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Canadian Urological Association Journal... Apr 2024Methoxyflurane (MEOF) (Penthrox™) is an inhaled, self-administered, non-opioid analgesic approved by Health Canada for the short-term relief of moderate to severe...
INTRODUCTION
Methoxyflurane (MEOF) (Penthrox™) is an inhaled, self-administered, non-opioid analgesic approved by Health Canada for the short-term relief of moderate to severe acute pain associated with trauma or interventional medical procedures. In this pilot study, we evaluated the feasibility of using MEOF as an anesthetic agent in 11 patients undergoing outpatient cystoscopic procedures.
METHODS
The average duration of the procedure was 24 (range 20-35) minutes and this included 10 minutes of administration time of the drug and five minutes of wait time before the procedure. The average monitoring time from start to end of the procedure was 23 (range 20-35) minutes and this included 15 minutes of monitoring post-procedure. On a scale of 0-10, patients on average rated the pain 4/10 (standard deviation [SD] 2.6).
RESULTS
Global performance was on average 3/4 (SD 1.3) for the patients and 3/4 (SD 1.1) for the operator. Of the 11 patients, four reported adverse events; two experienced euphoria, one experienced dizziness, and one was unable to tolerate the medication. Two patients noted their adverse events to be of moderate intensity, while the other two were of mild intensity. None of the adverse events was deemed serious.
CONCLUSIONS
Our findings in this pilot study provide proof of principle for the design of a randomized control trial to evaluate MEOF as an anesthetic in an outpatient cystoscopic procedural setting. As more urologic procedures are being performed in an outpatient setting, this may offer significant clinical benefit.
PubMed: 38587974
DOI: 10.5489/cuaj.8676 -
JBMR Plus May 2024Skeletal fluorosis is rare and occurs secondary to chronic high amounts of fluoride consumption, manifesting as diffuse osteosclerosis, skeletal pain, connective tissue...
UNLABELLED
Skeletal fluorosis is rare and occurs secondary to chronic high amounts of fluoride consumption, manifesting as diffuse osteosclerosis, skeletal pain, connective tissue calcification, and increased fracture risk. Methoxyflurane is a volatile, fluorinated hydrocarbon-inhaled analgesic, and the maximum recommended dose is 15 mL (99.9 % w/w) per wk. A rodent study found increased skeletal fluoride after methoxyflurane exposure. However, skeletal fluorosis secondary to methoxyflurane use in humans has rarely been reported. We present the case of a 47-yr-old female with diffuse osteosclerosis secondary to fluorosis from methoxyflurane use for chronic pain, presenting with 3 yr of generalized bony pain and multiple fragility fractures. Lumbar spine BMD was elevated. CT and radiographs demonstrated new-onset marked diffuse osteosclerosis, with calcification of interosseous membranes and ligaments, and a bone scan demonstrated a grossly increased uptake throughout the skeleton. Biochemistry revealed an elevated alkaline phosphatase and bone turnover markers, mild secondary hyperparathyroidism with vitamin D deficiency, and mild renal impairment. Zoledronic acid, prescribed for presumed Paget's disease, severely exacerbated bony pain. Urinary fluoride was elevated (7.3 mg/L; reference range < 3.0 mg/L) and the patient revealed using methoxyflurane 9 mL per wk for 8 yr for chronic pain. A decalcified bone biopsy revealed haphazardly arranged cement lines and osteocytes lacunae and canaliculi, which was consistent with an osteosclerotic process. Focal subtle basophilic stippling around osteocyte lacunae was suggestive of fluorosis. Although fluorosis is not a histological diagnosis, the presence of compatible histology features was supportive of the diagnosis in this case with clinical-radiological-pathological correlation. Skeletal fluorosis should be considered as a cause of acquired diffuse osteosclerosis. Methoxyflurane should not be recommended for chronic pain. The risk of repeated low-dose exposure to fluoride from methoxyflurane use as analgesia may be greater than expected, and the maximum recommended dose for methoxyflurane may require re-evaluation to minimize skeletal complications.
