Intramuscular Morphine Research Articles

Perception and Practice Among Emergency Medicine Health Care Providers Regarding Discharging Patients After Opioid Administration

PurposeThis study aimed to determine the current attitudes, perceptions, and practices of emergency medicine providers and nurses (RNs) regarding the discharge of adult patients from the emergency department (ED) after administration of opioid analgesics. MethodsA cross-sectional survey was administered at 3 hospital sites with a combined annual ED census of >180,000 visits per year. All 59 attending emergency physicians (EPs), 233 RNs, and 23 advanced practice clinicians (APCs) who worked at these sites were eligible to participate. FindingsThirty-five EPs (59.3%), 88 RNs (37.8%), and 14 APCs (60.9%) completed the survey for an overall response rate of 51.75%. Most respondents were female (95 [69.9%]). The factor ranked most important to consider when discharging a patient from the ED after administration of opioids was the patient’s functional status and vital signs (median, 2.00; interquartile range, 2.00–3.50). More RNs (84 [96.6%]) than EPs (29 [82.9%]) reported that developing an ED policy or guideline for safe discharge after administration of opioids is important to clinical practice (P = 0.02). Only 8 physicians (23.5%) reported that they did not prescribe intramuscular morphine, and 15 (42.9%) reported that they did not prescribe intramuscular hydromorphone. EPs (7 [20.0%]) and RNs (3 [3.4%]) differed in regard to whether they were aware if any patients to whom they administered an opioid had experienced an adverse drug-related event (P = 0.01). Most EPs (24 [68.6%]) and RNs (54 [61.4%]) believed that the decision for patient discharge should be left to both the emergency medicine provider and the RN. ImplicationsMost study participants believed that developing a policy or guideline for safe discharge after administration opioids in the ED is important to clinical practice. Only a few physicians reported that they did not prescribe intramuscular hydromorphone or morphine. Most participants believed the discharge decision after administration of opioids in the ED should be primarily determined by both the emergency medicine provider and the RN.

Effects of the Introduction of Intranasal Fentanyl on Reduction of Pain Severity Score in Children: An Interrupted Time-Series Analysis.

Children are at risk of inadequate analgesia due to paramedics' inexperience in assessing children and challenges in administering analgesics when the patient is distressed and uncooperative. This study reports on the outcome of a change to practice guidelines that added intranasal fentanyl and intramuscular morphine within a large statewide ambulance service. This retrospective study included patients younger than 15 years treated by paramedics between January 2008 and December 2011. The primary outcome of interest was the proportion of patients having a 2/10 or greater reduction in pain severity score using an 11-point Verbal Numeric Rating Scale before and after the intervention. Segmented regression analysis was used to estimate the effect of the intervention over time. A multiple regression model calculated odds ratios with 95% confidence intervals. A total of 92,378 children were transported by paramedics during the study period, with 9833 cases included in the analysis. The median age was 11 years; 61.6% were male. Before the intervention, 88.1% (n = 3114) of children receiving analgesia had a reduction of pain severity of 2 or more points, with 94.2% (n = 5933) achieving this benchmark after intervention (P < 0.0001). The odds of a reduction in pain of 2 or more points increased by 1.01 per month immediately before the intervention and 2.33 after intervention (<0.0001). This large study of a system-wide clinical practice guideline change has demonstrated a significant improvement in the outcome of interest. However, a proportion of children with moderate to severe pain did not receive analgesia.

Effect of metoclopramide on nausea and emesis in dogs premedicated with morphine and dexmedetomidine

