Effectiveness of nalbuphine for relief of burn debridement pain

A prospective double-blind study was undertaken to compare the effectiveness of the agonist-antagonist nalbuphine hydrochloride with morphine sulfate in relieving pain from burn debridement. The study consisted of two groups in which each was given a preprocedure dose of the study medication followed by administration of incremental doses up to one half the initial dose as requested. After reviewing the literature, we set the ratio of nalbuphine hydrochloride/morphine sulfate at 2:1 mg, respectively. Safety and efficacy were determined by measurements of vital signs, sedation, adverse effects, and patient evaluation of pain intensity and relief with the use of both an adjective and a visual analogue scale. Analysis showed no significant differences in the variables measured. Therefore in relieving burn debridement pain, we found nalbuphine hydrochloride to be as effective as morphine sulfate. We also found that respiratory depression was not a problem in either group.     

氯诺昔康对异丙酚静脉注射痛的预防作用

目的：与利多卡因和安慰剂对照比较，观察氯诺昔康对异丙酚静脉注射引起的疼痛缓解程度。方法：选择120例ASAⅠ～Ⅱ级的择期手术病人，随机分为4组：Ⅰ组在施行异丙酚诱导之前60s,给予氯诺昔康4mg(2m1)；Ⅱ组在施行异丙酚诱导之前60s给予氯诺昔康8mg(2m1)；Ⅲ组在施行异丙酚诱导之前60s给予利多卡因40mg(2m1)；Ⅳ组在施行异丙酚诱导之前60s给予生理盐水(2m1)。观察每组疼痛的发生率和根据Ambesh法进行疼痛评分。结果：与安慰剂对照组相比，氯诺昔康和利多卡因一样可以降低异丙酚静脉注射疼痛发生率，不同剂量的氯诺昔康与降低疼痛程度无显著差异，氯诺昔康与利多卡因之间也无显著差异。结论：氯诺昔康作为麻醉的辅助用药，可降低异丙酚引起的静脉注射痛，与利多卡因比较无明显差异，而氯诺昔康4mg与8mg剂量疼痛缓解率相同。     

Hitting them where it hurts? Low dose nalbuphine therapy

Methods: Prospective cohort of 115 patients given nalbuphine by paramedics in Wales and the English borders.

Outcome measures: (1) Mean total dose of nalbuphine administered, change in pain score, time to adequate pain relief (score below four), and change in respiratory rate and systolic blood pressure; (2) proportion of patients continuing to suffer moderate to severe pain on arrival at hospital; (3) incidence of adverse events.

Results: Full data were obtained for all patients. The mean total dose of nalbuphine administered was 6.09 mg (range 2.5 to 12.5 mg). This was significantly higher in trauma than ischaemic chest pain patients (7.03 versus 5.13 mg). The mean reduction in pain score was -3.97 (95% CI -4.38 to -3.57, p<0.001). The mean time to adequate pain relief (where this was achieved) was 15.7 minutes (95% CI 13.4 to 17.9 minutes). On arrival at hospital 60% of patients (n=69, 95% CI 50.9 to 68.5%) still met ambulance criteria for analgesia (70.7% of trauma patients and 49.1% with ischaemic chest pain). Systolic blood pressure fell by a mean of -3.67 (95% CI -6.76 to -0.58, p=0.02) and respiratory rate increased by a mean of 1.63 (95% CI 1.08 to 2.17, p<0.001). Two patients complained of nausea (1.74%, 95% CI 0.5 to 6.0%). No other adverse events were reported.

Conclusion: Low dose nalbuphine results in few adverse events, but offers poor pain control for a high proportion of patients.

     

Oral versus Intravenous Opioid Dosing for the Initial Treatment of Acute Musculoskeletal Pain in the Emergency Department