ABBREVIATED ABSTRACT
Skeletal fluorosis is rare and occurs secondary to chronic high amounts of fluoride consumption, manifesting as diffuse osteosclerosis, skeletal pain, connective tissue calcification, and increased fracture risk. We present the case of a 47-yr-old female with skeletal fluorosis secondary to long-term methoxyflurane for chronic pain. The risk of repeated low-dose exposure to fluoride from methoxyflurane use for analgesia may be greater than expected, and the maximum recommended dose for methoxyflurane may require re-evaluation to minimize skeletal complications.
PubMed: 38577522
DOI: 10.1093/jbmrpl/ziae032 -
Cureus Feb 2024Background Penthrox is a handheld inhaler that administers methoxyflurane. Its use is approved for analgesia in moderate-to-severe trauma-related pain in adults in the...
Background Penthrox is a handheld inhaler that administers methoxyflurane. Its use is approved for analgesia in moderate-to-severe trauma-related pain in adults in the ED. The literature currently lacks methodologically robust qualitative data on individual patient experiences. Using a structured qualitative study, we set out to address this shortcoming. Methods Five patients were selected as a focus group to identify key themes they felt were important to explore, and these were included in the questionnaire design. We retrospectively identified all uses of Penthrox in the ED from June to August 2021. Qualitative data was gathered using the Trickett short interview method, and responses were grouped into positive and negative descriptors. In addition, quantitative data concerning their experience using the 5-point Likert scale was also gathered. Results A total of 101 participants responded to the questionnaire. Penthrox was utilised mainly for the manipulation of fractures, most commonly those of the ankle and wrist. Around 90% reported an overall satisfaction of ≥ good, and 97% reported the ease of use to be ≥ good. Its analgesic effectiveness was rated as excellent by 52%, and ≥ good by 89%. The most reported side effects were drowsiness (13%) and nausea (7%). The majority reported no side effects (74%). About 94% of the participants said they would take it again if required. An NVivo word cloud (Lumivero, Denver, CO, USA) was created visually, confirming an overall positive experience amongst the patients. Conclusions This study shows that Penthrox is a well-tolerated and user-friendly means of alleviating trauma-related pain in the ED. It highlights the importance of taking into consideration the individual patient journey alongside robust evidence-based data on safety and efficacy for the development of a holistic treatment.
PubMed: 38445124
DOI: 10.7759/cureus.53537 -
The Canadian Journal of Urology Feb 2024Minimally invasive surgery techniques (MIST) have become newly adopted in urological care. Given this, new analgesic techniques are important in optimizing patient...
Minimally invasive surgery techniques (MIST) have become newly adopted in urological care. Given this, new analgesic techniques are important in optimizing patient outcomes and resource management. Rezūm treatment (RT) for BPH has emerged as a new MIST with excellent patient outcomes, including improving quality of life (QoL) and International Prostate Symptom Scores (IPSSs), while also preserving sexual function. Currently, the standard analgesic approach for RT involves a peri-prostatic nerve block (PNB) using a transrectal ultrasound (TRUS) or systemic sedation anesthesia. The TRUS approach is invasive, uncomfortable, and holds a risk of infection. Additionally, alternative methods such as, inhaled methoxyflurane (Penthrox), nitric oxide, general anesthesia, as well as intravenous (IV) sedation pose safety risks or mandate the presence of an anesthesiology team. Transurethral intraprostatic anesthesia (TUIA) using the Schelin Catheter (ProstaLund, Lund, Sweden) (SC) provides a new, non-invasive, and efficient technique for out-patient, office based Rezūm procedures. Through local administration of an analgesic around the prostate base, the SC has been shown to reduce pain, procedure times, and bleeding during MISTs. Herein, we evaluated the analgesic efficacy of TUIA via the SC in a cohort of 10 patients undergoing in-patient RT for BPH.
