Does morphine change the physical examination in patients with acute appendicitis?

Appendicitis and Analgesia in the Pediatric Emergency Department: Are We Adequately Controlling Pain?

OBJECTIVES

The primary objective of the study was to compare analgesia-prescribing practices and timing of analgesia administration between pediatric emergency medicine (PEM) and general emergency medicine (GEM) practitioners for children with appendicitis. The secondary objective was to compare analgesia administration versus triage pain score, pediatric appendicitis score (PAS), and body mass index (BMI).

METHODS

This was a retrospective chart review of patients younger than 21 years who presented to either an urban pediatric emergency department (ED) or 2 general EDs and were diagnosed with appendicitis.

RESULTS

Two hundred eighteen charts were reviewed, 153 (70%) from the pediatric ED and 65 (30%) from the general EDs. The patients seen by PEM physicians were younger than the patients seen by GEM physicians (mean age, 12.8 vs 15.4 years; P = 0.002). The patients evaluated by GEM physicians were more likely to receive analgesia in the ED (82% vs 60%, P = 0.003) and received analgesia sooner (mean, 178 vs 239 minutes; P = 0.026) than the patients evaluated by PEM physicians. The patients with triage pain scores higher than 6 of 10 were more likely to receive analgesia than the patients with pain scores lower than 6 (71% vs 51%, P = 0.015). There was no association between PAS or BMI and analgesia administration or time to analgesia (P = not significant).

CONCLUSIONS

The patients with appendicitis evaluated by GEM physicians were more likely to receive analgesia and receive analgesia quicker than the patients evaluated by PEM physicians. The patients with higher pain scores were more likely to receive analgesia, but PAS and BMI did not affect analgesia administration.

Analgesic treatment and predictors of satisfaction with analgesia in patients with acute undifferentiated abdominal pain

The objectives of this prospective, observational cohort study were to examine current practice of analgesia in adults with acute abdominal pain presenting to emergency department (ED), to assess patient-physician agreement on pain severity, and to measure patients' satisfaction with pain management.

METHODS

Emergency room nurse assessed initial patient's and physician's ranking on a 0-100mm visual analogue scale (VAS) as well as patient's VAS rankings 5min, 15min, and 60min after starting treatment for pain, and on discharge. In patients who received no therapy VAS scores were assessed 5min, 15min, and 60min after initial examination, and on discharge. Patient's satisfaction with pain management on discharge from ED was assessed using a four-point categorical scale in which 1=completely unsatisfied, 2=mostly unsatisfied, 3=mostly satisfied, and 4=completely satisfied.

RESULTS

A total of 185 patients were enrolled. Patients' mean initial VAS was higher than physicians' (76+/-20mm, vs. 59+/-20mm, p<0.001). Physician's VAS > or = 60mm was the sole independent predictor of receiving analgesic therapy (p<0.001). On discharge from ED, 111 patients (60%) were predominantly satisfied with analgesia (satisfaction score > or = 3). Drug titration (p=0.026) and decrease in VAS score > or = 20mm between initial and discharge score (p<0.001) independently predicted patients' satisfaction.

CONCLUSIONS

Patients with acute abdominal pain rated pain significantly higher than physicians who's pain estimation in turn tailored analgesia. Only 60% of patients were satisfied with analgesia. Analgesic drug titration and a decrease of > or = 20mm on VAS predicted patients' satisfaction.

An Evaluation of the Effect of Morphine on Abdominal Pain and PeritonealIrritation Signs in Patients with Acute Surgical Abdomen

INTRODUCTION

Acute surgical abdomen is one of the most common emergency surgical causes all over the world and also one of the most important abdominal pain causes which is sometimes intolerable for the patients referring to the emergency departments. Diagnosis and planning for operation in these cases is based on time-demanding serial examinations and results of paraclinical data. In this waiting period, patients have to tolerate pain.Therefore, we aimed to study the hypothesis that relieving pain has no influence on valuable findings in physical examination.

METHODS

This double blind randomized clinical trial was carried out on 120 patients above 12 years old referred to an emergency department of a referral hospital with acute abdomen. Patients were divided into two groups of receiving intravenous placebo and Morphine randomly. Pain score, change in tenderness as well as change in rebound tenderness before and after receiving morphine or placebo were measured based on Numeric Pain Assessment Scale.

RESULTS

Statistically significant difference was observed between both groups regarding the mean pain score. Prevalence of tenderness and rebound tenderness after medication administration revealed a significant difference between two groups. Furthermore, pain and tenderness showed a significant decrease in patients receiving morphine also a significant difference occurred in rebound tenderness between two groups.