ObjectiveTo evaluate whether subcutaneous (SC) metoclopramide (0.2 mg kg−1) administered 30 minutes prior to (T30) or simultaneously with (T0) intramuscular (IM) morphine (0.2 mg kg−1) and dexmedetomidine (0.003 mg kg−1) reduces the incidence of nausea and emesis in healthy dogs. Study designProspective, randomized and blinded study. AnimalsA total of 45 dogs scheduled for elective procedures. MethodsDogs were assigned randomly to three groups to be administered SC metoclopramide (0.2 mg kg−1) 30 minutes before (group M30) or simultaneously (group M0) to IM morphine (0.2 mg kg−1) and dexmedetomidine (0.003 mg kg−1). Dogs in the control group (group C) were administered SC saline at T30 and T0. Dogs were observed for 30 minutes after premedication to evaluate signs of nausea (continuous lip-licking and sialorrhoea) and emesis. Signs of pain or discomfort caused by SC injections were also recorded. ResultsThere were no statistical differences amongst groups for age, body weight and sex. More dogs developed continuous lip-licking in group C (12/15, 80.0%) compared to dogs in group M30 (1/15, 6.7%) and dogs in group M0 (5/15, 33.3%; p = 0.0001 and p = 0.01, respectively). More dogs developed sialorrhoea in group M0 (8/15, 53.3%) and in group C (10/15, 66.7%) compared to dogs in group M30 (2/15, 13.3%; p = 0.03 and p = 0.004, respectively). More dogs vomited in group M0 (4/15, 26.7%) and in group C (9/15, 60.0%) compared to dogs in group M30 (0/15, 0.0%; p = 0.05 and p = 0.0003, respectively). None of the dogs demonstrated signs of pain or discomfort during SC metoclopramide injection. Conclusions and clinical relevance:Subcutaneous metoclopramide at 0.2 mg kg−1 may reduce IM morphine and dexmedetomidine-induced nausea and emesis if administered 30 minutes in advance. It is effective in reducing lip-licking even when administered concurrently with IM morphine–dexmedetomidine.

Validation of a thermal threshold nociceptive model in bearded dragons (Pogona vitticeps)

ObjectivesTo validate a thermal threshold (TT) nociceptive model in bearded dragons (Pogona vitticeps) and to document TT changes after administration of morphine. Study designA two-part randomized, blinded, controlled, experimental study. AnimalsFive adult bearded dragons (242–396 g). MethodsA TT device delivered a ramped nociceptive stimulus (0.6 °C second−1) to the medial thigh until a response (leg kick/escape behavior) was observed or maximum (cut-off) temperature of 62 °C was reached. In phase I, period 1, six TT readings were determined at 20 minute intervals for evaluation of repeatability. Two of these readings were randomly assigned to be sham to assess specificity of the behavioral response. The same experiment was repeated 2 weeks later (period 2) to test reproducibility. In phase II, animals were administered either intramuscular morphine (10 mg kg−1) or saline 0.9%. TTs (maximum 68 °C) were determined before and 2, 4, 8, 12 and 24 hours after treatment administration. Data were analyzed using one-way anova (temporal changes and repeatability) and paired t tests (reproducibility and treatment comparisons) using Bonferroni correction (p < 0.05). ResultsMean TT values were 57.4 ± 3.8 °C and 57.3 ± 4.3 °C for periods 1 and 2, respectively. Data were repeatable within each period (p = 0.83 and p = 0.07, respectively). Reproducibility between periods was remarkable (p = 0.86). False-positive responses during sham testing were 10%. TTs were significantly increased after morphine administration at 2, 4 and 8 hours compared with baseline, and at 2 and 4 hours compared with saline 0.9%. The highest TT was 67.7 ± 0.7 °C at 4 hours after morphine administration. Conclusions and clinical relevanceTesting was repeatable, reproducible and well tolerated in bearded dragons. TT nociceptive testing detected morphine administration and may be suitable for studying opioid regimens in bearded dragons.

Single dose intra-articular morphine for pain control after knee arthroscopy.

