Correspondence

all deployed personnel are issued

two 10-mg morphine autojects for
i.m. self-administration or to be
given via buddy-aid [1].
In 2009, Smith et al. [2] published the results of a questionnaire
sent to 122 UK and US medical personnel exploring their clinical opinion of current battleeld analgesia.
All personnel responded; 52% disagreed that i.m. morphine had the
ideal properties for managing severe
pain in the pre-hospital environment. Over 50% of respondents
with operational experience reported
multiple instances of inadequate
analgesia from i.m. morphine.
During periods of shock, i.m.
morphine may not reach the systemic circulation until adequate perfusion is restored, potentially leading
to late boluses after administration.
In such cases, i.m. morphine is used
cautiously [3] for historical fear of
delayed morphine poisoning among
battle casualties [4].
We conducted an internetbased questionnaire survey among
physicians in anaesthesia and emergency medicine with experience of
resuscitating trauma cases in a eld
hospital over the last 10 years, in
order to determine current attitudes
towards, and problems arising
from, the use of i.m. morphine in
the battleeld.
We received 68 responses, all
from UK physicians, 49 (72%) of
who were anaesthetists and 19 (28%)
emergency medicine specialists; 45
(66%) replies were from consultants.
We were not able to determine a
denominator for the questionnaires
received.
Respondents were deployed for
627 months, recording a total of

Anaesthesia 2014, 69, 785798

9411 patient episodes. The actual

number of casualty resuscitations
experienced is unknown because
duplication of care could not be
accounted for in our survey. Eight
(12%) respondents supplied logbook
data, the remaining 60 (88%) providing best estimates.
Ten (14%) respondents had
observed complications attributable to
i.m. morphine following resuscitation,
all of which were secondary to inadequate analgesia rather than opioid
side-effects. Thirty-nine (57%) respondents recalled being taught to avoid
i.m. morphine in shocked patients.
Battleeld Advanced Trauma
Life Support prioritises the management of catastrophic haemorrhage, with analgesia given towards
the end of the primary survey once
bleeding is controlled. Our survey
suggests that conservation of circulating volume appears to avoid late
reperfusion
opioid
side-effects,
potentially enabling a safe increased
administration of opioid analgesia
to wounded soldiers. Further evaluation is needed before adjusting
clinical practice, however. An
experimental model combining
microdialysis sampling with lower
body negative pressure to simulate
various stages of haemorrhage may
help clarify the pharmacokinetics
of battleeld i.m. morphine [5].
C. P. Jones
Liverpool Heart and Chest Hospital,
Liverpool, England
Email: clintonpljones@hotmail.com
R. Chauhan
University Hospital Coventry,
Coventry, England
D. Aldington
Royal Hampshire County Hospital,
Winchester, England

2014 The Association of Anaesthetists of Great Britain and Ireland

No external funding and no competing interests declared. The

authors would like to thank their
colleagues within the Defence Medical Services, without whom this survey could not have been completed.

References
1. Gaunt C, Gill J, Aldington D. British military use of morphine: a historical
review. Journal of the Royal Army Medical Corps 2009; 155: 469.
2. Smith JE, Russell R, Mahoney PF, Hodgetts TJ. What is the ideal pre-hospital
analgesic? a questionnaire study. Journal of the Royal Army Medical Corps
2009; 155: 446.
3. Anon. Battlefield Advanced Trauma Life
Support. Journal of the Royal Army
Medical Corps 2003; 149: 297302.
4. Beecher HK. Delayed morphine poisoning in battle casualties. Journal of the
American Medical Association 1944;
124: 11934.
5. Cooke WH, Ryan KL, Convertino VA. Lower
body negative pressure as a model to
study progression to acute haemorrhagic
shock in humans. Journal of Applied
Physiology 2004; 96: 124961.
doi:10.1111/anae.12737