CONCLUSION

Despite the fact that opioid analgesics decrease pain in patients with acute surgical abdomen, they do not tend to eliminate required diagnostic data being obtained from physical examination like tenderness and rebound tenderness. Surprisingly, all the acute abdomen cases had rebound tenderness after morphine administration. Therefore, this research advises a cautious usage of morphine in patients with acute abdomen.

Analgesia in patients with acute abdominal pain

BACKGROUND

For decades, the indication of analgesia in patients with Acute Abdominal Pain (AAP) has been deferred until the definitive diagnosis has been made, for fear of masking symptoms, generating a change in the physical exploration or obstructing the diagnosis of a disease requiring surgical treatment. This strategy has been questioned by some studies that have shown that the use of analgesia in the initial evaluation of patients with AAP leads to a significant reduction in pain without affecting diagnostic accuracy.

OBJECTIVES

To determine whether the evidence available supports the use of opioid analgesics in the diagnostic process of patients with AAP.

SEARCH STRATEGY

Trials were identified through searches in Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library, issue 2, 2009), MEDLINE (1966 to 2009) and EMBASE (1980 to 2009). A randomised controlled trial (RCT) filter for a MEDLINE search was applied (with appropriate modification for an EMBASE search). Trials also were identified through "related articles". The search was not limited by language or publication status.

SELECTION CRITERIA

All published RCTs which included adult patients with AAP, without gender restriction, comparing any opioids analgesia regimen with the non-use of analgesic before any intervention and independent of the results.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the studies identified via the electronic search. Articles that were relevant and pertinent to the aims of the study were selected and their respective full-text versions were collected for subsequent blinded evaluation. The allocation concealment was considered in particular as an option to diminish the biases.The data collected from the studies were reviewed qualitatively and quantitatively using the Cochrane Collaboration statistical software RevMan 5.0. After performing the meta-analysis, the chi-squared test for heterogeneity was applied. In situations of significant clinical heterogeneity, statistical analyses were not applied to the pool of results. In situations of heterogeneity, the random effect model was used to perform the meta-analysis of the results. A sensitivity analysis was also applied based on the evaluation to the methodological quality of the primary studies.

MAIN RESULTS

Eight studies fulfilled the inclusion criteria. Differences with use of opioid analgesia were verified in variables: Change in the intensity of the pain, change in the patients comfort level.

AUTHORS' CONCLUSIONS

The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment.

Assessment and management of acute pain in adult medical inpatients: a systematic review

OBJECTIVE

To review the literature addressing effective care for acute pain in inpatients on medical wards.

METHODS

We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions.

RESULTS

We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion.

CONCLUSIONS

Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.

Radiologic procedures, policies and protocols for pediatric emergency medicine

Protocol development between radiology and pediatric emergency medicine requires a multidisciplinary approach to manage straightforward as well as complex and time-sensitive needs for emergency department patients. Imaging evaluation requires coordination of radiologic technologists, radiologists, transporters, nurses and coordinators, among others, and might require accelerated routines or occur at sub-optimal times. Standardized protocol development enables providers to design a best practice in all of these situations and should be predicated on evidence, mission, and service expectations. As in any new process, constructive feedback channels are imperative for evaluation and modification.

Analgesia in patients with acute abdominal pain

BACKGROUND

For decades, analgesia for patients with acute abdominal pain was withheld until a definitive diagnosis was established for fear of masking the symptoms, changing physical findings or ultimately delaying diagnosis and treatment of a surgical condition. This non-evidence-based approach has been challenged by recent studies demonstrating that the use of analgesia in the initial evaluation of patients with acute abdominal pain leads to significant pain reduction without affecting diagnostic accuracy. However, early administration of analgesia to such patients can greatly reduce their pain and does not interfere with a diagnosis, which may even be facilitated due to the severity of physical symptoms being reduced.

OBJECTIVES

To determine if the currently available evidence supports the use of opioid analgesia in patient management with acute abdominal pain; and to assess changes in a patient comfort while awaiting definitive diagnosis and final treatment decisions.

SEARCH STRATEGY

Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 4, 2006), MEDLINE (1966 to 2006) and EMBASE (1980 to 2006). Randomized controlled trial filter for MEDLINE and EMBASE search. Trials will also be identified by "related articles". The searches were not limited by language or publication status.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that include adult patients with acute abdominal pain, without gender restriction, comparing any opioid analgesia regime to no analgesia administered prior to any intervention regardless of outcomes.