Knee arthroscopy is a common procedure and is associated with postoperative pain. Intra-articular (IA) injection of morphine for pain control has been widely studied, but its analgesic effect after knee arthroscopy is uncertain. To evaluate the relative effects on pain relief and adverse events of IA morphine given for pain control after knee arthroscopy compared with placebo, other analgesics (local anaesthetics, non-steroidal anti-inflammatory drugs (NSAIDs), other opioids) and other routes of morphine administration. We searched CENTRAL (The Cochrane Library Issue 4, 2015), MEDLINE via Ovid (January 1966 to May 2015), EMBASE via Ovid (January 1988 to May 2015), and the reference lists of included articles. We also searched the metaRegister of controlled trials, clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials. We identified all the randomised, double-blind controlled trials that compared single dose IA morphine with other interventions for the treatment of postoperative pain after knee arthroscopy. We excluded studies with fewer than 10 participants in each group, using spinal or epidural anaesthesia, or assessing the analgesic effect of IA morphine on chronic pain. Two authors independently assessed the quality of each trial and extracted information on pain intensity, supplementary analgesics consumption and adverse events. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. We included 28 small, low quality studies (29 reports) involving 2564 participants. Of 20 studies (21 reports) comparing morphine with placebo, nine studies with adequate data were included in the meta-analysis. Overall, the risk of bias was unclear. Overall, the quality of the evidence assessed using GRADE was low to very low, downgraded primarily due to risk of bias, small study size, and imprecision.No statistical difference was found between 1 mg IA morphine and placebo in pain intensity (visual analogue scale (VAS)) at early phase (zero to two hours) (mean difference (MD) -0.50, 95% CI -1.15 to 0.14; participants = 297; studies = 7; low quality evidence), medium phase (two to six hours) (MD -0.47, 95% CI -1.09 to 0.14; participants = 297; studies = 7; low quality evidence) and late phase (six to 30 hours) (MD -0.88, 95% CI -1.81 to 0.04; participants = 297; studies = 7; low quality evidence). No significant difference was found between 1 mg and 2 mg morphine for pain intensity at early phase (MD -0.56, 95% CI -1.93 to 0.81; participants = 105; studies = 2; low quality evidence), while 4 mg/5 mg morphine provided better analgesia than 1 mg morphine at late phase (MD 0.67, 95% CI 0.08 to 1.25; participants = 97; studies = 3; low quality evidence). IA morphine was not better than local anaesthetic agents at early phase (MD 1.43, 95% CI 0.49 to 2.37; participants = 248; studies = 5; low quality evidence), NSAIDs at early phase (MD 0.95, 95% CI -0.95 to 2.85; participants = 80; studies = 2; very low quality evidence), sufentanil, fentanyl or pethidine for pain intensity. IA morphine was similar to intramuscular (IM) morphine for pain intensity at early phase (MD 0.21, 95% CI -0.48 to 0.90; participants = 72; studies = 2; very low quality evidence).Meta-analysis indicated that there was no difference between IA morphine and placebo or bupivacaine in time to first analgesic request. Eleven out of 20 studies comparing morphine with placebo reported adverse events and no statistical difference was obtained regarding the incidence of adverse events (risk ratio (RR) 1.09, 95% CI 0.51 to 2.36; participants = 314; studies = 8; low quality evidence). Seven of 28 studies reported participants' withdrawal. There were not enough data for withdrawals to be able to perform meta-analysis. We have not found high quality evidence that 1 mg IA morphine is better than placebo at reducing pain intensity at early, medium or late phases. No statistical difference was reported between IA morphine and placebo regarding the incidence of adverse events. The relative effects of 1 mg morphine when compared with IA bupivacaine, NSAIDs, sufentanil, fentanyl and pethidine are uncertain. The quality of the evidence is limited by high risk of bias and small size of the included studies, which might bias the results. More high quality studies are needed to get more conclusive results.

Preemptive Analgesia, Including Morphine, Does Not Affect Recovery Quality and Times in Either Pain-Free Horses or Horses Undergoing Orchiectomy

Recovery quality and times from general anesthesia in horses may be influenced by surgery, analgesia with morphine or combinations of both. Twenty-three adult healthy horses were enrolled in this prospective experimental trial in a clinical setting and were randomly allocated to one of the following groups: anesthesia only (GA; n = 6), preemptive analgesia and anesthesia (GAA; n = 5), anesthesia and castration (GC; n = 6), or preemptive analgesia, anesthesia, castration, and intraoperative local analgesia (GCA; n = 6). All horses were sedated with intramuscular (IM) xylazine (0.5 mg/kg). Anesthesia was induced with intravenous (IV) guaifenesin (100 mg/kg) and thiopental (5 mg/kg) and maintained with isoflurane in oxygen. Animals in groups with preemptive analgesia received IM morphine (0.2 mg/kg) and dipyrone (10 mg/kg) and IV flunixin meglumine (1.0 mg/kg) immediately before sedation. Recoveries from general anesthesia were rope-assisted. Recovery scores (from 8 [excellent recovery] to 70 [worst recovery]) and times were compared between groups, using a one-way analysis of variance followed by a Tukey's test (P < .05). Mean ± standard deviation (SD) and range recovery scores were 22 ± 14 (8–45), 9 ± 2 (8–12), 14 ± 5 (8–22), and 12 ± 1 (10–13) in groups GA, GAA, GC, and GCA, respectively. Mean ± SD times to stand in minutes were 21 ± 10, 18 ± 7, 33 ± 12, and 35 ± 21 in groups GA, GAA, GC and GCA, respectively. No statistically significant differences were found for any of the variables. Neither preoperative administration of analgesics, including morphine, nor castration interfered with the recovery qualities and times in horses undergoing general anesthesia. Preemptive morphine did not worsen anesthetic recovery quality in horses.

