Hutchings C, Yadav K, Cheung WJ, et al. A systematic review of sufentanil for the management of adults with acute pain in the emergency department and pre-hospital setting. Am J Emerg Med. 2023 Apr 28;70:10-18. doi: 10.1016/j.ajem.2023.04.020. (Systematic review)

BACKGROUND: Pain is commonly encountered in the Emergency Department (ED) and pre-hospital setting and often requires opioid analgesia. We sought to synthesize the available evidence on the effectiveness of sufentanil for acute pain relief for adult patients in the pre-hospital or ED setting.

METHODS: This systematic review was conducted in accordance with PRISMA guidelines. Medline, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to February 1, 2022. The grey literature was also searched. We included randomized controlled trials of adult patients with acute pain who were treated with sufentanil. Two reviewers independently completed screening, full text review, and data extraction. Primary outcome was reduction in pain. Secondary outcomes included adverse events, need for rescue analgesia, and patient and provider satisfaction. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A meta-analysis was not performed due to heterogeneity.

RESULTS: Of 1120 unique citations, four studies (3 ED and 1 pre-hospital) met full inclusion criteria (n = 467 participants). The overall quality of the included studies was high. Intranasal (IN) sufentanil was superior to placebo for pain relief at 30 min (difference 20.8%, 95% CI 4.0-36.2%, p = 0.01). Both IN (two studies) and IV sufentanil (one study) were comparable to IV morphine. Mild adverse events were common and there was a higher propensity for minor sedation in patients receiving sufentanil. There were no serious adverse events requiring advanced interventions.

CONCLUSION: Sufentanil was comparable to IV morphine and was superior to placebo for rapid relief of acute pain in the ED setting. The safety profile of sufentanil is similar to IV morphine in this setting, with minimal concern for serious adverse events. The intranasal formulation may provide an alternative, rapid, non-parenteral route that could benefit our unique emergency department and pre-hospital patient population. Due to the overall small sample size of this review, larger studies are required to confirm safety.

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Comments from MORE raters

Physician rater

Intranasal sufentanyl is better than placebo and comparable to morphine. Not a shocker but potentially of interest

Physician rater

Sufentil in this form could be highly abused. I recall "ketopops" (ketamine lollipops) for sedation in children. They could not be kept in stock as the staff made off with them.

Physician rater

This is a well-done systematic review of sufentanil for analgesia in the prehospital and emergency department (ED) settings. The search for studies was exhaustive; 4 were found with 467 patients (3 were ED studies, 1 prehospital). Overall, sufentanil provided better analgesia than placebo, but did not differ from morphine. The results suggest that intranasal sufentanil is as efficacious as IV morphine.

Physician rater

It seems this study just collected the clinical trials that used sufentanil and concluded that sufentanil is effective and safe. It can be misleading to say suefentanil has "minimal concern for serious adverse events," since we all know sedative effects and respiratory suppression from mu-receptor is dose-dependent. As the author wrote in the Conclusion, this paper reviewed a small number of studies that limits the purpose of a systematic review. I do not find this study helpful for managing my patients in the ED.
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