Topics: Male; Humans; Quality of Life; Prostatic Hyperplasia; Anesthesiology; Transurethral Resection of Prostate; Nerve Block; Methoxyflurane; Catheters; Analgesics; Treatment Outcome
PubMed: 38401260
DOI: No ID Found -
Trials Jan 2024Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to manage anxiety in adults with an autism diagnosis. However, their effectiveness and adverse...
Sertraline for anxiety in adults with a diagnosis of autism (STRATA): study protocol for a pragmatic, multicentre, double-blind, placebo-controlled randomised controlled trial.
BACKGROUND
Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to manage anxiety in adults with an autism diagnosis. However, their effectiveness and adverse effect profile in the autistic population are not well known. This trial aims to determine the effectiveness and cost-effectiveness of the SSRI sertraline in reducing symptoms of anxiety and improving quality of life in adults with a diagnosis of autism compared with placebo and to quantify any adverse effects.
METHODS
STRATA is a two-parallel group, multi-centre, pragmatic, double-blind, randomised placebo-controlled trial with allocation at the level of the individual. It will be delivered through recruiting sites with autism services in 4 regional centres in the United Kingdom (UK) and 1 in Australia. Adults with an autism diagnosis and a Generalised Anxiety Disorder Assessment (GAD-7) score ≥ 10 at screening will be randomised 1:1 to either 25 mg sertraline or placebo, with subsequent flexible dose titration up to 200 mg. The primary outcome is GAD-7 scores at 16 weeks post-randomisation. Secondary outcomes include adverse effects, proportionate change in GAD-7 scores including 50% reduction, social anxiety, obsessive-compulsive symptoms, panic attacks, repetitive behaviours, meltdowns, depressive symptoms, composite depression and anxiety, functioning and disability and quality of life. Carer burden will be assessed in a linked carer sub-study. Outcome data will be collected using online/paper methods via video call, face-to-face or telephone according to participant preference at 16, 24 and 52 weeks post-randomisation, with brief safety checks and data collection at 1-2, 4, 8, 12 and 36 weeks. An economic evaluation to study the cost-effectiveness of sertraline vs placebo and a QuinteT Recruitment Intervention (QRI) to optimise recruitment and informed consent are embedded within the trial. Qualitative interviews at various times during the study will explore experiences of participating and taking the trial medication.
DISCUSSION
Results from this study should help autistic adults and their clinicians make evidence-based decisions on the use of sertraline for managing anxiety in this population.
TRIAL REGISTRATION
ISRCTN, ISRCTN15984604 . Registered on 08 February 2021. EudraCT 2019-004312-66. ANZCTR ACTRN12621000801819. Registered on 07 April 2021.
Topics: Adult; Humans; Anxiety; Anxiety Disorders; Autistic Disorder; Multicenter Studies as Topic; Quality of Life; Randomized Controlled Trials as Topic; Sertraline; Pragmatic Clinical Trials as Topic
PubMed: 38212784
DOI: 10.1186/s13063-023-07847-3 -
Strategies in Trauma and Limb... 2023External fixator (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of...
INTRODUCTION
External fixator (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under general anaesthesia in an operating theatre. This practice is resource-intensive and limits the amount of time available for other surgical cases in the operating theatre. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate the EF removal in an outpatient setting.
DESIGN AND METHODS
This prospective case series evaluated the first 50 consecutive cases of EF removal in the outpatient clinic between 10/06/22 and 03/02/23. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirements and then were asked to evaluate their experience and perceived pain using the visual analogue scale (VAS).
RESULTS
Fifty patients were included in the study. The mean age was 46.8 years (range 21-85 years). About 54% of the patients were male patients ( = 27). Post-procedure, all patients indicated positive satisfaction ratings, each participant responded as either ( = 6), ( = 24) or ( = 20). In addition, 90% of the participants reported that they would opt for this method of EF removal again in future. The VAS for pain immediately following completion of the procedure was low, with a mean score of 0.36 (range 0-4), where a score of 0 = 'No pain', and 10 = 'worst pain possible'. The median score was 0.
