RETRAMAL : étude épidémiologique rétrospective de l’utilisation extrahospitalière des opioïdes à visée antalgique au Service Mobile d'Urgence et de Réanimation (SMUR) de Bordeaux en 2016

Abstract : Background: Moderate-to-severe pain defined by a Digital Scale (EN) ≥6 or a Visual Analogue Scale (VAS) ≥6 are common in the pre-hospital setting, and their timely and effective management is a priority. The use of an opioid analgesic is recommended as first line in this context. Morphine is the opioid of choice for fast and safe analgesia, but it is not the only opioid available for intervention. The context of pre-hospital oligo-analgesia associated with discussions of opioid selection and use makes it necessary to describe the modalities of opioid use. Objectives: The main objective was to describe the use of opioids in the management of pre-hospital pain. Our secondary objective was to evaluate the efficacy of an algesic management. Methods: We conducted a retrospective descriptive study from January 1st to December 31st, 2016 on the Mobile Emergency and Resuscitation Service (SMUR) of the University Hospital Center (CHU) in Bordeaux. All conscious patients (G≥13), with no age limit, receiving a first opioid treatment with morphine or sufentanil during an intervention of a SMUR team by an emergency physician or anesthesiologist-resuscitator from Bordeaux were included. Results: One thousand two hundred and fifty-four patients were analyzed, 537 were included, intravenous morphine was used in 93% of the procedures, the average initial bolus was 4.2mg (± 1.7mg), the mean total dose was administered was 7.2 mg (± 3.6 mg). The total dose of morphine was higher in a context of traumatic pain with an average total dose of 7.8 mg (p = 0.0001). Only 43.5% of patients received a first bolus of 2 or 3 milligrams, 10.8% of patients under 60 kg received a bolus of 2mg, 29.5% of patients over 60 kg received a bolus of 3mg . The mean dose of morphine was 0.06 mg.kg-1 (N = 125), 34.6% of patients received a dose of 0.05 mg / kg and 19.3% received a dose of 0.1 mg .kg-1. Sufentanil was used for analgesic purposes in spontaneous ventilation in 23 patients (4.3%). The average weight dose used was 0.15 μg.kg-1. Morphine was associated with Ketamine in 13.9% with an average dose of ketamine of 0.4 mg.kg-1. Traumatic pain accounted for 55% of the interventions, traumatized patients were significantly more painful with an initial EN at 8.3 (± 1.9) (p = 0.001). At the end of management, there was no significant deference of EN between medical and traumatic pains (p = 0.3). Only 40% of patients were relieved (EN≤3) at the end of management, with a median EN final of 4 [2-6], the total dose of morphine ≥7mg seemed to be the only factor favoring the reduction of pain in our study with a OR at 2,2 [1,2-4]. Conclusion: The use of opioids in SMUR de Bordeaux does not meet the 2010 good practice recommen dations. The recommended initial morphine boluses are used only in half of the cases, the use of an initial weight dose seems to be used. with a first bolus of 0.06 mg.kg-1. A dose increase of the first morphine bolus seems desirable especially in the important context of oligoanalgesia that this study recalls. Antalgic management is to be improved with only 40% of patients relieved at the end of the procedure.
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Master Thesis
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Clément Mathio. RETRAMAL : étude épidémiologique rétrospective de l’utilisation extrahospitalière des opioïdes à visée antalgique au Service Mobile d'Urgence et de Réanimation (SMUR) de Bordeaux en 2016. Médecine humaine et pathologie. 2018. ⟨dumas-02062404⟩

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