winterallsummer Posted January 29, 2016 Share Posted January 29, 2016 Completely hypothetical situation. You have a patient with advanced and incurable, chronic disease that causes pain. Their BP always runs low (systolic of 90s). They are a full code and in pain but BP at that time is 80s. Otherwise cognition and sats are unchanged. What is your threshold for holding morphine in these settings? How low of BP will you tolerate for giving morphine (Specitifally what MAP if any)? Their pain is fully legitamite. Thoughts? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 29, 2016 Moderator Share Posted January 29, 2016 would probably use fentanyl in that setting myself... Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted January 29, 2016 Share Posted January 29, 2016 Emed, could you expand on that a little? Just curious to get some insight. Thanks. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 29, 2016 Moderator Share Posted January 29, 2016 fentanyl is easily titratable and causes less hypotension than morphine due to less vasodilation. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted January 29, 2016 Share Posted January 29, 2016 Are you talking a fentanyl patch? Start at 25 mcg or go by body weight or by hx of narc tolerance? Any thought toward Butrans? Curious... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 29, 2016 Moderator Share Posted January 29, 2016 IV if inpatient, patch if outpt. Link to comment Share on other sites More sharing options...
cbrsmurf Posted January 29, 2016 Share Posted January 29, 2016 Is BP drop from morphine due to some kind of vasodilatory effect or is the drop due to pain relief? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted January 29, 2016 Administrator Share Posted January 29, 2016 Any thought toward Butrans? Butrans is not readily titratable, and WILL interfere with other pain meds--by design, really. I only use it for stable chronic pain. Patients hate it because it costs them so much. Never considered what effect it might have on lowering BP in the inpatient setting, because that's not the population I work with. Link to comment Share on other sites More sharing options...
winterallsummer Posted January 29, 2016 Author Share Posted January 29, 2016 Great point about the fentanyl and here is link for the data for those interested http://www.ncbi.nlm.nih.gov/m/pubmed/7457946/ However I specifically want to know what are your guys MAP or SBP thresholds for morphine? Link to comment Share on other sites More sharing options...
dmdpac Posted January 29, 2016 Share Posted January 29, 2016 Another vote for fentanyl. Pretty stable as far as pressure concerns go. Works well for pain. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 29, 2016 Moderator Share Posted January 29, 2016 I only use morphine rarely now and mostly use dilaudid or fentanyl for almost everything. might give ms to acs or chf. sometimes to kids with fxs. Link to comment Share on other sites More sharing options...
winterallsummer Posted January 29, 2016 Author Share Posted January 29, 2016 Emed why the change from morphine to fentanyl? Correct me if I'm wrong but doesn't morphine have a longer half life and peak concentration? Anecdotally have you noticed any higher risk to the airway with fentanyl? Are your RNs comfortable giving it? In the ER I used fentanyl for procedures (eg I and D in sensitive area) but otherwise have stuck to morphine or dilaudid for acute medical pain. What kind of doses are you using? I believe equivalency is about 10:1? I do use the patch at times. But am not terribly familiar with IV do sing outside of procedures. I agree it's much more titrable than morphine and can also be used at sedating doses for procedures. What made you decide to switch over? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 30, 2016 Moderator Share Posted January 30, 2016 so many folks get nauseated with MS and it just seems to have a rougher side effect profile than fentanyl. 100 mcg of fentanyl is about the same as 10 mg of ms or 1.25 mg of dilaudid so dose accordingly. most adults in real pain I give 75-100 mcg of fentanyl. different places I work prefer different analgesics and stock accordingly. at my primary job we mainly use dilaudid. at my rural jobs we tend to use fentanyl. nurses have no problem giving it for pain. if I use it with lots of benzos they start asking me about sedation paperwork unless I clearly document for pain/for anxiety. Link to comment Share on other sites More sharing options...
cinntsp Posted January 30, 2016 Share Posted January 30, 2016 Is BP drop from morphine due to some kind of vasodilatory effect or is the drop due to pain relief? Morphine > morphine metabolites > histamine and NO-mediated vasodilation > hypotension. Giving a combination of an H1+H2 blocker can theoretically help, but if someone's pressure is at the point where this is even an issue then it's probably best to use another agent if possible. Pain control itself can certainly help with BP/HR though. Link to comment Share on other sites More sharing options...
sk732 Posted February 16, 2016 Share Posted February 16, 2016 For low BP's, I use fentanyl too...as for short half life, if you can get the really ugly part of the pain issue under control, the person will relax enough to switch to something to deal with that nagging left over stuff. Depending on age, I might actually go to MS, but I tend to like Dilaudid in older folks because it makes them a little less goofy. If they're at the point to tolerate PO stuff, I'll give something by known effects and age for the person, day of the week and moon phase AISF. SK Link to comment Share on other sites More sharing options...
fakingpatience Posted February 16, 2016 Share Posted February 16, 2016 Has there been much movement in y'alls ERs towards the use of ketamine for pain control? I know it is gaining popularity in the EMS realm, but from that perspective it is especially a good one to carry because it's multipurpose drug. Also, unlike the narcotics it's not a schedule 2 so the increasingly strict DEA rules shouldn't effect it's use standing order for paramedics. Link to comment Share on other sites More sharing options...
JohnnyM2 Posted February 16, 2016 Share Posted February 16, 2016 Yeah, it (ketamine) was used by a couple of the rough necks on Harry Stamper's asteroid drill team and they went on to save the world. I say, give it a chance.???? Link to comment Share on other sites More sharing options...
PJ82 Posted February 16, 2016 Share Posted February 16, 2016 Use of ketamine in EMS makes sense since paramedics usually have limited scope and carry few drugs to begin with. We used ketamine like it was going out of style in Afghanistan for all the trauma we saw. Typically carried morphine, fentanyl, versed, and ketamine along with induction agents for RSI. I definitely think ketamine has its place if people are trained to use it. A friend of mine was shot a few times and he was given ketamine and made us all promise to never give it to him again if he got hurt, he had super bad tripping episodes on it. Link to comment Share on other sites More sharing options...
bike mike Posted February 16, 2016 Share Posted February 16, 2016 Agree with EMEDPA, in that situation ( which I see frequently in the CCU) I use fentanyl. Less of an issue with causing hypotension. Link to comment Share on other sites More sharing options...
ajnelson Posted February 16, 2016 Share Posted February 16, 2016 I've gone to using fentanyl more and more as well, especially in the elderly where it's easy to give too much of a narcotic. In patients with borderline BPs, it is also good for pain relief, because as E said, it doesn't have as much of an effect on their BP. Morphine is a good drug in those that don't have lots of side effects, but the side effect profile can make some people very ill, and I completely understand why they wouldn't want to take it Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 16, 2016 Moderator Share Posted February 16, 2016 nice to see you back AJ after a bit of a hiatus. Link to comment Share on other sites More sharing options...
ajnelson Posted February 16, 2016 Share Posted February 16, 2016 Thanks E! Been a crazy few months. Move across the country. New job. And a newborn! It's great to be back though! Link to comment Share on other sites More sharing options...
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