Nalbuphine and slow release morphine
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《英国医生杂志》
1 Accident and Emergency Department, Derriford Hospital, Plymouth PL6 8DH
Correspondence to: J Smith jasonesmith@doctors.org.uk
Introduction
A 60 year old woman fell in her garden, injuring her right leg. She had a history of renal cell carcinoma with cerebral and bony metastases, and was taking 90 mg of slow release morphine tablets twice a day to control her pain. Ambulance paramedics diagnosed a fractured femur, and her prehospital care included giving her 30 mg of nalbuphine intravenously for analgesia. She became agitated, and on arrival in the emergency department she was unable to keep still; her agitation was severe enough to cause involuntary movements of all four limbs, including the injured right leg. On questioning, she complained that the main problem at that stage was agitation, which was causing the pain in her leg to be much worse.
Examination and x ray imaging confirmed a closed fracture of the mid-shaft of the right femur, and subsequent radiological investigation showed evidence of a pathological fracture. We saw no neurovascular deficit. The woman's symptoms of agitation along with tachycardia, hypertension, and sweating were typical of opiate withdrawal.
Initially, her management was complicated by resistance to intravenous opiate analgesia (she was given incremental doses of intravenous morphine for her pain to a total of 40 mg but with little effect), and she required a femoral nerve block and application of a traction splint to control her symptoms. Also, her agitation was controlled by giving intravenous lorazepam, titrated to achieve control of her involuntary movements—a total 4 mg was given in 30 minutes. She remained agitated, although pain free, for about 4 hours after taking the nalbuphine. Subsequently she went on to have internal fixation of her femoral fracture and made an uneventful recovery from her operation.
Discussion
Lo MW, Lee FH, Schary WL, Whitney CC Jr. The pharmacokinetics of intravenous, intramuscular, and subcutaneous nalbuphine in healthy subjects. Eur J Clin Pharmacol 1987;33: 297-301.
Stene JK, Stofberg L, MacDonald G, Myers RA, Ramzy A, Burns B. Nalbuphine analgesia in the prehospital setting. Am J Emerg Med 1988;6: 634-9.
Chambers JA, Guly HR. Prehospital intravenous nalbuphine administered by paramedics. Resuscitation 1994;27: 153-8.
Johnson GS, Guly HR. The effect of pre-hospital administration of intravenous nalbuphine on on-scene times. J Accid Emerg Med 1995;12: 20-2.
Houlihan KP, Mitchell RG, Flapan AD, Steedman DJ. Excessive morphine requirements after pre-hospital nalbuphine analgesia. J Accid Emerg Med 1999;16: 29-31.
Robinson N, Burrows N. Excessive morphine requirements after pre-hospital nalbuphine analgesia. J Accid Emerg Med 1999;16: 392.
Preston KL, Bigelow GE, Liebson IA. Antagonist effects of nalbuphine in opioid-dependent human volunteers. J Pharmacol Exp Ther 1989;248: 929-37.(Jason Smith, specialist r)
Correspondence to: J Smith jasonesmith@doctors.org.uk
Introduction
A 60 year old woman fell in her garden, injuring her right leg. She had a history of renal cell carcinoma with cerebral and bony metastases, and was taking 90 mg of slow release morphine tablets twice a day to control her pain. Ambulance paramedics diagnosed a fractured femur, and her prehospital care included giving her 30 mg of nalbuphine intravenously for analgesia. She became agitated, and on arrival in the emergency department she was unable to keep still; her agitation was severe enough to cause involuntary movements of all four limbs, including the injured right leg. On questioning, she complained that the main problem at that stage was agitation, which was causing the pain in her leg to be much worse.
Examination and x ray imaging confirmed a closed fracture of the mid-shaft of the right femur, and subsequent radiological investigation showed evidence of a pathological fracture. We saw no neurovascular deficit. The woman's symptoms of agitation along with tachycardia, hypertension, and sweating were typical of opiate withdrawal.
Initially, her management was complicated by resistance to intravenous opiate analgesia (she was given incremental doses of intravenous morphine for her pain to a total of 40 mg but with little effect), and she required a femoral nerve block and application of a traction splint to control her symptoms. Also, her agitation was controlled by giving intravenous lorazepam, titrated to achieve control of her involuntary movements—a total 4 mg was given in 30 minutes. She remained agitated, although pain free, for about 4 hours after taking the nalbuphine. Subsequently she went on to have internal fixation of her femoral fracture and made an uneventful recovery from her operation.
Discussion
Lo MW, Lee FH, Schary WL, Whitney CC Jr. The pharmacokinetics of intravenous, intramuscular, and subcutaneous nalbuphine in healthy subjects. Eur J Clin Pharmacol 1987;33: 297-301.
Stene JK, Stofberg L, MacDonald G, Myers RA, Ramzy A, Burns B. Nalbuphine analgesia in the prehospital setting. Am J Emerg Med 1988;6: 634-9.
Chambers JA, Guly HR. Prehospital intravenous nalbuphine administered by paramedics. Resuscitation 1994;27: 153-8.
Johnson GS, Guly HR. The effect of pre-hospital administration of intravenous nalbuphine on on-scene times. J Accid Emerg Med 1995;12: 20-2.
Houlihan KP, Mitchell RG, Flapan AD, Steedman DJ. Excessive morphine requirements after pre-hospital nalbuphine analgesia. J Accid Emerg Med 1999;16: 29-31.
Robinson N, Burrows N. Excessive morphine requirements after pre-hospital nalbuphine analgesia. J Accid Emerg Med 1999;16: 392.
Preston KL, Bigelow GE, Liebson IA. Antagonist effects of nalbuphine in opioid-dependent human volunteers. J Pharmacol Exp Ther 1989;248: 929-37.(Jason Smith, specialist r)