The French Syrette of morphine for administration to combat casualties.

As French military physicians currently deployed in Theatre of Operations, we read with great interest the study by Blankenstein et al. determining the opinions of recently deployed British Army personnel with forward medical care experience on the importance of effective battlefield analgesia, the efficacy and shortcomings of current battlefield analgesia and desirable features of the ideal battlefield analgesic.1 Their results supported existing evidence for the introduction of an adjunct to intramuscular (IM) morphine. Surprisingly, in the introduction section, the authors stated that ‘The British armed forces are unique in supplying parenteral opiates to all deployed soldiers, comprising two 10 mg morphine auto-injectors designed for intramuscular (IM) administration to casualties’. We don’t totally agree with this statement since the French Army has a long experience of battlefield analgesia, using a 10 mg morphine auto-injector, also known as the Syrette of morphine. The Syrette is a device for injecting liquid through a needle, almost similar to a syringe, except that it has a closed flexible tube, instead of a rigid tube and piston. Before deployment in a combat zone, every French soldier undergoes the Forward Combat Casualty Care Level 1-courses and is trained to use his combat first aid kit, including the subcutaneous injection of 10 mg of morphine, using this Syrette.2 Finally, in the French Military Health Service policy for combat analgesia, and also suggested by the authors, other techniques are encouraged, including titration of intravenous morphine, use of ketamine and fascia-iliaca compartment block for lower limb injuries.3

Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial

BackgroundThe clinical use of peripheral analgesic effects of opioids has been investigated in numerous controlled clinical trials. The majorities of these have tested the local, intra-articular administration of morphine in knee surgery and have demonstrated marginal postoperative analgesia. ObjectiveWe examined direct morphine infiltration of the surgical site in a clinical model of tooth pain under two different conditions. Eighty-eight patients undergoing surgical tooth removal entered into the two prospective, parallel, randomized, double-blind studies. MethodsPatients undergoing surgical tooth removal received a standard local anaesthetic solution (articaine plus epinephrine) before surgery.Patients were assigned to an injection of peripheral 2mg morphine either into non-inflamed (Trial I) or inflamed (Trial II) submucous tissue before the surgery. Patients who received an intramuscular morphine in the upper arm were concomitantly given 1ml isotonic saline (NaCl) as a submucous injection. Patients who received a submucous injection of morphine peripherally were concomitantly given an intramuscular injection (IM) of 1ml of NaCl in the upper arm. Postoperative pain intensity was assessed by the numeric rating scale every 30min for the first 2h and then every hour for the next 8h after surgery. In addition, patients recorded the occurrence of side effects and the supplemental consumption of ibuprophen and codeine+paracetamol combination tablets. ResultsOf the eighty-eight original participants, nine patients (4 patients in Trial I and 5 patients in Trial II) were withdrawn for protocol noncompliance and loss at follow-up. Thirty-one patients in trial I and forty-eight patients in trial II were analyzed. Patients receiving 2mg morphine into non-inflamed tissue did not show any further reduction in pain scores and pain medication consumption compared to IM morphine group (Trial I).In patients receiving 2mg morphine into inflamed tissue, pain scores at rest were reduced to a similar extent in both groups at all measurement times up to 10h in the follow-up (Trial II). At the same time, in the area under the curves pain scores on swallowing between 2 and 6h in the peripheral morphine group (5.2±5.6) were significantly lower than in the IM morphine group (9.3±7.3, p=0.03), demonstrating the marginal analgesic efficacy of additional morphine. Sedation scores were significantly higher in the peripheral morphine group only 1h after surgery in Trial I (p=0.008). The time to first analgesic intake was similar between groups. No serious side effects were reported. ConclusionsOur results showed in patients undergoing surgical tooth removal that injection of 2mg of morphine into inflamed tissue results in significantly lower pain scores on swallowing in the early postoperative state while administration into non-inflamed tissue is not effective. ImplicationsOur studies indicate that the peripheral administration of opioids, at the doses and conditions set out for these two studies, produces significant analgesia by a pharmacologically specific mechanism that is active in chronically, but not acutely, inflamed tissue. Thus, consistent with preclinical experimental studies, the requirement of an inflammatory process for the occurrence of the peripheral opioid effects is also found in the clinical setting.

