A Randomized Controlled Trial Comparing Intranasal Fentanyl to Intravenous Morphine for Managing Acute Pain in Children in the Emergency Department
Presented at the Australasian College for Emergency Medicine annual scientific meeting, Melbourne, Australia, November 2005.
Received 6 January 2006; received in revised form 14 April 2006, 19 May 2006 and 31 May 2006; accepted 8 June 2006. published online 02 November 2006.
Study objective
We compare the efficacy of intranasal fentanyl versus intravenous morphine in a pediatric population presenting to an emergency department (ED) with acute long-bone fractures.
Methods
We conducted a prospective, randomized, double-blind, placebo-controlled, clinical trial in a tertiary pediatric ED between September 2001 and January 2005. A convenience sample of children aged 7 to 15 years with clinically deformed closed long-bone fractures was included to receive either active intravenous morphine (10 mg/mL) and intranasal placebo or active intranasal concentrated fentanyl (150 μg/mL) and intravenous placebo. Exclusion criteria were narcotic analgesia within 4 hours of arrival, significant head injury, allergy to opiates, nasal blockage, or inability to perform pain scoring. Pain scores were rated by using a 100-mm visual analog scale at 0, 5, 10, 20, and 30 minutes. Routine clinical observations and adverse events were recorded.
Results
Sixty-seven children were enrolled (mean age 10.9 years [SD 2.4]). Fractures were radius or ulna 53 (79.1%), humerus 9 (13.4%), tibia or fibula 4 (6.0%), and femur 1 (1.5%). Thirty-four children received intravenous (IV) morphine and 33 received intranasal fentanyl. Statistically significant differences in visual analog scale scores were not observed between the 2 treatment arms either preanalgesia or at 5, 10, 20, or 30 minutes postanalgesia (P=.333). At 10 minutes, the difference in mean visual analog scale between the morphine and fentanyl groups was −5 mm (95% confidence interval −16 to 7 mm). Reductions in combined pain scores occurred at 5 minutes (20 mm; P=.000), 10 minutes (4 mm; P=.012), and 20 minutes (8 mm; P=.000) postanalgesia. The mean total INF dose was 1.7 μg/kg, and the mean total IV morphine dose was 0.11 mg/kg. There were no serious adverse events.
Conclusion
Intranasal fentanyl delivered as 150 μg/mL at a dose of 1.7 μg/kg was shown to be an effective analgesic in children aged 7 to 15 years presenting to an ED with an acute fracture when compared to intravenous morphine at 0.1 mg/kg.
aPrincess Margaret Hospital for Children, Subiaco (Borland, King)
bSchool of Paediatrics and Child Health, University of Western Australia, Perth (King)
cDiscipline of Emergency Medicine, University of Western Australia, Perth (Jacobs)
dEmergency Department, Sir Charles Gairdner Hospital, Nedlands (O'Brien) WA, Australia
Address for correspondence: Meredith Borland, MBBS, FACEM, GPO Box D184, Perth WA 6840, Australia; 61-(0)-8-9340-8222, fax 61-(0)-8-9340-8118
Supervising editor: Steven M. Green, MD
Author contributions: MB conceived, designed, and conducted the study and undertook article writing and acts as guarantor. IJ assisted in planning and manuscript revision and undertook statistical analysis. BK conducted patient enrollments and article revision. DO'B was involved in planning, obtaining funding, and article revision.
Reprints not available from the authors.
Funding and support: Funded by an ACEM Morson Taylor Research Grant.
ABSTRACT