MONA. Fentanyl does not have the vasodialatory properties that morphine does, but it does help with pain. Let's face it, in the end the pt needs the cath lab.

Dust, it's interesting that you brought that up. When I was in NY, it seemed that 2-5 mg of IV morphine could cure almost all pain. Now that I am practicing in the midwest, morphine is pretty useless. Everyone needs at least 3 does of 2mg IV dialudid to even touch the pain. I'm not sure what the difference is. It must be something reasonable. In my 3 years practicing in NY, I can probably count on my fingers how many times I gave dilaudid and it was usually in femur fx, hip fx, etc. Here in the great midwest I give it several times per day. There are also a lot more people here on methadone, chronic narcs, etc as well as SSRIs. Again, I don't quite understand the difference.

[Arizonaffcep]

Now that I am practicing in the midwest, morphine is pretty useless. Everyone needs at least 3 does of 2mg IV dialudid to even touch the pain. I'm not sure what the difference is. It must be something reasonable.

It's all them damned corn fed folk!

[fiznat]

Morphine makes me nervous because it is so unpredictable. 0.1 mg/kg will snow one patient, have another vomiting violently, and won't even touch a different patient. Push it too fast and they puke, push it too slow and it does nothing. It seems like everyone reacts to this drug differently, and there are a lot of negative side effects. I would much rather have a drug that is more consistent and predictable so that I can feel like I am actually doing some good more of the time.

And by the way our morphine for ACS protocol is 2mg Q 5 mins up to 6mg. Knowing how rarely 2mg touches anyone, I can't imagine that it makes much of a difference for these patients either. Another reason not to bother with it.