Botulinum toxin type A as an adjunct in postoperative pain management in dogs undergoing radical mastectomy

The aim of this randomised placebo-controlled, observer-blinded study was to evaluate the analgesic effects of botulinum toxin type A (BoNT-A) as an adjunct for postoperative pain control in dogs. Sixteen...

A single preoperative dose of diclofenac reduces the intensity of acute postcraniotomy headache and decreases analgesic requirements over five postoperative days in adults: A single center, randomized, blinded trial

ObjectivePostcraniotomy headache causes considerable pain and can be difficult to treat. We therefore tested the hypothesis that a single 100-mg preoperative dose of diclofenac reduces the intensity of postcraniotomy headache, and reduces analgesic requirements. Methods200 patients having elective craniotomies were randomly assigned to diclofenac (n=100) or control (n=100). Pain severity was assessed by an independent observer using a 10-cm-long visual analog scale the evening of surgery, and on the 1st and 5th postoperative days. Analgesics given during the first five postoperative days were converted to intramuscular morphine equivalents. Results were compared using Mann–Whitney-tests; P<0.05 was considered statistically significant. ResultsBaseline and surgical characteristics were comparable in the diclofenac and control groups. Visual analog pain scores were slightly, but significantly lower with diclofenac at all times (means and 95% confidence intervals): the evening of surgery, 2.47 (1.8–3.1) vs. 4. 37 (5.0–3.7), (P<0.001); first postoperative day, 3.98 (3.4–4.6) vs. 5.6 (4.9–6.2) cm (P<0.001) and 5th postoperative day: 2.8 (2.2–3.4) vs. 4.0±(3.3–4.7) cm (P=0.013). Diclofenac reduced systemic analgesic requirements over the initial five postoperative days (mean and 95% CI): 3.3 (2.6–3.9) vs. 4.3 (3.5–5.1) mg morphine equivalents (P<0.05). ConclusionsPreoperative diclofenac administration reduces postcraniotomy headache and postoperative analgesic requirements — a benefit that persisted throughout five postoperative days.

Gabapentin as an adjuvant for postoperative pain management in dogs undergoing mastectomy.

This study aimed to evaluate the analgesic efficacy of gabapentin as an adjuvant for postoperative pain management in dogs. Twenty dogs undergoing mastectomy were randomized to receive perioperative oral placebo or gabapentin (10 mg/kg). All dogs were premedicated with intramuscular acepromazine (0.03 mg/kg) and morphine (0.3 mg/ kg). Anesthesia was induced with propofol (4 mg/kg) intravenously and maintained with isoflurane. Intravenous meloxicam (0.2 mg/kg) was administered preoperatively. Postoperative analgesia was evaluated for 72 hr. Rescue analgesia was provided with intramuscular morphine (0.5 mg/kg). Dogs in the Placebo group received significantly more morphine doses than the Gabapentin group (P=0.021), despite no significant differences in pain scores. Perioperative gabapentin reduced the postoperative morphine requirements in dogs after mastectomy.

Intranasal fentanyl for the management of acute pain in children.

Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula. We identified and evaluated all randomized controlled trials (RCTs) and quasi-randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of "rescue analgesia," patient/parental satisfaction and patient mortality. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014). We included RCTs comparing INF versus any other pharmacological/non-pharmacological intervention for the treatment of children in acute pain (aged < 18 years). Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a "bad taste" and vomiting with INF. Overall the risk of bias in all studies was considered low. INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non-inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a "medical" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a "medical" cause.

