Paper 1 chosen by group: Analgesic Efficacy, Practicality and Safety of Inhaled Methoxyflurane Versus Standard Analgesic Treatment for Acute Trauma Pain in the Emergency Setting
Paper 2 chosen by group: Comparison between intravenous Morphine versus Fentanyl in acute pain relief in drug abusers with acute limb traumatic injury
- Synthesis of papers and analysis: (12 marks)
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Question |
Answer |
Answer |
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Did the studies address a clearly focused issue? |
Article 1 has a clear focused issue. The issue that was presented is if Methoxyflurane would be more of a pain relief in moderate to severe pain with patients that were presented to the ED with acute trauma pain. |
Yes, paper 2 compares Morphine and Fentanyl in pain reduction in drug abusers with acute limb traumatic injury. |
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Are the sample sizes justified? |
Article 1 had 272 patients that were randomised with 136 per treatment group. This shows that the sample size was justified as it included the study across 15 different Italian emergency departments. |
Yes, 307 patients seem like a justified sample size in such study. However, the larger the better. |
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Is the design appropriate to the stated aims? |
This article has stated that it was going to see the analgesic efficacy between inhaled Methoxyflurane versus the standard analgesic treatments for acute trauma patients in the emergency setting in Italy. It was designed according to what the aims were stated, and it was clear. It was a clear systematic review. |
Yes, the Double blind randomized clinical trial allows for perfect comparison of results in the two groups. |
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Are the measurements likely to be valid and reliable? |
The measurements in this article are valid and reliable due to the where the measurements were conducted and how often they were conducted. |
In paper 2 there is also margin for error and discrepancies with the numerical self-evaluation of pain score. |
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Are the statistical methods and statistical significance described? |
Article 1 had very good and reliable statistics due to the confidence interval, p-value and all the statistical data was collected and tested against the 272 patients that conducted the study. |
Yes, methods included the doses given and the results being measured clearly. |
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Did untoward events occur during any of the studies? |
There were no untoward events that occurred during the study. |
No, no unexpected events. |
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Were the basic data adequately described? |
All the data that was described in this article have been adequately described throughout the article. They have also shown promising results. |
The data was well described, both numerically and in terms of values and observations. Meaning the reader can interpret and see a clear result. |
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Do the numbers add up (do the statistics or values provided appear to represent all of the data from the study, or has the data been modified to produce a convenient result)? |
Everything in this article adds up, with the numbers, the maths, the way that the trial was conducted and the amount of people that were tested against this study. This article also compared other articles that did a similar study and have found promising results. |
The numbers also add up, and values appear correct after analysing results and methods. |
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Are potential sources of bias within the study identified? |
There were no bias found in this article. |
Unable to identify source of bias. |
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What do the findings mean for each study and as a whole? |
The findings that were found in this article were accurate and even found that with the effect of Methoxyflurane being more effective at the 20-minute mark, they found in this article it was actually at the 10-minute mark that it was helping to relieve pain. |
The findings of the study support Fentanyl being a faster effect (at 5-minute interval) however at any other time comparable. |
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Are important effects overlooked (is there any finding within the paper that may impact paramedicine, for example a drug that could not be stored effectively on an ambulance, but is not highlighted within the original study as a potential implementation issue? |
There is no impact in this article in paramedicine as any paramedic that is working and going to a case that has trauma, knows what pain relief to use and what the effects are with the patient. |
Yes, the 5-minute interval score contrast between Morphine and Fentanyl can be something to consider for ambulance paramedics and their guideline. |
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What implications do these studies have for your practice? |
There are no real implications that this study has for my practice. The only thing that can be considered is that when there is trauma, using Methoxyflurane for more than just a mild pain relief, as well as using it in conjunction with other analgesia, would be beneficial to the patient. |
Consideration of Fentanyl for faster acting pain relief in the prehospital setting in contract to Morphine. |
- Synthesis of results: (9 marks)
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Question |
Answer |
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What are the main results when the two individuals’ evidence are synthesised? (find the common agreements between the papers) |
Paper 1’s results showed that Methoxyflurane is an excellent option in moderate-to-severe trauma pain. This was demonstrated by "Excellent", "Very Good" or "Good" by 90% of clinicians. Important to note that this was done on adult patients, whom had suffered a trauma to the limb with a pain score greater than 4. Another finding was that Methoxyflurane at the 10-minute interval was found to have relieved pain in patients, greater than IV Morphine. Paper 2 in contrast, compares another two drugs which are used by Ambulance Victoria, Morphine and Fentanyl. The results of this paper show that both IV Morphine and IV Fentanyl are comparable in terms of pain relief in drug abusers with acute limb traumatic injury and are able to drop their pain scores equally. The results also highlight that Fentanyl is quicker acting and patients pain score was able to be dropped at the 5-minute mark. Common agreements between papers is that an intervention of either drugs is bound to provide pain relief and some benefit to the patient. Methoxyflurane is an ‘excellent’ option for moderate to severe pain, and likewise Morphine and Fentanyl. |
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Do these results agree with each other (is there a commonality)? |
The results of the two articles do support current Ambulance Victoria guidelines on pain relief with their safety and benefits. There is no commonality in the results, however, paper 1 provides evidence which has proven that Methoxyflurane at the 10-minute interval was superior to IV Morphine, thus is something paper 2 didn’t explore. |
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What is the quality of the results overall? |
Overall the individual quality of either paper is of good quality as it was undertaken methodically and followed the process of research. Sample size was under 310 patients for both studies, which brings the total combined of both papers to 577 adult patients. The results provide good insight into the effectiveness of pain relief, however, to be of extremely high standard and to be definite, more research needs to be done. As well as looking into paediatric patient. |
- Discussion (900 words as a guide): (20 marks)
Current Ambulance Victoria Clinical Practice Guidelines (AV CPG) indicates the use of Morphine and Fentanyl for moderate and severe pain. Methoxyflurane is indicated for moderate procedural pain and moderate pain where intranasal (IN) Fentanyl is unable to be administered. (Clinical practice guidelines for ALS and MICA paramedics, 2019). Article 1, Analgesic Efficacy, Practicality and Safety of Inhaled Methoxyflurane Versus Standard Analgesic Treatment for Acute Trauma Pain in the Emergency Setting, provides evidence that a significant change in visual analogue scale (VAS) pain scores following administration of Methoxyflurane after 10 minutes is greater than standard analgesic treatment, such as paracetamol, intravenous (IV) Morphine and Fentanyl in the trauma pain setting. (Mercadante et al., 2019). Current practice circumstantially indicates the use of Methoxyflurane, with suggestions to use for procedural pain and moderate pain as almost a fall back, however, it is proven within Article 1 that Methoxyflurane is significantly beneficial in the treatment of pain in a time conscious period. This evidence partially agrees with current practice in the sense that AV CPG indicates the use of Methoxyflurane in procedural pain such as splinting fractures and dislocations which was also depicted in the article. The discrepancy within current practice and the article was the additional use of Methoxyflurane for trauma pain that is associated with contusion and crushing (Mercadante et al., 2019). Mercadante demonstrated a clinical significance in treating trauma pain associated with fractures, dislocations, contusions and crushing, which is significant enough to consider a change in current practice.
