The Effect of Fentanyl Compared to Morphine on Pain Score and Cardiorespiratory Vital Signs in Out-of-Hospital Adult STEMI Patients
Article Sidebar
Main Article Content
Abstract
Objective: ST-elevation myocardial infarction (STEMI) is a leading cause of mortality in Australia. Paramedics treating adults with STEMI in the out-of-hospital environment can use fentanyl or morphine to manage the patient’s pain, although there is little research comparing the efficacy and safety of these drugs. Therefore, the objective of this study was to compare the effects of fentanyl to morphine on cardiac chest pain and cardiorespiratory vital signs in adult STEMI patients in the out-of-hospital environment.
Methods: We conducted a retrospective analysis of records of 1902 STEMI cases attended by Queensland Ambulance Service paramedics during the 4-year interval from 2013 to 2016. We compared pain score, blood pressure, respiratory rate, and pulse rate between patients administered intravenous fentanyl and intravenous morphine. We used a two-way mixed effects model (drug, time) to assess for main and interaction effects, and where the interaction effect was significant, applied Mann-Whitney U tests to further analyze between-group differences at each time point.
Results: We observed a significant main effect of time on pain score (p < 0.001), respiratory rate (p < 0.05), and pulse rate (p = 0.025), such that these variables all decreased over time. Additionally, we observed a significant drug-time interaction for systolic and diastolic blood pressures (both p < 0.01), such that blood pressures decreased over time in the morphine, but not fentanyl, group.
Conclusion: We compared the effects of fentanyl to morphine on cardiac chest pain and cardiorespiratory vital signs in out-of-hospital adult STEMI patients and observed differences in blood pressures only. Morphine appeared to have a depressive effect on systolic and diastolic blood pressure, whereas fentanyl did not. An unanticipated behavioural finding of this research is that, in the absence of a definitive guideline, paramedics appear to use fentanyl when patients may be at risk of developing hypotension.
Article Details
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Publishing in IJOP allows authors to keep their copyright while giving IJOP unrestricted copyright permissions. Articles published in IJOP use Creative Common Attribution 4.0 International (CC BY-ND 4.0) licensing. This license requires that re-users give credit to the creator. It allows re-users to copy and distribute the material in any medium or format in unadapted form only, even for commercial purposes. Additional terms apply and can be accessed here.
Publishing in IJOP also allows authors to have contracts for non-exclusive distribution of the Journal's published version of the article, such as posting to an institutional repository or publication in a book, on the condition that the original publication in the original layout format in IJOP is retained and acknowledged.
We permit and encourage authors to post the articles they published in IJOP on their affiliated websites. This helps share the information, encourages citation in other works, and promotes scholarly discourse in the spirit of open access.
References
Alexander, J. C. (2023). Pharmacokinetics for IV opioids used in the perioperative setting. In G. P. Joshi, & N. A. Nussmeier (Eds.), UpToDate. Retrieved June 11, 2023 from: https://www.uptodate.com/contents/image/print?imageKey=ANEST%2F111780
Australian Bureau of Statistics. (2022). Causes of death, Australia, 2021 (Report No.: 3303.0). Australian Bureau of Statistics. https://www.abs.gov.au/statistics/health/causes-death/causes-death-australia/2021/2021_1%20Underlying%20causes%20of%20death%20%28Australia%29.xlsx
Australian Government Productivity Commission. (2022). 11 Ambulance services [dataset]. In Australian Government Productivity Commission (Ed.), Report on Government Services 2022. Retrieved June 11, 2023 from: https://www.pc.gov.au/ongoing/report-on-government-services/2022/health/ambulance-services/rogs-2022-parte-section11-ambulance-services-data-tables.xlsx
Baruah, R., & Hartley, A. (2023). BMJ Best Practice: ST-elevation myocardial infarction. BMJ Best Practice [Internet]. Retrieved June 11, 2023 from: https://bestpractice.bmj.com/topics/en-gb/3000103#:~:text=ST%2Delevation%20myocardial%20infarction%20(STEMI,unwell%20patient%20in%20cardiogenic%20shock