Diclofenac sodium in
Hartmanns solution
In response to Maddens letter about
intravenous diclofenac [1], we wish to
inform readers that we have undertaken stability testing of 375 mg diclofenac sodium (Voltarol, Novartis
Pharmaceuticals UK Ltd, Camberley,
UK) in 500 ml Hartmanns solution
(MacoPharma (UK) Ltd, Twickenham, UK), which represents the maximum concentration (75 mg.100 ml 1)
in the Novartis Summary of Product
Characteristics [2].
Novartis recommends diluting
diclofenac in sodium chloride 0.9%, or
glucose 5% if buffered with 0.5 mmol
sodium bicarbonate. The smallest volume of sodium bicarbonate 4.2% or
797

Anaesthesia 2014, 69, 785798

8.4% pharmaceutical product available

in the UK is 10 ml, of which only
1.0 ml or 0.5 ml, respectively, would
be required, the expense and product
availability of which has resulted in a
number of anaesthetists routinely
diluting diclofenac in Hartmanns
solution (Compound Sodium Lactate
Infusion BP) [3].
For simplicity, and to reduce
any infection risk through multiple
steps in the preparation of the solution, we undertook stability testing
based on principles outlined in the
Handbook of Injectable Drugs [4],
checking the resultant solution for
haze, precipitate, particulate, colour
change, gas evolution, pH and difference in the weight of solution
over a period of 96 hours at a range
of temperatures (28 C, 1825 C
and 3035 C). We observed no visible haze, precipitate or particulate
in any solution at any temperature
during the 96 hours monitoring. Gas formation was negligible,
at < 0.1 ml in a 500-ml bag, and
could not be differentiated from a
failure to remove 100% of the air in
the bag at the point of preparation.
The change in weight of each bag

Correspondence

was consistently < 0.02 mg.500 ml 1.

There was no change in colour
observable from photographic comparisons in a controlled articial
lighting environment. The pH of
control Hartmanns solution and
diclofenac in Hartmanns solution
remained in the range 6.57.5 when
tested at 30 minutes and 96 hours,
which is consistent with the stated
pH range for stability of diclofenac
in sodium chloride 0.9% (7.17.8)
and glucose 5% (6.88.3).
We conclude that the Voltarol
brand of diclofenac sodium diluted in
Hartmanns solution at a maximum
concentration of 75 mg.100 ml 10
is sufciently stable for preparing
solution for immediate intravenous
administration (over a maximum of
two hours), and that this provides a
practical method of using a buffered
solution without resorting to the
addition of sodium bicarbonate to
the infusion solution.
D. J. S. de Monteverde-Robb
T. House
Cambridge University Hospitals
NHS Foundation Trust,
Cambridge, UK

Email: david.demonteverde-robb@
addenbrookes.nhs.uk
No external funding and no competing interests declared. We are
grateful to the Quality Assurance
Department and Prakash Solanki
for their assistance. Previously
posted on the Anaesthesia correspondence website: www.anaesthesia
correspondence.com.

References
1. Madden GB. Co-administering diclofenac
with intravenous paracetamol or Hartmanns solution. Anaesthesia 2014; 69:
1912.
2. Novartis Pharmaceuticals Ltd UK.
Summary of Product Characteristics for
Voltarol ampoules. Electronic Medicines
Compendium
http://www.medicines.
org.uk (accessed 14/03/2014).
3. MacoPharma UK. Summary of Product
Characteristics for Compound Sodium
Lactate Intravenous Infusion BP. March
2008. http://www.imb.ie/images/uplo
aded/swedocuments/LicenseSPC_PA093
1-009-001_25022011151137.pdf (accessed 14/03/2014).
4. Handbook of Injectable Drugs. Selected
Revisions January 23, 2014. Ed: American Society of Health-System Pharmacists, Maryland, USA. http://www.
medicinescomplete.com (accessed 14/
03/2014).
doi:10.1111/anae.12760

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798

2014 The Association of Anaesthetists of Great Britain and Ireland