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Intranasal fentanyl and intravenous morphine did not differ for pain relief in children with closed long-bone fractures

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M Borland

M Borland, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia; meredith.borland{at}health.wa.gov.au

QUESTION

In children presenting to the emergency department (ED) with acute long-bone fractures, is intranasal fentanyl equivalent to intravenous (IV) morphine for pain control?

METHODS

Design:

randomised controlled trial.

Allocation:

{concealed}.*

Blinding:

blinded (patients, {clinicians, data collectors, outcome assessors, data analysts, and monitoring committee}*).

Follow-up period:

30 minutes after initial analgesic administration.

Setting:

tertiary paediatric ED in a hospital in Australia.

Patients:

67 patients 7–15 years of age (mean age 11 y, 79% with fractures of the radius or ulna), who presented to the ED with clinically deformed, closed, long-bone fractures. Exclusion criteria were narcotic analgesia within 4 hours of arrival, significant head injury, allergy to opiates, nasal blockage or trauma, and inability to perform pain scoring.

Intervention:

33 patients were given intranasal fentanyl (weight-determined initial dose: 21–30 kg, 30 µg; 31–40 kg, 45 µg; 41–50 kg, 60 µg) plus IV normal saline (placebo). 34 patients were given IV morphine (initial dose: 21–30 kg, 2 mg; 31–40 kg, 3 mg; 41–50 kg, 4 mg) plus intranasal placebo. Additional fentanyl (15 µg) or morphine (1 mg) could be given every 5 minutes until pain relief, patient refusal, or maximum number of doses ( =  initial dose).

Outcomes:

patient-reported pain (100 mm unmarked visual analogue scale [VAS], 0 =  no pain and 100 =  worst pain) assessed at baseline and 5, 10, 20, and 30 minutes after analgesic administration; and adverse effects, including sedation and respiratory or cardiovascular effects. 32 patients per group were required to detect a 13 mm change in pain score (baseline 80 mm, power 90%, α = 0.05).

Patient follow-up:

97% (intention-to-treat analysis).

MAIN RESULTS

The fentanyl and morphine groups did not differ for pain relief up to 30 minutes after analgesic administration (p = 0.3, table), although 2 children required rescue doses of morphine. No significant adverse events were reported with either treatment.

Intranasal fentanyl v intravenous morphine for pain in children with closed long-bone fractures*

CONCLUSION

In children 7–15 years of age presenting to the emergency department with closed long-bone fractures, intranasal fentanyl and intravenous morphine did not differ for pain relief.

*Information provided by author.

A modified version of this abstract also appears in Evidence-Based Medicine.

ABSTRACTED FROM

Borland M, Jacobs I, King B, et al. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med 2007;49:335–40.

Clinical impact ratings: Emergency 6/7; Paediatrics 5/7; Pain management 6/7

Commentary

Effective pain management for children is an important issue for clinicians in ED settings. Barriers to effective management in the ED include accurately assessing pain in children of various ages, determining appropriate routes and doses of drugs for children, more challenging IV access, and coping with the varied responses of children to pain. Previous studies have demonstrated the safety and efficacy of intranasal fentanyl in paediatric populations.1 Borland et al compared intranasal fentanyl to IV morphine, the “gold standard,” for managing acute pain in children presenting to the ED with long-bone fractures. Study strengths include blinding of patients and clinicians, placebo-controlled design, power analysis to determine the required sample size to detect a statistically significant difference between groups, use of a validated VAS for pain assessment,2 and similarity of groups at baseline. Trial limitations include use of a convenience sample and inclusion of participants with weights outside of the study drug dosage weight intervals (21–50 kg). In addition, the authors did not address the need to train clinicians on the use of intranasal fentanyl.

Borland et al conclude that intranasal fentanyl and IV morphine did not differ for pain reduction across the 30-minute study period. Although the data suggest a difference at 5 minutes, routine statistical practice is not to look for individual differences in the absence of significant overall results. The findings of Borland et al support the use of intranasal fentanyl as an alternative to IV morphine for acute pain management of long-bone fractures in EDs, although commercial availability, cost, and clinician education may be barriers to use. Intranasal fentanyl would have the advantage of providing more rapid analgesia without the time delay and pain of IV access. Further studies should focus on improving drug dosing for different weight intervals and assessing the use of intranasal fentanyl for children with other diagnoses and in other pre-hospital and hospital settings.

References

View Abstract

Footnotes

  • Source of funding: ACEM Morson Taylor Research Grant.

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