Objectives: The objective was to compare the time to medication administration, the side effects, and the analgesic effect at sequential time points after medication administration of an oral treatment strategy using oxycodone solution with an intravenous (IV) treatment strategy using morphine sulfate for the initial treatment of musculoskeletal pain in emergency department (ED) patients. Methods: This was a prospective randomized clinical trial of patients >6 years old who were going to receive IV morphine sulfate for the treatment of musculoskeletal pain but did not yet have an IV. Consenting patients were randomized to have the treating physician order either 0.1 mg/kg morphine sulfate IV or 0.125 mg/kg oxycodone orally in a 5 mg/5 mL suspension as their initial treatment for pain. The time from the placement of the order to the administration of the medication was recorded. Pain was measured using a 100‐mm visual analog scale (VAS) and recorded at 0, 10, 20, 30 and 40 minutes after drug administration. Results: A total of 405 eligible patients were identified during the study period; 328 (81.0%) patients consented to be in the study. A total of 158 patients were randomized to the IV morphine sulfate treatment group, and 162 were randomized to the oral oxycodone treatment group. Of the patients who were randomized to IV therapy, 34 were withdrawn from the study prior to drug administration; leaving 125 patients in the IV group for analysis. Of the patients who randomized to oral therapy, 22 were withdrawn from the study prior to drug administration, leaving 140 patients for analysis. No serious adverse events were detected. There was a 12‐minute difference between the median time of the order and the administration of oral oxycodone (8.5 minutes) and IV morphine (20.5 minutes). The mean percent change in VAS score was larger for patients in the IV therapy group than those in the oral therapy group at 10 and 20 minutes. At 30 and 40 minutes, the authors could no longer detect a difference. The satisfaction scale score was higher after treatment for the morphine group (median = 4; interquartile range [IQR] = 4 to 5) than for the oxycodone group (median = 4; IQR = 2 to 5; p = 0.008). Conclusions: The oral loading strategy was associated with delayed onset of analgesia and decreased patient satisfaction, but a shorter time to administration. The oral loading strategy using an oxycodone solution provided similar pain relief to the IV strategy using morphine 30 minutes after administration of the drug. Oral 0.125 mg/kg oxycodone represents a feasible alternative to 0.1 mg/kg IV morphine in the treatment of severe acute musculoskeletal pain when difficult or delayed IV placement greater than 30 minutes presents a barrier to treatment.     

Effects on patient care of introducing prehospital intravenous nalbuphine hydrochloride.

OBJECTIVE: Since March 1992, intravenous nalbuphine hydrochloride has been used prehospital by paramedics in the Plymouth area. This study assesses the impact of this intervention. METHODS: A prospective study of the parenteral analgesic requirements of 1000 consecutive patients arriving by ambulance at the accident and emergency (A&E) department of a large district general hospital. Where parenteral analgesia was given in the A&E department but not by ambulance personnel, a questionnaire was sent to the ambulance crew concerned to ascertain the reasons for not having given nalbuphine. RESULTS: Of 1000 consecutive patients arriving by ambulance, 87 (8.7%) had been given parenteral analgesia either prehospital, in A&E, or in both places. Seventy five (7.5%) needed parenteral analgesia in the A&E department, 29 (2.9%) had been given prehospital intravenous analgesia by paramedics, and a further seven (0.7%) had been given parenteral analgesia by a general practitioner (GP). Thus 36 (3.6%) received prehospital analgesia. Ten patients who had been given analgesia by paramedics required no further analgesia in A&E, whereas 51 patients who had not been given prehospital analgesia required parenteral analgesia in the A&E department. CONCLUSIONS: The introduction of nalbuphine for use by paramedics in prehospital care has increased prehospital parenteral analgesia from 1% in 1992 (given by GPs only) to 3.6% in the current study group, and 41% of patients requiring parenteral analgesia received analgesia prehospital. There may be further scope for extending the indications for nalbuphine use by ambulance personnel.     

Prehospital use of heparin locks: A cost-effective method for intravenous access

Intravenous (IV) infusions were ordered in nearly 95% of paramedic runs called into a busy base station hospital. Most of the patients received IV lines for either prophylactic access or administration of single or multiple bolus medications. In this group of patients, the application of a heparin lock injection port directly to the IV catheter, followed by the injection of 10 units of heparin, was evaluated. Of 102 consecutive patients treated in the field, 98 (97%) were treated with heparin locks only. The total number of patients requiring an IV infusion drip (either by paramedics or in the emergency department of the receiving hospital) was 20 (20%). If all 102 patients had received conventional IV drip infusions, the total patient equipment charges would have been $4,610.40. The actual charges for all patients in this series, either with heparin locks or IV infusion sets, was $1,846.14--a 60% savings. The results of the study indicate that the heparin lock is a safe, convenient, and cost-effective method for maintaining IV access in the prehospital environment.     

