Efficacy and safety of intravenous fentanyl administered by ambulance personnel.

BACKGROUND: Management of pain in the pre-hospital setting is often inadequate. In 2011, ambulance personnel were authorized to administer intravenous fentanyl in the Central Denmark Region. The aim of this study was to evaluate the efficacy and safety of intravenous fentanyl administered by ambulance personnel. METHODS: Pre-hospital medical charts from 2348 adults treated with intravenous fentanyl by ambulance personnel during a 6-month period were reviewed. The primary outcome was the change in pain intensity on a numeric rating scale (NRS) from before fentanyl treatment to hospital arrival. Secondary outcomes included the number of patients with reduction in pain intensity during transport (NRS ≥ 2), the number of patients with NRS > 3 at hospital arrival, and potential fentanyl-related side effects. RESULTS: Fentanyl reduced pain from before treatment (8, IQR 7-9) to hospital arrival (4, IQR 3-6) (NRS reduction: 3, IQR 2-5; P = 0.001), 79.3% of all patients had a reduction in > 2 on the NRS during transport, and 58.4% of patients experienced pain at hospital arrival (NRS > 3). Twenty-one patients (0.9%) had oxygen saturation < 90%. A decrease in Glasgow Coma Scale was seen in 31 patients (1.3%) and hypotension observed in 71 patients (3.0%). CONCLUSION: Intravenous fentanyl caused clinically meaningful pain reduction in most patients and was safe in the hands of ambulance personnel. Many patients had moderate to severe pain at hospital arrival. As the protocol allowed higher doses of fentanyl, feedback on effect and safety should be part of continuous education of ambulance personnel.

[The prevention of postoperative vomiting following strabismus surgery in children]. / Die Prophylaxe des postoperativen Erbrechens nach Strabismusoperationen bei Kindern.

Children recovering from anaesthesia for strabismus surgery are particularly prone to nausea and vomiting as a result of intraoperative vagus irritation. Besides being disturbing to the patient, vomiting can be dangerous during emergence from anesthesia and can result in delayed discharge. Droperidol is a powerful antiemetic drug that has been shown to reduce the incidence and severity of postoperative nausea and vomiting in pediatric strabismus patients, although the best timing for administration is not clear. MATERIAL AND METHODS. We compared three randomized groups totalling 61 patients. Droperidol 0.075 mg/kg i.v. was given either at induction of anesthesia after intubation (n = 20) or during the last muscle suture (n = 21). The third group received no antiemetic treatment. The patients' ages ranged from 3 to 14 years (mean 5.9 +/- 2.84 years). There was no difference in age or sex between the three groups. Anesthesia was standardized with rectal midazolam premedication, atropine, thiopental, succinylcholine, O2/N2O = 1:2, enflurane, intubation, and a gastric tube. RESULTS. Nausea, retching, or vomiting occurred in 2/20 children (10%) given droperidol preoperatively, 4/21 children (19%) with droperidol during the operation, and 9/20 children (45%) with no antiemetic treatment. The difference between groups I and III was significant (p less than 0.05). Comparison of groups II and III and groups I and II showed no statistical significance. Operation time was similar in each group and there was no delay in time of extubation. In each group 1 case of hypotension occurred. No child showed extrapyramidal symptoms. The lower incidence of vomiting in all study groups compared to the literature is thought to be due to three factors: (1) emptying the stomach at the end of the operation by a gastric tube, which is removed before extubation; (2) avoidance of opioids; (3) surgical procedure being done by a very experienced surgeon in 57/61 children (12 vomiting versus 45 not vomiting) in contrast to 3/4 children vomiting postoperatively after surgery by a less experienced surgeon. CONCLUSIONS. We recommend preoperative droperidol 75 micrograms/kg i.v. as the best prophylaxis of postoperative emesis without severe side effects in pediatric strabismus surgery.