Comparison of the Effects of Ketamine and Morphine on Performance of Representative Military Tasks

BackgroundWhen providing care under combat or hostile conditions, it may be necessary for a casualty to remain engaged in military tasks after being wounded. Prehospital care under other remote, austere conditions may be similar, whereby an individual may be forced to continue purposeful actions despite traumatic injury. Given the adverse side-effect profile of intramuscular (i.m.) morphine, alternative analgesics and routes of administration are of interest. Ketamine may be of value in this capacity. ObjectivesTo delineate performance decrements in basic soldier tasks comparing the effects of the standard battlefield analgesic (10 mg i.m. morphine) with 25 mg i.m. ketamine. MethodsRepresentative military skills and risk propensity were tested in 48 healthy volunteers without pain stimuli in a double-blind, placebo-controlled, crossover design. ResultsOverall, participants reported more symptoms associated with ketamine vs. morphine and placebo, chiefly dizziness, poor concentration, and feelings of happiness. Performance decrements on ketamine, when present, manifested as slower performance times rather than procedural errors. ConclusionsParticipants were more symptomatic with ketamine, yet the soldier skills were largely resistant to performance decrements, suggesting that a trained task skill (autonomous phase) remains somewhat resilient to the drugged state at this dosage. The performance decrements with ketamine may represent the subjects’ adoption of a cautious posture, as suggested by risk propensity testing whereby the subject is aware of impairment, trading speed for preservation of task accuracy. These results will help to inform the casualty care community regarding appropriate use of ketamine as an alternative or opioid-sparing battlefield analgesic.

Is intramuscular morphine satisfying frontline medical personnels' requirement for battlefield analgesia in Helmand Province, Afghanistan? A questionnaire study.

All deployed British Army personnel carry intramuscular (IM) morphine auto-injectors to treat battlefield casualties. No other nation supplies parenteral opiate analgesia on individual issue. Studies highlight this agent's inefficacy and safety issues, but are limited by a relative lack of inclusion of frontline personnel. We aimed to determine the opinions of frontline medical personnel on current battlefield analgesia. We surveyed 88 British Army frontline medical personnel (medical officers (n = 12), nurses (n = 7), combat medical technicians (CMTs) (n = 67), paramedics (n = 1) and health-care assistants (n = 1)) upon completion of a six-month deployment (September 2011 to April 2012) to Helmand Province, Afghanistan, using Likert scale questions on the efficacy of battlefield analgesia, complications of IM morphine, safety of morphine auto-injectors and its suitability for treating child casualties. A total of 88/88 questionnaires were returned. Of these, 61/88 had treated casualties on the battlefield, 26/86 agreed that current battlefield analgesia is effective, 80/87 agreed that a more potent analgesic with a faster onset than IM morphine is desirable in the first hour following injury, 47/65 CMTs agreed that they can manage complications of current battlefield analgesia and 53/86 respondents correctly disagreed that current battlefield analgesia is suitable for child casualties. The potential for accidental self-injection was reported. A more potent, faster onset analgesic than IM morphine is desirable in the first hour following injury. Pre-deployment training should emphasise management of complications of opiate analgesics and treatment of child casualties. Oral transmucosal fentanyl citrate is now being issued to all frontline medical personnel. IM morphine will remain on individual issue to all deployed soldiers for environments where an oral agent is not suitable, for example, chemical, biological, radiological and nuclear warfare. Frontline medical personnel agree that a more potent, faster onset analgesic than IM morphine is desirable in the first hour following injury.The two most desirable features of the ideal analgesic were ranked as rapid onset of action, and when fully onset produces a high degree of pain relief.Oral transmucosal fentanyl citrate (OTFC) has now been issued to all frontline medical personnel as an adjunct to IM morphine.IM morphine will remain on individual issue for situations where parenteral analgesia is required.Consideration should be given to individual issue of OTFC to all deployed personnel in the future.Pre-deployment training should emphasise management of complications of opiate analgesics and treatment of child casualties.