Intravenous Lidocaine as an Adjuvant for Pain Associated with Sickle Cell Disease

The objectives of this study were to evaluate the efficacy and safety of adjuvant intravenous (IV) lidocaine in adults with sickle cell disease (SCD). This was a retrospective review. Adults with SCD receiving at least one IV lidocaine infusion from 2004 to 2014 were included. Patient demographics, lidocaine treatment parameters, pain scores, pain medications, and adverse effects were recorded. Eleven patients were identified, yielding 15 IV lidocaine trials. Clinical improvement in pain scores from pre-lidocaine challenge to 24 hours post-lidocaine challenge, defined by ≥20% reduction in pain scores, was achieved in 53.3% (8 of 15) of IV lidocaine challenges. Of the 8 clinically successful trials, the mean reduction in morphine dose equivalents (MDE) from 24 hours pre-lidocaine challenge to 24 hours post-lidocaine challenge was 32.2%. Additionally, clinically successful trials had a mean initial and a maximum dose of 1 mg/kg/h (range: 0.5–2.7 mg/kg/h) and 1.3 mg/kg/h (range: 0.5–1.9 mg/kg/h), respectively. On average, these patients underwent 3 dose titrations (range: 1–8) and received lidocaine infusions for 4.4 days (range: 2–8 days). Two patients experienced disorientation and dizziness. The authors conclude that adjuvant IV lidocaine provided pain relief and a mean reduction in MDE during sickle cell pain crisis. These results provide preliminary insight into the use of IV lidocaine for treating pain in patients with SCD, although prospective studies are needed to determine efficacy, dosing, and tolerability of IV lidocaine in this patient population.     

A randomized, double-masked, placebo-controlled pilot trial of extended IV lidocaine infusion for relief of ongoing neuropathic pain

OBJECTIVES: To determine the dose-response effect and safety of IV lidocaine at different dose infusion rates on spontaneous ongoing neuropathic pain. METHODS: In this double-masked, placebo-controlled, parallel study conducted in an outpatient clinical research center, patients with peripheral neuropathic pain received a 6-hour infusion of three doses (1, 3, and 5 mg/kg) of lidocaine or placebo. The main outcome measure was relief of pain intensity (percentage pain intensity difference [PID %]). Other measures were responder rate, adverse events, and correlation between lidocaine levels and PID %. RESULTS: There was a significant difference in the median PID % between the group treated with lidocaine 5 mg/kg/h (-34.60) and the placebo group (-11.96, P=0.012). Such effect began 4 hours after the onset of treatment and lasted until the end of the study. Lidocaine at lower infusion rates was no better than placebo in relieving pain. A modest but significant correlation was found between methylethylglycinexylidide (MEGX) levels and pain relief (R=0.60). There were no serious adverse events, but in two patients lidocaine was stopped prematurely. CONCLUSIONS: Lidocaine at 5 mg/kg/h was more effective than placebo at relieving neuropathic pain. The effect started 4 hours after the onset of treatment and continued for at least 4 hours after the end of the infusion. Additional research is needed using higher infusion rates with larger sample sizes to confirm these results and to explore the role of MEGX in the relief of neuropathic pain.     

The effectiveness of analgesics in traumatic injuries of the extremities

In this study, the effectiveness of different analgesics was investigated in patients who presented to the emergency room with traumatic injuries or fractures of the extremities. We observed 100 patients (42 male, 58 female) who presented to the Konya State Hospital emergency service with isolated traumatic injuries of the extremities. We used different analgesics intravenously or intramuscularly in those patients with a high or moderate level of pain according to a visual analog pain scale. Patient pain levels were assessed 15, 30, and 45 minutes after administration of the analgesics. Metamizole sodium 1 g IV was used in 36 patients and diclofenac sodium 75 mg IM was given to 40 patients; tramadol hydrochloride 100 mg IV was administered to 24 patients. Pain became less severe after 15 minutes in 92% of patients who received tramadol IV; pain became less severe after 30 minutes in 72% of those who received metamizole IV. In contrast, pain became less severe after 45 minutes in 65% of patients who received diclofenac IM. Tramadol was the most effective analgesic and was also more effective earlier than the other analgesics tested.     

