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A Guide to Fast, Effective Pain Management Designed for Fast, Efficient Patient Management

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A Guide to Fast, Effective Pain Management Designed for Fast, Efficient Patient Management NEW Advancing Acute Pain Management At last, PENTHROX® is here... A guide to Fast, effective pain management designed for fast, efficient patient management. Inhaled patient-controlled analgesia PENTHROX is indicated for the emergency relief of moderate to severe pain in conscious adult patients with trauma and associated pain What is inhaled patient-controlled analgesia? Inhaled patient-controlled analgesia allows fully conscious patients to self-administer analgesia by inhaling a gas through a facemask or mouthpiece. The patient determines the concentration of drug delivered. Although various inhalational anaesthetics have been used for inhaled patient-controlled analgesia (examples include isoflurane and sevoflurane) there are currently only two drugs licensed for this purpose in the UK: nitrous oxide 50% combined with oxygen 50% (N2O/O2) and methoxyflurane. Inhaled patient-controlled analgesia has the advantage over oral and parenteral drugs in that it is non-narcotic, with minimal side effects. It allows the patient to regulate the dose he/she receives while requiring relatively little training for the clinician. Table 1 outlines some indications for inhaled analgesia. Penthrox is indicated for the emergency relief of moderate to severe pain in conscious adult patients with Adverse events should be reported. On the other hand, inhaled patient-controlled trauma and associated pain. Please consult the Summary Reporting forms and information can be analgesia has to be used with the same caution of Product Characteristics before prescribing. Information found at www.mhra.gov.uk/yellowcard. Dr John Wright is Consultant in Emergency about this product, including adverse reactions, Adverse events should also be reported to as other forms of analgesia in some cases, such Galen Limited on 028 3833 4974 and select Medicine, Royal Victoria Infirmary, Newcastle- precautions, contra-indications and method of use can as patients with head injury, while it is uniquely be found at www.medicines.org.uk/emc. Legal category: the customer services option, or e-mail upon-Tyne NE1 4LP ([email protected]) POM. Further information is available on request from [email protected]. contraindicated (in the case of N2O/O2) in the Medical information enquiries should also Dr Will Passmore is Specialist Registrar in Galen Limited, Seagoe Industrial Estate, Craigavon, BT63 be directed to Galen Limited. presence of pathological air-containing spaces such 5UA, United Kingdom. Emergency Medicine, Royal Victoria Infirmary, Newcastle-upon-Tyne as pneumothorax. Penthrox Educational materials and training on its administration are available from Galen on request. Date of preparation: January 2016. PMR-JAN-2016-0042. Untitled-3PEN-15-075 1 A5 Abbreviated ED Ad.indd 1 01/02/2016 17:0616:41 There are many analgesic options in the of inhaled patient-controlled analgesia. The 50:50 management of acute pain episodes (Figure 1). Oral mix of nitrous oxide and oxygen is commonly analgesia is often limited by the latency of onset known as Entonox and also Nitronox or Equanox, of therapeutic effect. Acute pain episodes require and is colloquially known as ‘gas and air’. N2O/ rapid and effective pain relief. In these situations O2 is inhaled and exhaled from a portable cylinder clinicians will use more than one route of analgesic through a mouthpiece or facemask, via a regulator. drug administration to achieve rapid analgesia. Indications Prescribing inhaled N2O/O2 is a popular option because of its rapid patient-controlled analgesia onset and recovery characteristics combined Nitrous oxide 50% and oxygen 50% (N2O/O2) with predictable and reliable analgesic properties Until recently, doctors and allied health professionals (O’Sullivan and Benger, 2003). The analgesic only had this gas as the sole readily available choice effect is reported to be equivalent to a dose of Table 1. Indications for inhaled analgesia Medical* Surgical* Trauma Breakthrough pain, Postoperative pain Fracture reduction palliative patients Splint or plaster application Acute on chronic pain in Renal colic Burns dressings application and changes patients where intravenous access is not possible Obstetric labour pain from Procedural sedation Injured patient without intravenous access in contractions Flexible sigmoidoscopy acute pain Venepuncture Dental procedures Procedural sedation, e.g. joint reduction Tooth extraction Minor surgical procedures: Distressed and in pain, injured paediatric suturing, incision and drainage patient not tolerating intramuscular or intravenous drug administration *Inhaled methoxyflurane is only licensed in the UK for use in trauma