CONCLUSION
We present the first description of outpatient EF removal using regional anaesthesia, with a prospective case series of 50 fully conscious patients from whom the EF was removed. This novel technique is likely to be cost-effective, reproducible, and safe. This technique reduces the burden of EF removal from an operating list and also improves the patient's experience when compared with other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this technique also demonstrates a method of improving environmental sustainability.
HOW TO CITE THIS ARTICLE
Williams LM, Stamps G, Peak H, . Circular External Fixator Removal in the Outpatient Clinic Using Regional Anaesthesia: A Pilot Study of A Novel Approach. Strategies Trauma Limb Reconstr 2023;18(1):7-11.
PubMed: 38033926
DOI: 10.5005/jp-journals-10080-1582 -
Heliyon Nov 2023To describe the types of analgesic medications administered to patients who were attended by ambulance on recreational trails while mountain biking or hiking and report...
OBJECTIVE
To describe the types of analgesic medications administered to patients who were attended by ambulance on recreational trails while mountain biking or hiking and report on the reduction in pain by these agents.
METHODS
This is a retrospective cohort study of patients attended by ambulance (2015-2021) after mountain biking or hiking, on Western Australia (WA) trails. All data were extracted from electronic patient care records created by ambulance personnel who attended the patient. We compared patient and case characteristics between mountain bikers and hikers and the reduction in pain scores achieved by different analgesics.
RESULTS
A total of 717 patients were included. Paramedics reported traumatic aetiology for mountain bikers in 92 % of cases and hikers in 58 % of cases. A pain score out of 10 was recorded for 538 (75 %) patients. The median (inter-quartile range) initial pain score was 6 (2-8) and the median final pain score was 3 (1-5). Around 48 % of these 538 patients reported ≥25 % reduction in their pain score. A reduction of ≥25 % in their pain score was greatest in those patients who received intravenous fentanyl (81 %), followed by patients administered multiple analgesics (72 %) and methoxyflurane only (52 %). Even 37 % of 134 patients who received no analgesia still reported ≥25 % reduction in their pain score by hospital arrival.
CONCLUSION
Trauma was the most common reason mountain bikers and hikers on trails called an ambulance and a large proportion of these patients were in pain on ambulance arrival. Further work assessing the effectiveness of safe, non-opioid analgesics, additional to methoxyflurane, is needed to ensure non-registered practitioners such as first aid providers and event medical teams can offer suitable safe analgesics to these patients. Additionally, among patients given no pharmacological analgesic agent, almost half still achieved a >25 % reduction in their pain scores which reiterates the importance of non-pharmacological pain reduction strategies.
PubMed: 38027834
DOI: 10.1016/j.heliyon.2023.e21717 -
Strategies in Trauma and Limb... 2023Methoxyflurane has excellent analgesic properties and is approved for use in the United Kingdom and Ireland since 2015. It is currently used in emergency departments for...
INTRODUCTION
Methoxyflurane has excellent analgesic properties and is approved for use in the United Kingdom and Ireland since 2015. It is currently used in emergency departments for analgesia during fracture reductions. During the COVID-19 pandemic, with theatre access severely restricted, Penthrox® had the potential to provide adequate pain relief to aid frame and wire removal in the clinic setting.
MATERIALS AND METHODS
Patients presenting to the limb reconstruction service elective clinic and requiring frame removal or minor procedures were included in the study. Patients with renal, cardiac or hepatic disease, a history of sensitivity to fluorinated anaesthetic agents and those on any nephrotoxic or enzyme-inducing drugs were excluded. All procedures were performed in an appropriate isolated room in the clinic. Patient demographics, procedure details, visual analogue score, Richmond Agitation Scale and patient satisfaction were recorded.
RESULTS
A total of 39 patients were included in the study of which 17 had Ilizarov frames removed, 10 had hexapod removals, nine had heel rings removed and three had an external fixator removed. Eleven patients received additional pain relief in the form of oral analgesia. All patients were satisfied or very satisfied with the experience. One patient required a general anaesthetic for the removal of a wire that could not be removed in the clinic due to bony overgrowth.