Isoflurane Concentration when Compared with Intramuscular Morphine during Patellar Luxation Repair in Dogs

Isoflurane Concentration when Compared with Intramuscular Morphine during Patellar Luxation Repair in Dogs

How much do soldiers know about the morphine they carry on operations? A questionnaire study of knowledge and understanding of the morphine auto-injector on Op HERRICK 17

IntroductionMorphine auto-injectors are issued to all British soldiers on operations in Afghanistan who deploy forward of Camp Bastion, the main British base. Previous studies have reviewed the effectiveness of various...

Influence of bile acid derivates on morphine analgesic effect in mice.

It is known that bile acids improve the absorption, bioavailability and pharmacodynamic characteristics of some drugs. Morphine analgesia is produced by activation of opioid receptors within the central nervous system (CNS) at both spinal and supraspinal levels. Since a morphine molecule contains 3 polar groups and therefore hard to transfer through the blood-brain barrier, the aim of the study was to examine the potential influence of bile acids derivates, namely sodium salt of monoketocholic acid (MKH-Na) and methyl ester of monoketocholic acid (MKH-Me), on analgesic effect of morphine. White male mice of NMRI-Haan strain, with body weight of 20-24 g, were used in this study. The analgesic effect of morphine (administered by subcutaneous and intramuscular route in a dose of 2 mg/kg), with and without pretreatment with MKH-Na (4 mg/kg) and MKH-Me (4 mg/kg) was estimated by the hot plate method. Administration of MKH-Me prior to subcutaneous administration of morphine increased the morphine analgesic effect but the increase was not statistically significant. At the same time administration of MKH-Na did not affect morphine analgesic effect. The analgesic effect of morphine increased when administered intramuscularly 20 min after MKH-Me administration. When compared with the group of animals treated only with morphine, a statistically significant increase in analgesic effect was detected 10, 30, 40 and 50 min after morphine administration (p < 0.05). Pretreatment with MKH-Na did not affect morphine analgesic effect. According to the results of this study it can be presumed that after intramuscular morphine administration methyl ester of monoketocholic acid increases morphine transport into the central nervous system and consequently the analgesic effect, as well. Further research on bile acids-morphine interaction both in vitro and in vivo is necessary to completely elucidate the mechanism of this interaction and increase in the morphine analgesic effect.

Clinical evaluation of alfaxalone to induce and maintain anaesthesia in cats undergoing neutering procedures.

This study looked at the use and efficacy of alfaxalone for total intravenous anaesthesia (TIVA) in cats. Following intramuscular medetomidine (20 μg/kg) and morphine (0.3 mg/kg) premedication, anaesthesia was induced and maintained with intravenous alfaxalone. Patients were breathing 100% oxygen. Heart rate (HR), respiratory rate (RR), end-tidal carbon dioxide, oxygen saturation of haemoglobin and indirect arterial blood pressure via Doppler (DAP) were recorded every 5 mins. Thirty-four cats (10 males and 24 females), between the age of 6 and 18 months, and weighing between 1.8 and 5.3 kg, and undergoing neutering procedures were included in this study. The results are presented as median (min, max) values. The time to first spontaneous movement (TS) was >30 mins in 19 cats, of which 12 received atipamezole for reversal of the effects of medetomidine. The TS was 53 (43, 130) mins in these 12 cats and 50 (40, 72) mins in the other seven cats. The body temperature in those 19 cats was significantly lower than the other cats (P = 0.05). The alfaxalone induction dose and maintenance infusion rate were1.7 (0.7, 3.0) mg/kg and 0.18 (0.06, 0.25) mg/kg/min, respectively. The HR, RR and DAP were 145 (68, 235) beats/min, 17 (5, 40) breaths/min and 110 (58, 210) mmHg, respectively. Apnoea was not observed in any cat. In conclusion, alfaxalone TIVA in combination with medetomidine and morphine premedication was effective in feral and domestic cats for the performance of neutering surgery; low body temperature might have resulted in longer recoveries in some cats.

