P-024 - Effects of morphine to fentanyl interchange in post-anesthesia care unit order sets

Abstract Title: Effects of morphine to fentanyl interchange in post-anesthesia care unit order sets

Background: The impact of opioid misuse and opioid- related adverse events has been a long-standing issue in the United States, leading to an increase in opioid stewardship. An important part of opioid stewardship entails using the lowest effective dosage of opioids and mitigating their side effects in all healthcare settings, including for surgical patients in the post-anesthesia care unit (PACU). Intravenous (IV) opioids such as morphine and fentanyl are used in the PACU for postoperative pain. Fentanyl is considered more potent, has a faster onset, and shorter duration of analgesia. Morphine is more associated with hypotension. Limited literature comparing the two agents in the PACU suggests that they are equally effective in treating post-operative pain, although morphine may be associated with more side effects. Opioid stewardship in the PACU involves selecting an agent that provides analgesia using the lowest effective dose of opioids and minimizing the side effects associated with its administration.

Purpose/Objectives: The study was conducted at a tertiary medical center that performs more than 21,000 surgeries per year. The preferred IV opioid for post-surgery analgesia changed from morphine to fentanyl when an internal review observed that morphine use was possibly associated with more side effects. The previous order set called for morphine two milligrams (mg) IV push every one to five minutes as needed, and this order was switched to fentanyl 25 micrograms (mcg) every five minutes as needed up to 100 mcg. This study aimed to analyze the impact of this interchange, including differences in morphine milligram equivalents (MME) consumption, adverse drug reactions (ADRs), and need for conversion to a different opioid in the PACU.


Methods: This study was an IRB-approved, single center, retrospective cohort evaluation. An electronic medical record (EMR) report from December 1, 2016 to December 1, 2019 identified the pre-intervention group, and a report from September 1, 2020 to September 1, 2023 identified the post-intervention group. The primary outcome for this study was to evaluate the difference in MME consumption in the morphine and fentanyl groups pre- and post-PACU order set change. The two secondary outcomes included comparing the incidence of ADRs as well as analyzing the percentage of patients converted to another opioid in the PACU in the two groups. Patients included in the study were adults who received an elective laparoscopic general abdominal surgery and were transferred to a medical-surgery floor. Exclusion criteria included patients with nerve blocks, transabdominal plane blocks, ON-Q pumps, pregnancy, substance misuse, chronic pain, or chronic opioid use greater than three months before surgery. Descriptive statistics were used for baseline characteristics. An estimated 150 patients were required to detect a 12% difference in the primary outcome with an alpha of 0.05 and power of 80%. A Mann-Whitney U test and chi-squared test of independence were used for statistical analysis of the primary and secondary outcomes, respectively.


Results: The pre-intervention group and post-intervention group had 279 and 221 screened patients, respectively. Patients were screened for inclusion in reverse chronological order until 150 patients were included in both groups. Baseline characteristics were similar except more patients in the pre-intervention group received both fentanyl and morphine in the operating room. More patients in the post-intervention group received one-time pre-operation doses of acetaminophen.

The median MME consumption in the post-intervention group (30 MME) was statistically greater than in the pre-intervention group (24 MME). The MME corresponds to four administrations of each assigned opioid, but the pre-intervention group received 2 mg of morphine (6 MME) while the post-intervention group received 25 mcg of fentanyl (7.5 MME). Similar percentages in both groups were converted to another opioid in the PACU. The morphine to fentanyl interchange resulted in a statistically significant reduction in ADRs, with the post-intervention group demonstrating 12% less ADRs than the pre-intervention group, including hypotension, respiratory depression, and increase in supplemental oxygen requirements.

Conclusions/Implications for future research and/or clinical care: Conversion from morphine to fentanyl in the order sets showed an increase in MME requirements in the PACU. However, the MME consumption corresponds to four administrations of both agents, suggesting the difference in MME consumption reflects the lack of dosage equivalency rather than an actual increase in opioid requirements. The percentage of patients requiring additional opioid supplementation or conversion to a different agent was not different between the two groups. Lastly, conversion to fentanyl resulted in less ADRs. The difference in MME consumption after the morphine to fentanyl interchange may be statistically significant, but the corresponding reduction in adverse drug reactions may have a greater clinical significance and positive impact on patient care and opioid stewardship in the acute care setting.


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