Morphine Kills in Severe Decompensated Heart Failure Background: Intravenous morphine use has actually been reported in almost among 7 patients hospitalized with intense decompensated heart failure( ADHF ). I have anecdotally, even seen doctors providing morphine as a “first-line” agent: Nitroglycerine, Non-Invasive Favorable Pressure Ventilation (NIPPV), and Morphine. There is remarkably little evidence supporting regular usage of morphine in ADHF, and no major American cardiology or emergency medicine society has really backed or published any recommendations on the treatment of ADHF with morphine.Most of us were taught the acronym “MONA,” Morphine, Oxygen, Nitroglycerin, and Aspirin for treatment of acute lung edema and typically, estimated physiologic/clinical beliefs for the usage of morphine in ADHF are: advantageous hemodynamic results, handling anxiety/agitation in air hunger, reduction in preload, and perhaps to a lesser degree, afterload, and finally, reducing heart rate. We need to also consider the usage of morphine in a framework of risk and benefit. For example intravenous morphine can likewise have some deleterious effects like triggering central nerve system suppression, ventilatory anxiety, and hypotension.The Acute Decompensated Heart Failure National Computer System Registry(ADHERE)is a large multicenter windows registry that tape-records information from clients hospitalized with ADHF with more than 175,000 hospitalizations from over 250 hospitals across America. To be included in this windows registry clients must be > 18years of age, confessed to an acute care hospital and get a discharge medical diagnosis of ADHF. Information for this pc registry are gathered by retrospective chart evaluation and got in by means of an electronic web-based case report type for all successive eligible patients.What Study are we Discussing?Peacock WF et al. Morphine and Results in Acute Decompensated Cardiac Arrest: An ADHERE Analysis. Emerg Medication J 2008; 25: 205
— 209. PMID: 18356349 What They Did: Retrospective analysis of the ADHERE Computer registry Patients stratified into 2 accomplices
- : Whether or not they received intravenous morphine
- Results: Need for Mechanical Ventilation Usage of Inotropes and Vasodilators Typical Hospitalization(
Days)Need
- for ICU Admission Death Outcomes:147,362 patient cases were in the ADHERE windows registry at December 2004 20,782 (14.1%
- )received IV morphine 126,580(
- 85.9%)did
not receive IV morphine IV
- Morphine vs No Morphine in ADHF Outcome IV Morphine No IV Morphine Need
- for IV Diuretic 90.9%87.6% Time to IV Diuretic
- ( hr) 2.0 2.5 Required for Vasoactive Representative 48.5%24.9%Time to Vasoactive Representative(hr )3.8 4.8 Required for Inotropes 23.3%9.9%Gotten
CPR 3.1%
0.9 %Required Cardiac Catheterization
16.1 %8.9 %Required Mechanical Ventilation
15.4%
2.8% Required Initiation of Hemodialysis 3.0%
1.2
%Death 13.0%2.4% Hospitalization Length of Stay(days)
5.6 4.2 ICU Admission Rate 38.7%14.4%ICU Length of Stay(days
)3.0 2.2
Strengths
: The authors controlled for factors
such as BUN,
systolic BP, age
, creatinine, dyspnea at rest, persistent
dialysis,
heart rate
, inotrope
or vasodilator usage, elevated troponin, ejection portion, use of morphine as adjunct for endotracheal intubation, and throughout all threat groups the usage
of morphine
was associated with significantly increased death that was statistically considerable Likewise, to control for the reality
that repeat
- hospitalizations vs unique patients could have taken place, the mortality analysis was duplicated taking a look at unique patients that made for a smaller final analysis of 30,276 patients and the increased mortality connected with morphine usage in ADHF stayed statistically significant.Limitations: This was a retrospective research study and for that reason restricts the findings of this study to that of hypothesis generation and not conclusive proof that morphine triggers an increased threat of harm in ADHF. This research study reveals an increased association of death danger and should raise concern about the usage of morphine in the armamentarium of medical treatment for the management of ADHF. There are no large randomized regulated trials demonstrating security or efficacy for morphine in ADHF, however this research study can only show association in between using morphine and death and not causation.The morphine group had some baseline differences vs the non-morphine group: Greater prevalence of rest dyspnea, congestion on CXR, rales, and raised troponin. This might imply that patients getting morphine represent an associate with more extreme health problem and baseline and for that reason would be predicted to have a greater mortality. However, even after comprehensive risk adjustment there was still a statistically significant relationship between increased death and morphine as evidenced by high chances ratios and considerable p values.There was a boost in the association in between mechanical ventilation and morphine usage, but due to the restrictions of the research study, one can not figure out if morphine resulted in endotracheal intubation or if it was utilized as a sedative during the treatment(i.e. the timing of morphine use was not collected in ADHERE). The computer registry only taped if patients got morphine, however the total dose used, the timing of its administration, and the accurate temporal relationships to negative events might not be determined There was no long-lasting follow-up in this study with findings being limited to in-hospital problems just. Effects, such as rehospitalization after health center discharge can not be determined.Discussion: Reducing filling pressures are an essential objective in the early treatment of ADHF and it is frequently presumed that morphine supplies benefit in ADHF by reducing venous tone and pressure, therefore increasing peripheral venous pooling, all of which decline heart filling pressure. There has actually been an extremely small study nevertheless by Timmis AD et al [2], that showed the administration of morphine leads to decrease in both systemic blood pressure and heart rate, however left ventricular filling pressures were unchanged.Approximately 80%of clients with ADHF initially present to the emergency department and many get here by ambulance. There are not that lots of studies taking a look at making use of prehospital morphine early in the