Intravenous parecoxib sodium as an analgesic alternative to morphine in acute trauma pain in the emergency department

Background

Parecoxib sodium is the first parenteral COX-2 inhibitor used for pain management licensed for postoperative pain. However, no study has assessed the usage of parecoxib for acute traumatic pain in the emergency department (ED). The objective of this study was to investigate a potential alternative analgesic agent in the ED by determining the mean reduction of pain score between acute traumatic pain patients who were administered with intravenous (IV) parecoxib sodium versus IV morphine sulfate. The onset of perceptible analgesic effect and side effects were also evaluated.

Methods

A randomized, double-blinded study comparing IV parecoxib 40 mg versus IV morphine at 0.10 mg/kg was conducted in adult patients presented with acute traumatic pain with numeric rating scale (NRS) of 6 or more within 6 hours of injury. Patients were randomized using a computer-generated randomization plan. Drug preparation and dispensing were performed by a pharmacist. Periodic assessment of blood pressure, pulse rate, oxygen saturation, and NRS were taken at 0, 5, 15, and 30 minute intervals after the administration of the study drug. The primary outcome was the reduction of NRS. Side effect and drug evaluation was conducted within 30 minutes of drug administration.

Results

There was no statistically significant difference in the reduction of mean NRS between patients in the IV parecoxib group or IV morphine group (P?=?0.095). The mean NRS for patients treated with IV morphine were 7.1 at 0 minutes, 4.5 at 5 minutes, 3.1 at 15 minutes, and 2.0 at 30 minutes. Whereas mean NRS for patients who received IV parecoxib were 7.8 at 0 minutes, 5.7 at 5 minutes, 4.7 at 15 minutes, and 3.9 at 30 minutes. The onset of perceptible analgesic effects could be seen as early as 5 minutes. Dizziness was experienced in 42.9% of patients who received IV morphine compared to none in the parecoxib group.

Conclusions

There was non-significant trend toward superiority of IV morphine over IV parecoxib. Looking at its effectiveness and the lack of opioid-related side-effects, the usage of IV parecoxib sodium may be extended further to a variety of cases in the ED.     

Intravenous Chlorpromazine vs Intravenous Metoclopramide in Acute Migraine Headache

Objective: To compare the efficacy of IV chlorpromazine with that of IV metoclopramide in the treatment for acute migraine headache in the ED.
Methods: A prospective randomized double-blind trial was undertaken at two university-affiliated urban EDs with a combined annual census of more than 85,000 patients. Included in the study were patients presenting to the ED with a diagnosis of migraine headache. The subjects were randomized to receive 0.1 mg/kg/dose IV of either chlorpromazine (CPZ) or metoclopramide (MC), up to a total of three doses.
Results: Ninety-one patients completed the protocol; 44 received MC and 47 received CPZ. The demographics of the two groups were similar. Both drugs provided, for the majority of patients, adequate pain relief as measured on a visual analog scale (VAS) completed every 15 minutes from T = 0 minutes to T = 45 minutes. The average pain relief over 45 minutes (ΔVAS) for CPZ was 4.87 cm, vs 4.34 cm for MC (p = 0.35). There also was no statistically significant difference in blood pressure (BP) changes (ΔBP < 2 mm Hg for both systolic and diastolic BPs, p = 0.47 and 0.33) or numbers of patients reporting adverse effects (AEs) (CPZ: 16 of 35; MC: 13 of 29, p = 0.43). There was no severe AE with either study drug.
Conclusions: Metoclopramide and chlorpromazine administered IV are both effective in the management of acute migraine headache. They are associated with similar minor side-effect profiles.     

Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury

BACKGROUND: Rapid and effective pain relief in acute traumatic limb injuries (ATLI) is one of the most important roles of emergency physicians. In these situations, opioid addiction is an important concern because of the dependency on opioids. The study aims to compare the effectiveness of intravenous (IV) fentanyl versus morphine in reducing pain in patients with opioid addiction who suffered from ATLI. METHODS: In this double-blind randomized clinical trial, 307 patients with ATLI, who presented to the emergency department (ED) from February 2016 to April 2016, were randomly divided into two groups. One group (152 patients) received 0.1 mg/kg IV morphine. The other group (155 patients) received 1 mcg/kg IV fentanyl. Patients’ demographic data, pain score at specific intervals, vital signs, side effects, satisfaction and the need for rescue analgesia were recorded. RESULTS: Eight patients in the morphine group and five patients in the fentanyl group were excluded. Pain score in the fentanyl group had a significant decrease at 5-minute follow-up (P value=0.00). However, at 10, 30, and 60-minute follow-ups no significant differences were observed between the two groups in terms of pain score reduction. The rescue analgesia was required in 12 (7.7%) patients in the fentanyl group and in 48 (31.6%) patients in the morphine group (P value=0.00). No significant difference was observed regarding side effects, vital signs and patients’ satisfaction between the two groups. CONCLUSION: Fentanyl might be an effective and safe drug in opioid addicts suffering from ATLI.     

Randomized double-blind,double-dummy crossover clinical trial of oral tramadol versus rectal tramadol administration in opioid-naive cancer patients with pain

Tramadol is commonly used as second step drug of the analgesic ladder. In circumstances where the oral route is unavailable, rectal administration of opioids might be a simple alternative. The aim of this study was to compare the analgesic activity and tolerability of tramadol by oral and rectal administration in a double-blind, double-dummy crossover trial. The study included 60 cancer patients with cancer pain no longer responsive to non-opioid drugs. Each patient initially received oral tramadol 50 mg (drops), followed by tramadol sustained release 100 mg orally, and placebo rectally, or tramadol 100 mg rectally and placebo orally, twice a day, in a randomized sequence, on each of 3 days. Patients were allowed to take 50 mg of oral tramadol by drops as needed (four doses per day, to a maximum of 400 mg/day, including the basal dose given by the oral or rectal route). Pain intensity and relief and symptom scores were recorded every day and at the end of each phase of the crossover. The mean age of the patients was 66.1 years (SD 13.5 years); 36 were female, and 44 completed both periods. Patients dropped out due to adverse effects (15 patients) and refusal (1 patient). No differences in the use of rescue dose of oral tramadol were observed between the groups. No differences in pain intensity and relief scores, or in other symptoms between the two treatments were observed. No differences in treatment efficacy as judged by the clinician (P=0.73), in patient compliance (P=0.35), or in patient satisfaction regarding treatment (P<0.35) were found. No differences in adverse effects were found between the two treatments (25.5%, 13 patients, and 20.4%, 11 patients, with oral and rectal treatment, respectively). The proportion of preferences favored oral administration for both physicians (P=0.0002) and patients (P=0.002). Rectal administration of tramadol appears a reliable, noninvasive alternative method of pain control for patients no longer responsive to non-opioid analgesics, unable to take oral tramadol.     

Out-of-hospital Intravenous Access: Unnecessary Procedures and Excessive Cost

Abstract. Objective : To evaluate the concordance with criteria developed by the study investigators and supply costs associated with placement of IV lines and saline locks by paramedics in the out-of-hospital setting. Methods: This was a retrospective consecutive case series at an urban base hospital. Patients were treated by paramedics using one base hospital for medical control during December 1995. Base hospital written records and taped patient calls were reviewed to determine actual IV access method used by paramedics, chief complaint, and whether fluid administration was ordered. Indicated method of IV access was determined for each patient based on predetermined criteria developed by the investigators. IV access methods were ranked by cost of supplies as follows: IV line (IV) < saline lock (SL) < no IV line (NoIV). An assignment of concordant treatment was made when actual = indicated method, discordant-overtreatment when actual < indicated, and discordant-undertreatment when actual < indicated. Results: 452 patients were treated via radio by the base hospital during the study period. 380 of 452 (84%) received an IV. 28 of 380 (7%) received fluid resuscitation in the field. 166 of 452 (37%) received concordant treatment; 253 (56%) discordant-overtreatment; and 33 (7%) discordant-undertreatment. Pediatric patients (≥14 years of age) were more likely to be undertreated as compared with adults, 33% vs 3% (p < 0.001). Patients who had medical chief complaints were more likely to receive discordant-overtreatment as compared with patients who had trauma chief complaints, 61% vs 32% (p < 0.001). 73% of chest pain patients received discordant-overtreatment. Based on these data, the yearly cost of supplies used in IV access discordant-overtreatment was $13,735 for this base hospital and $560,000 for the Los Angeles County emergency medical services (EMS) system. 91% of the excess supply cost is due to patients' receiving an IV instead of a SL. Conclusion: Based on study criteria for utilization of IV lines vs SLs in the field, paramedics and base hospital personnel often provide discordant-overtreatment of patients by placement of an IV when a SL or NoIV would suffice, resulting in unnecessary costs for EMS systems.     