Effects of dexmedetomidine pretreatment on haemodynamics and bispectral index during anesthetic induction in patients undergoing cardiac valve replacement surgery with cardiopulmonary bypass

Objective To evaluate the influence of dexmedetomidine(Dex)(highly selective α2-adrenergic receptor agonist) on haemodynamics and bispectral index (BIS) during anesthetic induction in patients undergoing valve replacement surgery.Methods Thirty NYHA class Ⅱ or Ⅲ patients,aged between 30 y and 70 y,undergoing cardiac value replacement with cardiopulmonary bypass,were randomly divided into two groups (n=15):Dex group(group D) and control group(group C).In group Dex,pump diluted with saline to 50 ml of Dex (4 mg/L)0.5 μg/kg was administered iv 10 min before the induction of anesthesia,while in group C,same volume of 0.9％ normal saline was given.The patients were premedicated with intramuscular morphine and scopolamine.Anesthesia was induced with 0.06 mg/kg,fentanyl 6 μg/kg,etomidate 0.3 mg/kg and pipecuronium 0.10 mg/kg.Anesthesia was maintained with midazolam,fentanyl,intermittently.In two group,heart rate(HR),arterial blood pressure(ABP)[systolic blood pressure(SBP),diastolic blood pressure(DBP),mean arterial pressure(MAP)] and bispectral index(BIS) were recorded at the time before Dex infusion(T1),5 min after loading dose(T2),10 min after loading dose(T3),1,3 min after anesthesia induction(T4,T5),just before endotracheal intubation(T6),endotracheal intubation(T7) and 1,3,5 min after endotracheal intubation(T8-10).Results BIS of T2,T3 in group D was decreased significantly [from(92.6±2.5) to (73.2±1.9) and (70.1±2.3)](P＜0.05 or P＜0.01) compared with T1.During anesthesia induction compared with T3,BIS in both groups were decreased significantly.During endotracheal intubation compared with T6,BIS of T7 (34.8±2.2) was increased significantly in group C(P＜0.05 or P＜0.01),while BIS in group C were similar to the initial values.Compared with group C,BIS decreased significantly at time T2～5、T7 in group D (P＜0.05 or P＜0.01).Before anesthesia induction compared with T1,ABP of T2、T3 in group D was increased slightly,HR of T2、T3 was decreased significantly (P＜0.05 or P＜0.01); During anesthesia induction compared with T3,ABP and HR in both groups were decreased significantly.Compared with T6,DBP,MAP and HR of T7,T8 were increased slightly,that of T9,T10 were similar to the values in group D.During endotracheal intubation,while ABP and HR of T7-T1o was increased significantly in group C (P＜0.05 or P＜0.01).Compared with group C,SBP,MAP of T4-T10 and DBP of T3-T10 were increased significantly in group D.HR of T2-T10 were decreased significantly in group D (P＜0.05 or P＜0.01).Conclusions Dex pretreatment might decrease BIS and alleviate haemodynamics reaction during anesthetic induction in patients undergoing valve replacement surgery with cardiopulmonary bypass. Key words: Dexmedetomidine; Valve replacement; Bispectral index; Stress reaction; Hemodynamics

Effect of wound infiltration with bupivacaine on pulmonary function after elective lower abdominal operations

Subcutaneous or intrafascial wound infiltration of local anaesthetic with systemic opioids has been shown to enhance patient comfort with improved analgesia and reduced opioid requirements. To demonstrate improved pulmonary function when postoperative analgesia was provided by combined bupivacaine wound infiltration and systemic opioid. In a prospective, randomized, placebo-controlled study, 46 patients (23 per group) scheduled for elective gynaecological surgery under general anaesthesia had subcutaneous and intrafascial wound infiltration of 40 ml, 0.25% bupivacaine (study patients) or 40 ml 0.9% saline (control) just before the end of surgery. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and peak expiratory flow rate (PEFR) were done before surgery and at 6, 12 and 24 hours postoperatively. Student's T and chi-square tests were used for tests of significance set at P < 0.05. Postoperative analgesia was provided with intramuscular morphine 0.15 mg/kg 4 hourly and 10mg/kg of intravenous paracetamol as rescue analgesia. PEFR, FVC and FEV1 were reduced in both the control and study groups but the reduction was greater in the control group. Bupivacaine wound infiltration produced statistically significant elevations in pulmonary function tests results at all assessment periods.