pain, not medical or surgical pain Figure 1. Analgesic options in acute pain. Methoxyflurane (Penthrox) Nitrous oxide/oxygen Intranasal opioids, (Entonox) e.g. fentanyl, sulfentanyl Options Intravenous analgesia Intranasal benzodiazepines, e.g. midazolam, lorazepam, diazepam Intranasal ketamine Intranasal diamorphine 15 mg subcutaneous morphine (Chapman et al, There are a number of restrictions to its use. 1943). It has proved to be a very safe agent with Nitrous oxide inhalation is contraindicated in the minimal side effects and is particularly useful for presence of pathological air-containing spaces. managing transient acute pain caused by short- These spaces may expand as the nitrous oxide term procedures such as wound dressings. Its poor diffuses into them faster than nitrogen diffuses out. solubility in blood allows rapid achievement of The manufacturers explicitly warn against use in analgesia, with an effect usually apparent within conditions such as gross abdominal distension, bowel 60 seconds. When the patient inhales, gas first obstruction, pneumothorax, middle ear and sinus enters the lungs then the pulmonary and systemic disease (BOC Healthcare, 2015). N2O/O2 should circulations. It takes 1–2 minutes to build up be used with caution in patients with significant head reasonable concentrations of nitrous oxide in the injury or decreased levels of consciousness. Since brain. It is also fast to washout of the system (the nitrous oxide affects white blood cell production effects begin to wane after about 30 seconds; Latto et and function if it is used for several hours, it has al, 1973), which is excellent for its safety profile, but been recommended that N2O/O2 should not be also means patients need to have a constant supply administered to immunosuppressed patients or at hand available for adequate analgesia. to patients requiring multiple general anaesthetics (Lazyer, 1978; Brodsky and Cohen, 1986). Clinical management The contraindications to using 2N O/O2 can In most UK clinical settings, N2O/O2 is supplied be limiting in the pre-hospital environment and as an Entonox cylinder, which is white with blue for many patients who attend the emergency and white shoulders (Figure 2). The additional department requiring pain relief. An unusual feature equipment required consists of a demand valve, of this analgesia is that at temperatures below -7°C inhalation tubing, an individual patient filter and the two constituent gases separate, resulting in the either a mask or individual patient mouthpiece potential outcome of hypoxia because an oxygen-rich (Figure 3). The demand valve ensures that the gas mixture is inhaled initially (Litwin, 2010). Another does not flow unless a negative pressure is achieved, disadvantage of having to have a constant supply of i.e. the patient inhales through the closed circuit. N2O/O2 available is that when a patient is required to move from one department to another, e.g. Figure 2. Entonox cylinder. emergency department to radiology, he/she has to be escorted by a porter who also has to transport a large cylinder of gas. Similarly, storage and replacement Figure 3. Mouthpiece used to deliver Entonox. of these large cylinders can be a logistical problem A single dose of 3 ml of methoxyflurane provides for many emergency departments. approximately 25–30 minutes of effective analgesia if used continuously and up to 1 hour if used Methoxyflurane intermittently. An additional dose of 3 ml (total of The alternative inhaled patient-controlled analgesia 6 ml) can be administered subsequently, providing up is methoxyflurane. Methoxyflurane is an almost to 2 hours of effective analgesia (Galen Ltd, 2016). It colourless liquid belonging to the fluorinated is self-administered under observation (with assistance hydrocarbon group of volatile anaesthetic agents. if necessary) using the hand-held Penthrox inhaler. It has the characteristic pungent but not unpleasant At the recommended dose, anaesthesia cannot occur. odour of the halogenated anaesthetics (Coffey et The Penthrox inhaler is a small, lightweight, al, 2014). Initially used as an anaesthetic agent, it cylindrical polyethylene device, approximately fell out of favour with the introduction of newer, 15 cm long. It has a distinctive green colour and non-gaseous anaesthetic techniques and because of effectively looks like a large green whistle. At one concerns about renal toxicity (Crandell et al, 1966). end is a mouthpiece, near which is sited an activated However, methoxyflurane has analgesic properties carbon chamber which has a dilutor hole on top not shared by other halogenated anaesthetics. At which, when covered with the patient’s index finger, sub-anaesthetic levels it is a safe and very effective allows a higher concentration of methoxyflurane analgesic (Tomi et al, 1993). to be inhaled. Internally, the device contains a polypropylene
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