Evaluation of Ketorolac in Children with Forearm Fractures

Objectives : To evaluate ketorolac for pain relief and an opioid-sparing effect in children with forearm fractures necessitating reduction.
Methods : A prospective, randomized, double-blind study was conducted at an urban children's hospital ED. A convenience sample of children aged 3–18 years with isolated forearm fractures was studied. None received prior pain medication. A 10-point visual analog scale (VAS) was used to assess pain at the time of study entry and prior to sedation/analgesia. The Children's Hospital of Eastern Ontario's Pain Score (CHEOPS), a 13-point behavioral score, was used to assess pain during sedation. Patients received either IV ketorolac (K), 1 mg/kg, or saline (S) after entry into the study. After a minimum of 20 minutes, pain was reassessed and supplemental analgesia/sedation administered. A standard dose of midazolam, 0.1 mg/kg to a maximum of 6 mg, was given to all patients, and fentanyl was titrated at 1-μg/kg increments based on patient need. Once the patient was comfortable, reduction was performed and a reduction CHEOPS score assigned.
Results : For the 34 study children (17 K, 17 S), there was no difference in sex or mean age between the groups. Mean total doses of fentanyl were 2.26 μg/kg in the K group and 2.85 μg/kg in the S group (p = 0.07). The median changes in VAS score before and after receiving the study drug were —1.13 K and -0.18 S (p = 0.06). The median CHEOPS score was 10 for both groups. Seven of the 17 patients in the S group required the maximum fentanyl dose (4 μg/kg), compared with 2 of 17 in the K group (p = 0.06).
Conclusions : Although ketorolac seems to add to patient comfort in children with forearm fractures, it does not have a significant opioid-sparing effect. Ketorolac showed a trend toward pain relief, but statistical significance was not reached.     

Pharmacokinetics of nalbuphine in infants, young healthy volunteers, and elderly patients

Nalbuphine is a new agonist and antagonist opioid analgesic agent that undergoes an important hepatic metabolism. In this study, we compared the pharmacokinetics of intravenous and oral nalbuphine in three groups of subjects: group I consisted of 14 children from 1 1/2 to 5 years of age (group IA) and from 5 through 8 1/2 years of age (group IB), group II consisted of 9 healthy male volunteers from 23 to 32 years of age, and group III consisted of 9 elderly patients from 65 to 90 years of age. All subjects and patients had normal hepatic and renal functions. The children received an intravenous injection of nalbuphine (0.2 mg/kg), and the subjects and patients in groups II and III received, at random, 10 mg intravenous injections and 30 mg oral doses of nalbuphine on two separate occasions. The distribution of nalbuphine was not modified with age. Elimination half-life (t1/2) was significantly shorter in group I (0.9 hour) than it was in group II (1.9 hours) and in group III (2.3 hours). Systemic clearance of nalbuphine decreased significantly with age. Absolute bioavailability of nalbuphine increased from F = 12% in group II to 46.3% in group III (p less than 0.01). These findings suggest that doses and rates of administration of nalbuphine should be adapted in younger patients and in elderly patients.     

Intranasales Fentanyl zur Therapie akuter Schmerzspitzen bei Karzinompatienten

Background and aim of the study

Despite regular administration of analgesics, a high percentage of patients with chronic malignant pain experience break-through cancer pain or incident pain. Such pain peaks in patients with chronic malignant pain require “rescue” medication in addition to basic analgesia with for example slow-release morphine or buprenorphine. For rescue medication a fast acting and powerful analgesic should be available to the patient. Recent studies have shown that intranasal fentanyl provides rapid onset of pain relief.

