Prehospital intravenous fentanyl administered by ambulance personnel: a cluster-randomised comparison of two treatment protocols

Kristian D Friesgaard, Hans Kirkegaard, Claus-Henrik Rasmussen, Matthias Giebner, Erika F Christensen, Lone Nikolajsen, Kristian D Friesgaard, Hans Kirkegaard, Claus-Henrik Rasmussen, Matthias Giebner, Erika F Christensen, Lone Nikolajsen

Abstract

Background: Prehospital acute pain is a frequent symptom that is often inadequately managed. The concerns of opioid induced side effects are well-founded. To ensure patient safety, ambulance personnel are therefore provided with treatment protocols with dosing restrictions, however, with the concomitant risk of insufficient pain treatment of the patients. The aim of this study was to investigate the impact of a liberal intravenous fentanyl treatment protocol on efficacy and safety measures.

Methods: A two-armed, cluster-randomised trial was conducted in the Central Denmark Region over a 1-year period. Ambulance stations (stratified according to size) were randomised to follow either a liberal treatment protocol (3 μg/kg) or a standard treatment protocol (2 μg/kg). The primary outcome was the proportion of patients with sufficient pan relief (numeric rating scale (NRS, 0-10) < 3) at hospital arrival. Secondary outcomes included abnormal vital parameters as proxy measures of safety. A multi-level mixed effect logistic regression model was applied.

Results: In total, 5278 patients were included. Ambulance personnel following the liberal protocol administered higher doses of fentanyl [117.7 μg (95% CI 116.7-118.6)] than ambulance personnel following the standard protocol [111.5 μg (95% CI 110.7-112.4), P = 0.0001]. The number of patient with sufficient pain relief at hospital arrival was higher in the liberal treatment group than the standard treatment group [44.0% (95% CI 41.8-46.1) vs. 37.4% (95% CI 35.2-39.6), adjusted odds ratio 1.47 (95% CI 1.17-1.84)]. The relative decrease in NRS scores during transport was less evident [adjusted odds ratio 1.18 (95% CI 0.95-1.48)]. The occurrences of abnormal vital parameters were similar in both groups.

Conclusions: Liberalising an intravenous fentanyl treatment protocol applied by ambulance personnel slightly increased the number of patients with sufficient pain relief at hospital arrival without compromising patient safety. Future efforts of training ambulance personnel are needed to further improve protocol adherence and quality of treatment.

Trial registration: ClinicalTrials.gov ( NCT02914678 ). Date of registration: 26th September, 2016.

Keywords: Acute pain; Ambulance personnel; Intravenous fentanyl; Prehospital.

Conflict of interest statement

Ethics approval and consent to participate

Approved by the Danish Data Protection Agency (no. 1-16-02-294-16) and the National Board of Health (no. 3-3013-2002/1). The local ethics committee was consulted, and the study was approved with a waiver of patient consent.

Consent for publication

Not required.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flowchart for included patients. Abbreviations: EMTs; Emergency Medical Technicians, PMs, Paramedics, NRS; Numeric Rating Scale, adm.; administration
Fig. 2
Fig. 2
Map of Central Denmark Region with the clusters of included patients. Orange dots = Patients treated according to the standard treatment protocol (max 2 μg/kg). Green dots = Patients treated according to the liberal treatment protocol (max 3 μg/kg)

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