Braun, S. R. (1990). Respiratory Rate and Pattern. In H. K. Walker, W. D. Hall, & J. W. Hurst (Eds.). Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.). https://pubmed.ncbi.nlm.nih.gov/21250206/
Chew, D. P., Scott, I. A., Cullen, L., French, J.K., Briffa, T.G., Tideman, P.A., Woodruffe, S., Kerr, A., Branagan, M., & Aylwward, P. E. (2016). National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. The Medical Journal of Australia, 205(3), 128-133. https://doi.org/10.5694/mja16.00368
Duarte, G. S., Nunes-Ferreira, A., Rodrigues, F. B., Pinto, F. J., Ferreira, J.J., Costa, J., & Caldeira, D. (2019). Morphine in acute coronary syndrome: systematic review and meta-analysis. BMJ Open, 9(3), e025232. https://doi.org/10.1136/bmjopen-2018-025232
Fleischman, R. J., Frazer, D. G., Daya, M., Jui, J., & Newgard, D. (2011). Effectiveness and safety of fentanyl compared with morphine for out-of-hospital analgesia. Prehospital Emergency Care, 14(2), 167-175. https://doi.org/10.3109/10903120903572301
Gabb, G. M., Mangoni, A. A., Anderson, C. S., Cowley, D., Dowden, J. S., Golledge, J., Hankey, G. J., Howes, F. S., Leckie, L., Perkovic, V., et al. (2016). Guideline for the diagnosis and management of hypertension in adults — 2016. The Medical Journal of Australia, 205(2), 85-89. https://doi.org/10.5694/mja16.00526
Galinski, M., Dolveck, F., Borron, S. W., Tual, L., Van Laer, V., Lardeur, J. Y., Lapostolle, F., & Adnet, F. (2005). A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia. American Journal of Emergency Medicine, 23(2), 114-119. https://doi.org/10.1016/j.ajem.2004.03.010
Huang, M., Watso, J. C., Belval, L. N., Cimino, F. A., Fischer, M., Jarrard, C. P., Hendrix, J. M., Laborde, C. H., & Crandall, C. G. (2022). Low-dose fentanyl does not alter muscle sympathetic nerve activity, blood pressure, or tolerance during progressive central hypovolemia. American Journal of Physiology: Regulatory, Integrrative, and Comparative Physiology, 322(1), R55-R63. https://doi.org/10.1152/ajpregu.00217.2021
Kontos, M. C., Scirica, B. M., Chen, A. Y., Thomas, L., Anderson, M. L., Diercks, D. B., Jollis, J. G., & Roe, M. T. (2015). Cardiac arrest and clinical characteristics, treatments and outcomes among patients hospitalized with ST-elevation myocardial infarction in contemporary practice: A report from the National Cardiovascular Data Registry. American Heart Journal, 169(4), 515-522. https://doi.org/10.1016/j.ahj.2015.01.010
Menon, V., & Hochman, J. S. (2002). Management of cardiogenic shock complicating acute myocardial infarction. Heart, 88(5), 531-537. https://doi.org/10.1136/heart.88.5.531
Ostchega, Y., Porter, K. S., Hughes, J., Dillon, C. F., & Nwankwo, T. (2011). Resting pulse rate reference data for children, adolescents, and adults: United States, 1999-2008. National health statistics reports, 41, 1–16. https://pubmed.ncbi.nlm.nih.gov/21905522/
Queensland Ambulance Service. (2017). Queensland Ambulance Service Clinical Practice Manual. Queensland Government. https://www.ambulance.qld.gov.au/clinical.html
Rowbotham, M. C. (2001). What is a "clinically meaningful" reduction in pain? Pain, 94(2), 131-132. https://doi.org/10.1016/S0304-3959(01)00371-2
Stoeckel, H., Schuttler, J., Magnussen, & H., Hengstmann, H. (1982). Plasma fentanyl concentrations and the occurrence of respiratory depression in volunteers. British Journal of Anaesthesia, 54, 1087-1095. https://doi.org/10.1093/bja/54.10.1087
Thompson, P.I., Joel, S.P., John, L., Wedzicha, J.A., Maclean, M., & Slevin, M. L. (1995). Respiratory depression following morphine and morphine-6-glucuronide in normal subjects. British Journal of Clinical Pharmacology, 40(2), 145-52. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1365174/
Watso, J. C., Belval, L. N., Cimino, F. A. 3rd, Orth, B. D., Hendrix, J. M., Huang, M., Johnson, E., Foster, J., Hinojosa-Laborde, C., & Crandall, C. G. Low-dose morphine reduces tolerance to central hypovolemia in healthy adults without affecting muscle sympathetic outflow. American Journal of Physiology: Heart and Circulatory Physiology, 323(1), H89-H99. https://doi.org/10.1152/ajpheart.00091.2022
Weldon, E. R., Ariano, R. E., & Grierson, R. A. Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain. Prehospital Emergency Care, 20(1), 45-51. https://doi.org/10.3109/10903127.2015.1056893