Article 2 demonstrates that Morphine and Fentanyl are equally effective in reducing overall pain in opioid addicted trauma patients. The evidence suggests that Fentanyl requires less doses and Morphine has a longer time to achieve therapeutic effects, however overall, both are effective in the management of pain in opioid addicted patients (Vahedi, 2019). Currently AV CPG has known addictions to opioids as a precaution for the administration of pain relief with Morphine and Fentanyl (Clinical practice guidelines for ALS and MICA paramedics, 2019). The article and current practice agree and does not warrant a change in practice.
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The evidence provided by both articles can inform current practice. The sample size is significant to demonstrate that the data is reproducible. Both articles also had very focused goals and methods. The fact that article one demonstrated Methoxyflurane is beneficial in treating trauma pain associated with fracture, dislocation, contusion and crushing can inform current practice in those scenarios as all of them are not represented in the guideline. As with the second article, the use of Fentanyl and Morphine in patients with opioid addiction histories may present an obstacle, however the article states it is safe and effective to use opioid analgesics in patients with drug addictions. This can help inform current practice and paramedics.
What is essentially very limited and lacking, is research within the pre-hospital field. Given its difficulty to attain, it means that current Ambulance Practices may be difficult to improve and come up with greater and more effective strategies and treatments. Majority of the research studies conducted on pain relief and reduction in pain scores are done within a controlled definitive care environment which doesn’t reflect the dynamic nature of paramedic work and where most of the pain relief is actually administered. Therefore, more studies showing the use of the researched drugs above such as Methoxyflurane, Morphine and Fentanyl in dynamic environments may provide greater insight, as it is known movement has an effect on pain score. This is a limitation of controlled hospital setting based studies, when used to define paramedic practice. If ethical issues and legalities can be overcome and more data may be gathered in the pre-hospital setting, then this is essential and can provide greatest insight to future practices.
There is no cost associated with having Methoxyflurane, Morphine and Fentanyl then what there is already in the ambulance service. Ambulance Victoria already carry those drugs on board the ambulances and use them for pain relief for patients. In addition to this, there is no additional training, equipment or storage on the vehicles to accommodate the use of Methoxyflurane, Morphine and Fentanyl.
- Conclusions (200 words as a guide): (9 marks)
According to the current Ambulance Victoria CPG, the use of Morphine and Fentanyl is for moderate and severe pain. Methoxyflurane is used for moderate procedural pain and moderate pain where intranasal (IN) Fentanyl is unable to be administered. This, however, is not reflected by the studies that were conducted and mentioned in this report. The studies concluded that Methoxyflurane can be used for moderate to severe pain, where a trauma has happened. Which should be changed in the current practice of paramedics and the CPG, as it should not only be used for procedural pain as it is beneficial for traumatic pain. With Morphine and Fentanyl, the current CPG is in agreeance with the studies that were mention in this report. Thus, there is no need for change to the CPG that Ambulance Victoria has published. Overall, the studies have provided an insight to the current pain relief that both Ambulance Victoria use, as well as other countries. It has also revealed the use of the drugs, in certain circumstances, that normally a paramedic would not use and the benefits of using those drugs in those circumstances.
References
- Ambulance Victoria. (2019). Clinical practice guidelines for ALS and MICA paramedics.
- Mercadante, S., Voza, A., Serra, S., Ruggiano, G., Carpinteri, G., & Gangitano, G. et al. (2019). Analgesic Efficacy, Practicality and Safety of Inhaled Methoxyflurane Versus Standard Analgesic Treatment for Acute Trauma Pain in the Emergency Setting: A Randomised, Open-Label, Active-Controlled, Multicentre Trial in Italy (MEDITA). Advances In Therapy, 36(11), 3030-3046. doi: 10.1007/s12325-019-01055-9
- Vahedi, H. (2019). Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury. World Journal Of Emergency Medicine, 10(1), 27. doi: 10.5847/wjem.j.1920-8642.2019.01.004
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