DATA COLLECTION AND ANALYSIS

Two authors looked independently at the titles and abstracts of reports. Potentially relevant studies selected by at least one reviewer were retrieved in full text versions for potential inclusion. Allocation concealment was important to avoid bias and was graded using the Cochrane approach. The data from studies included was reviewed qualitatively and quantitatively using the Cochrane Collaborations methodology and statistical software RevMan Analysis 1.0.5. In the case of homogeneity or non- worrying heterogeneity, a random effects model was used. Sensitivity analysis was performed based on quality assessment.

MAIN RESULTS

Six studies fulfilled the inclusion criteria. Improvement with use of opioid analgesia was verified in variables patient comfort, reduction of pain, changes in physical examination.

AUTHORS' CONCLUSIONS

The review provide some evidence to support the notion that the use of opioid analgesics in patients with acute abdominal pain is helpful in terms of patient comfort and does not retard decisions to treat.

Abdominal Pain

Evaluation of the elderly patient with acute abdominal pain is sometimes difficult. Various factors can obscure the presentation, delaying or preventing the correct diagnosis and leading to adverse patient outcomes. Clinicians must consider multiple diagnoses, especially those life-threatening conditions that require timely intervention to limit morbidity and mortality. This article reviews abdominal pain in the elderly, discusses the clinical approach, and highlights key diagnostic considerations.

Randomized clinical trial of morphine in acute abdominal pain

STUDY OBJECTIVE

Administration of analgesia to patients with acute abdominal pain is controversial. We test the hypothesis that morphine given to emergency department (ED) patients with acute abdominal pain will reduce discomfort and improve clinically important diagnostic accuracy.

METHODS

Pain was measured with a standard 0- to 100-mm visual analog scale. ED patients with acute abdominal pain were randomized in a double-blind fashion to 0.1 mg/kg intravenous morphine or placebo. The primary endpoint was the difference between the 2 study arms in clinically important diagnostic accuracy. Clinically important diagnostic accuracy was defined a priori by its complement, clinically important diagnostic error, using 2 independent, blinded investigators to identify any discordance between the provisional and final diagnoses that might adversely affect the patient's health status. The provisional diagnosis was provided by an ED attending physician, who examined the patient only once, 15 minutes after administration of the study agent. The final diagnosis was obtained through follow-up at least 6 weeks after the index ED visit.

RESULTS

We randomized 160 patients, of whom 153 patients were available for analysis, 78 patients in the morphine group and 75 patients in the placebo group. Baseline features were similar in both groups, including initial median visual analog scale scores of 98 mm and 99 mm. The median decrease in visual analog scale score at 15 minutes was 33 mm in the morphine group and 2 mm in the placebo group. There were 11 instances of diagnostic discordance in each group, for a clinically important diagnostic accuracy of 86% (67/78) in the morphine group and 85% (64/75) in the placebo group. The difference in clinically important diagnostic accuracy between the 2 groups was 1% (95% confidence interval [CI] -11% to 12%). Analysis by efficacy and intention to treat yielded similar results. Kappa for interobserver concordance in classification of clinically important diagnostic accuracy was 0.94 (95% CI 0.79 to 1.00). No patients required naloxone.

CONCLUSION

Although administration of intravenous morphine to adult ED patients with acute abdominal pain could lead to as much as a 12% difference in diagnostic accuracy, equally favoring opioid or placebo, our data are most consistent with the inference that morphine safely provides analgesia without impairing clinically important diagnostic accuracy.

Diagnosis and management of diverticulitis and appendicitis

Diverticulitis and appendicitis are common infections of the gastrointestinal tract that require urgent medical and surgical attention. Successful management of these conditions requires a multidisciplinary approach among primary care providers, gastroenterologists, surgeons, and radiologists. The diagnosis of appendicitis, in particular, can be difficult. Advances in radiographic imaging have improved the diagnostic accuracy in these infections. Minimally invasive surgical techniques have improved the patient's postoperative recovery when surgery is necessary in the management of these conditions.

The social, professional, and legal framework for the problem of pain management in emergency medicine

The problem of harmful, unnecessary and neglected pain has been studied extensively in many health care settings over the past decade. Research has documented the incidence of untreated pain, and scholars and advocates have given the problem several names: “public health crisis,” “oligoanalgesia, and “moral failing,” among them. Articles have identified a litany of now familiar “obstacles” or “barriers” to effective pain relief. Each of these individual obstacles or barriers has been the subject of targeted remedial action in at least some context.

The checklist approach to improving care for patients in pain, however, is likely to have only limited effect. What really appears to be operating is a complex ecosystem that supports ambivalence, denial, and even suspicion of the circumstance of patients in pain and efforts to treat them. Pain relief in emergency medicine, a relatively new setting for the study of challenges to treating pain, provides a revealing context for viewing discrete obstacles to effective pain management in medicine as part of an integrated environment into which patients with pain enter for treatment.