Patients and methods

In this open pilot study five patients with chronic cancer pain (age: 42–62 years; weight: 55–80 kg) received demand-adapted intranasal fentanyl titration for treatment of acute breakthrough cancer pain. Intranasal fentanyl doses (0.027 mg) were repeated at 5-min intervals until the patients experienced marked pain relief. Pain intensity was evaluated (0–30 min: 5-min intervals; 30–120 min: 10-min intervals) with the aid of a numerical rating scale (0 = no pain; 100 worst pain possible).

Results and discussion

The patients received 2, 4, 6, 7 or 8 fentanyl boluses (totalling 0.054 mg, 0.108 mg, 0.162 mg, 0.189 mg or 0.216 mg, respectively). Rapid onset and marked reduction of pain intensity was achieved in all five patients. There were no clinically relevant changes in arterial haemoglobin oxygen saturation, heart rate, arterial blood pressure or respiratory rate. All five patients scored the pain relief obtained as good or very good. There were no reports of pain or burning sensations in the nose or other side-effects.     

Analgesic effect of paracetamol combined with low-dose morphine versus morphine alone on patients with biliary colic: a double blind,randomized controlled trial

BACKGROUND: Numerous drugs have been proposed to alleviate pain in patients with biliary colic, especially opioids, but still there is a tendency to use less narcotics because of their side effects and the unwillingness of some patients. The present study aimed to compare the analgesic effect of paracetamol combined with low-dose morphine versus morphine alone in patients with biliary colic.METHODS: A randomized double-blind controlled trial was performed in 98 patients with biliary colic, recruited from two emergency departments from August 2012 to August 2013. Eleven patients were excluded and the remaining were randomized into two groups: group A received 0.05 mg/kg morphine+1 000 mg paracetamol in 100 mL normal saline and group B received 0.1 mg/kg morphine+normal saline (100 mL) as placebo. Pain scores were recorded using visual analogue scale (VAS) at baseline and 15 and 30 minutes after drug administration. Adverse effects and the need for rescue medication (0.75 μg/kg intravenous fentanyl) were also reported within 60 minutes of drug administration.RESULTS: Before the infusion, the mean±SD VAS scores were 8.73±1.57 in group A and 8.53±1.99 in group B. At 15 minutes after drug administration, the mean±SD VAS scores were 2.16±1.90 in group A vs. 2.51±1.86 in group B; mean difference was -0.35, and 95%CI -1.15 to 0.45 (P=0.38). At 30 minutes the mean±SD VAS scores were 1.66±1.59 in group A vs. 2.14±1.79 in group B; mean difference was -0.48, and 95%CI -1.20 to 0.24 (P=0.19). The mean pain scores in the two groups at 15 and 30 minutes demonstrated no significant difference.CONCLUSION: Paracetamol combined with low-dose morphine may be effective for pain management in patients with biliary colic.     

Out-of-hospital Intravenous Cannulation: The Perspective of Patients Treated by London Ambulance Service Paramedics

OBJECTIVES: Previous research has highlighted concern about infection rates in field-placed intravenous (IV) cannulae. In a study of IV placement by London Ambulance Service (LAS) paramedics, 17% of placements were judged to be inappropriate. Large variations in rates of IV placement between LAS paramedics were found. The authors' hypothesis was that placement of an IV carries disadvantages-pain, discomfort, distress, and infection-which may be unacceptable to patients. METHODS: This was a survey of all patients having an IV placed by LAS paramedics and transported to one of three London emergency departments (EDs) over a three-week period in December 1996. Patients were excluded if they had a self-inflicted injury/illness, were less than 14 years old, had no known address, or were visitors to the UK, or if their family doctor suggested it was not appropriate to contact the patient. Pain, discomfort, and distress; infection; satisfaction; understanding of the reason for cannulation; and out-of-hospital cannula use were all ascertained and analyzed with chi-square analysis. RESULTS: Thirty-nine percent of the respondents experienced some discomfort, 39% some pain, and 17% some distress. No patient reported an infection. Distress was more likely to be reported if there was no understanding of why the IV cannula was placed (chi2 [1] 6.1; p < 0.05). Further unstructured information revealed satisfaction with the IV cannulation and with general care. CONCLUSIONS: Despite the disadvantages of IV placement being reported by some respondents, overall levels of satisfaction were high, suggesting that these disadvantages were not unacceptable to patients. However, in the context of the 24,000 patients cannulated each year by LAS paramedics, "costs" to the patient are considerable.