CONCLUSION
Patient satisfaction was very high (>95%), and it was possible to perform frame removals and minor procedures in the clinic environment during the COVID-19 pandemic. We see potential for regular use of Penthrox® in the future for the removal of external fixation outside of the operating theatre.
CLINICAL SIGNIFICANCE
Penthrox as an analgesic for frame adjustments and removals is safe and has the potential for significant financial savings for the National Health Service (NHS).
HOW TO CITE THIS ARTICLE
Debuka E, Birkenhead P, Shah S, . Penthrox® (Methoxyflurane) as an Analgesic for Removal of Circular External Fixators and Minor Procedures during the COVID-19 Pandemic. Strategies Trauma Limb Reconstr 2023;18(2):82-86.
PubMed: 37942432
DOI: 10.5005/jp-journals-10080-1587 -
Wilderness & Environmental Medicine Dec 2023The provision of analgesia in mass casualty incidents has traditionally been viewed as low-priority and reserved for later stages of care. Poor pain management is...
The provision of analgesia in mass casualty incidents has traditionally been viewed as low-priority and reserved for later stages of care. Poor pain management is commonplace in trauma victims, and inadequate acute pain management can hinder evacuation efforts and may lead to the development of chronic pain and posttraumatic stress disorder. New, safe, and simple methods for administering quality analgesia have proven to be safe and effective in the prehospital setting and, as such, could easily be implemented into mass casualty incident protocols and allow for analgesia at earlier stages in such incidents, thereby improving patient care.
Topics: Humans; Mass Casualty Incidents; Emergency Medical Services; Pain Management; Pain; Analgesia
PubMed: 37923685
DOI: 10.1016/j.wem.2023.09.003 -
Trials Sep 2023Pre-hospital pain management has traditionally been performed with intravenous (IV) morphine, but oligoanalgesia remain a recognized problem. Pain reduction is essential...
Comparison of three regimens with inhalational methoxyflurane versus intranasal fentanyl versus intravenous morphine in pre-hospital acute pain management: study protocol for a randomized controlled trial (PreMeFen).
BACKGROUND
Pre-hospital pain management has traditionally been performed with intravenous (IV) morphine, but oligoanalgesia remain a recognized problem. Pain reduction is essential for patient satisfaction and is regarded as a measure of successful treatment. We aim to establish whether non-invasive methods such as inhalation of methoxyflurane is non-inferior to intranasal fentanyl or non-inferior to the well-known IV morphine in the pre-hospital treatment of acute pain.
METHOD/DESIGN
The PreMeFen study is a phase three, three-armed, randomized, controlled, non-inferiority trial to compare three regimens of analgesics: inhalation of methoxyflurane and intranasal (IN) fentanyl versus IV morphine. It is an open-label trial with a 1:1:1 randomization to the three treatment groups. The primary endpoint is the change in pain numeric rating scale (NRS) (0-10) from baseline to 10 min after start of investigational medicinal product administration (IMP). The non-inferiority margin was set to 1.3, and a sample size of 270 patients per protocol (90 in each treatment arm) will detect this difference with 90% power.
DISCUSSION
We chose a study design with comparison of analgesic regimens rather than fixed doses because of the substantial differences in drug characteristics and for the results to be relevant to inform policymakers in the pre-hospital setting. We recognize that easier administration of analgesics will lead to better pain management for many patients if the regimens are as good as the existing, and hence, we chose a non-inferiority design. The primary endpoint, the change in pain (NRS) after 10 min, is set to address the immediate need of pain reduction for patients with acute prehospital pain. On a later stage, more analgesic methods are often available. PreMeFen is a non-inferiority randomized controlled trial comparing three analgesic regimens aiming to establish whether inhalation of methoxyflurane or intranasal fentanyl is as good as IV morphine for fast reduction of acute pain in the prehospital setting.
Topics: Humans; Acute Pain; Fentanyl; Morphine; Methoxyflurane; Hospitals; Randomized Controlled Trials as Topic
PubMed: 37670364
DOI: 10.1186/s13063-023-07590-9