treatment of
- ADHF. There is one study by Sacchetti et al [3] that did report an increase in intubation rates and longer remain in the ICU if morphine was used.Author Conclusion: In this initial computer registry analysis of ADHF, using morphine was associated with a longer remain in the health center, more frequent and longer ICU admissions, and a greater threat of in-hospital mortality.Clinical Take House Point: Using IV morphine in ADHF is connected with increased morbidity and death and must be abandoned totally as a”first-line” medical therapy. If you wish to decrease diastolic filling pressures in ADHF from venous pooling just utilize nitroglycerin.References: Post Peer Reviewed By: Anand Swaminathan(Twitter: @EMSwami )The following 2 tabs alter content below.Emergency Doctor at Greater San Antonio Emergency Situation Physicians( GSEP)Creator & Founder of R.E.B.E.L. EM Tags:,,
Related Post
- : Whether or not they received intravenous morphine
- Results: Need for Mechanical Ventilation Usage of Inotropes and Vasodilators Typical Hospitalization(
Days)Need
- for ICU Admission Death Outcomes:147,362 patient cases were in the ADHERE windows registry at December 2004 20,782 (14.1%
- )received IV morphine 126,580(
- 85.9%)did
not receive IV morphine IV
- for IV Diuretic 90.9%87.6% Time to IV Diuretic
- ( hr) 2.0 2.5 Required for Vasoactive Representative 48.5%24.9%Time to Vasoactive Representative(hr )3.8 4.8 Required for Inotropes 23.3%9.9%Gotten
CPR 3.1% 0.9 %Required Cardiac Catheterization 16.1 %8.9 %Required Mechanical Ventilation 15.4% 2.8% Required Initiation of Hemodialysis 3.0% 1.2 %Death 13.0%2.4% Hospitalization Length of Stay(days) 5.6 4.2 ICU Admission Rate 38.7%14.4%ICU Length of Stay(days )3.0 2.2 Strengths : The authors controlled for factors such as BUN, systolic BP, age , creatinine, dyspnea at rest, persistent dialysis, heart rate , inotrope or vasodilator usage, elevated troponin, ejection portion, use of morphine as adjunct for endotracheal intubation, and throughout all threat groups the usage of morphine was associated with significantly increased death that was statistically considerable Likewise, to control for the reality that repeat
- hospitalizations vs unique patients could have taken place, the mortality analysis was duplicated taking a look at unique patients that made for a smaller final analysis of 30,276 patients and the increased mortality connected with morphine usage in ADHF stayed statistically significant.Limitations: This was a retrospective research study and for that reason restricts the findings of this study to that of hypothesis generation and not conclusive proof that morphine triggers an increased threat of harm in ADHF. This research study reveals an increased association of death danger and should raise concern about the usage of morphine in the armamentarium of medical treatment for the management of ADHF. There are no large randomized regulated trials demonstrating security or efficacy for morphine in ADHF, however this research study can only show association in between using morphine and death and not causation.The morphine group had some baseline differences vs the non-morphine group: Greater prevalence of rest dyspnea, congestion on CXR, rales, and raised troponin. This might imply that patients getting morphine represent an associate with more extreme health problem and baseline and for that reason would be predicted to have a greater mortality. However, even after comprehensive risk adjustment there was still a statistically significant relationship between increased death and morphine as evidenced by high chances ratios and considerable p values.There was a boost in the association in between mechanical ventilation and morphine usage, but due to the restrictions of the research study, one can not figure out if morphine resulted in endotracheal intubation or if it was utilized as a sedative during the treatment(i.e. the timing of morphine use was not collected in ADHERE). The computer registry only taped if patients got morphine, however the total dose used, the timing of its administration, and the accurate temporal relationships to negative events might not be determined There was no long-lasting follow-up in this study with findings being limited to in-hospital problems just. Effects, such as rehospitalization after health center discharge can not be determined.Discussion: Reducing filling pressures are an essential objective in the early treatment of ADHF and it is frequently presumed that morphine supplies benefit in ADHF by reducing venous tone and pressure, therefore increasing peripheral venous pooling, all of which decline heart filling pressure. There has actually been an extremely small study nevertheless by Timmis AD et al [2], that showed the administration of morphine leads to decrease in both systemic blood pressure and heart rate, however left ventricular filling pressures were unchanged.Approximately 80%of clients with ADHF initially present to the emergency department and many get here by ambulance. There are not that lots of studies taking a look at making use of prehospital morphine early in the
treatment of
- ADHF. There is one study by Sacchetti et al [3] that did report an increase in intubation rates and longer remain in the ICU if morphine was used.Author Conclusion: In this initial computer registry analysis of ADHF, using morphine was associated with a longer remain in the health center, more frequent and longer ICU admissions, and a greater threat of in-hospital mortality.Clinical Take House Point: Using IV morphine in ADHF is connected with increased morbidity and death and must be abandoned totally as a”first-line” medical therapy. If you wish to decrease diastolic filling pressures in ADHF from venous pooling just utilize nitroglycerin.References: Post Peer Reviewed By: Anand Swaminathan(Twitter: @EMSwami )The following 2 tabs alter content below.Emergency Doctor at Greater San Antonio Emergency Situation Physicians( GSEP)Creator & Founder of R.E.B.E.L. EM Tags:,,
Related Post