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Raja Azlan N, Bulsara C, Monterosso L, Bulsara M, Ross-Adjie G. Clinician's perspectives on the feasibility of patient controlled analgesia in emergency departments: A qualitative descriptive study. Int Emerg Nurs 2024; 76:101505. [PMID: 39213760 DOI: 10.1016/j.ienj.2024.101505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 06/21/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Despite pain being the most common reason for patients to visit the emergency department (ED), conventional pain management methods are often inadequate. Patient controlled analgesia (PCA), which allows patients to self-administer intravenous analgesia, is widely used across many hospital wards, however, is not routinely used in ED. We aimed to identify clinicians' perceptions of PCA use in the ED setting. METHODS A qualitative descriptive approach was employed using semi-structured individual interviews conducted with ED clinicians from two hospitals in Western Australia. Interviews were recorded and transcribed. Data was analysed using qualitative content analysis. RESULTS Data saturation was achieved after 20 participant interviews. Five themes emerged from the interview data: sustainability and choosing the right patient; time; safety concerns and side effects; anticipating the patient's perspective (staff perception); facilitating PCA use in ED. CONCLUSION Most participants perceived that patients would experience several benefits from PCA use in ED. Several perceived barriers and facilitators were also identified. To facilitate the use of PCA in ED, there is a need for staff education on PCA use, patient selection guidelines and effective change management strategies. Further research about the time it takes to administer analgesia via PCA compared with conventional methods is needed.
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Affiliation(s)
- Natasya Raja Azlan
- The University of Notre Dame Australia, Fremantle, Western Australia, Australia; Edith Cowan University, Joondalup, Western Australia, Australia.
| | - Caroline Bulsara
- The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Leanne Monterosso
- The University of Notre Dame Australia, Fremantle, Western Australia, Australia; Murdoch University, Murdoch, Western Australia, Australia
| | - Max Bulsara
- The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Gail Ross-Adjie
- The University of Notre Dame Australia, Fremantle, Western Australia, Australia
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Oon MB, Nik Ab Rahman NH, Mohd Noor N, Yazid MB. Patient-controlled analgesia morphine for the management of acute pain in the emergency department: a systematic review and meta-analysis. Int J Emerg Med 2024; 17:37. [PMID: 38454338 PMCID: PMC10921802 DOI: 10.1186/s12245-024-00615-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/21/2023] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The ideal pain control approach is typically viewed as titration of analgesia for pain reduction and periodic pain evaluation. However, this method takes time and is not always possible in the crowded Emergency Department. Therefore, an alternative way to improve pain care in the Emergency Department is needed to avoid this unpleasant sensation in the patients. The best solution to tackle this situation is using Patient Controlled Analgesia (PCA), in the form of a PCA pump. STUDY OBJECTIVES This systematic review and meta-analysis was designated to evaluate the efficacy of PCA morphine in treating acute pain at Emergency Department. METHODS We searched databases Cochrane Central Register of Controlled Trials (CENTRAL), Medline, and Google Scholar up to February 2022 and identified randomized controlled trials with English language only that compare PCA morphine to IV morphine in treating patients presenting with acute pain at Emergency Department. RESULTS Eight trials were included in our review, comprising 1490 participants. We compared PCA morphine vs. IV morphine. There were no differences in the pain score between PCA and IV morphine (standard mean difference [SMD] = -0.20, p = 0.25). Further subgroup analyses (origin of the pain, time of assessment and the durations) showed no difference except for the dosages as the PCA morphine reduced the pain compared to IV morphine in low and high dosages but only two studies were involved. However, the analysis showed PCA morphine increased patient satisfaction and reduced the number of patients who required additional analgesia compared to IV morphine (MD 0.12, P < 0.001), (MD 0.47, P < 0.001) respectively. Data obtained in this review pertaining to adverse effects such as nausea, vomiting, pruritus, and drowsiness is limited since not all the trials reported the events. CONCLUSIONS PCA morphine do appear to have a beneficial effect on the outcome of patient satisfaction and the number of patients who required additional analgesia. However, further studies targeting a larger sample size is required to increase the certainty of the evidence.
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Affiliation(s)
- Muhammad Baihaqi Oon
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia
| | - Nik Hisamuddin Nik Ab Rahman
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia.
- Hospital Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia.
| | - Norhayati Mohd Noor
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia
| | - Mohd Boniami Yazid
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia
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Watchorn A, Curran J, Heilman J, Balfour N, McCarroll K, Speers S, Harris D. Feasibility of patient-controlled analgesia (PCA) for rural and remote transfers. CAN J EMERG MED 2023; 25:157-163. [PMID: 36565428 DOI: 10.1007/s43678-022-00417-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/11/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND In rural Canada, the majority of prehospital care is provided by basic life support paramedics, who cannot administer opioids or parenteral analgesics. Patients requiring transfer to a higher level of care have limited options for pain control. We aim to determine if ambulance-based patient-controlled analgesia (PCA) is feasible during inter-facility transfers. METHODS This is a prospective non-consecutive cohort feasibility study conducted in the East Kootenay region of British Columbia from 2016 to 2020. Patients in acute pain from an illness or injury requiring an opioid and transfer to a higher level of care were offered PCA. The study used respiratory depression as a marker of safety, assessed if PCA during transport provided efficacious analgesia, measured satisfaction scores from patients and paramedics, and tracked adverse events. RESULTS 84 patients received PCA. The majority had orthopaedic trauma and the average transfer time was 3 h 22 min. The average pain score at the start and end of the transfer was unchanged, at 4 out of 10. Patient and paramedic satisfaction scores at the end of the transfer were 4.6 and 4.7 out of 5, respectively. Three out of the 84 patients (3.6%) had desaturation episodes below or equal to 90% oxygen saturation; however, all resolved with supplemental oxygen. INTERPRETATION Ambulance-based PCA is feasible and has a high level of satisfaction among paramedics and patients. It has significant potential for inter-facility transport in rural regions in Canada where ambulances are staffed with paramedics who cannot administer opioids or other parenteral analgesics.
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Affiliation(s)
- Adam Watchorn
- University of British Columbia, Faculty of Medicine, Vancouver, BC, Canada.
- Interior Health Authority, Kelowna, BC, Canada.
| | | | - James Heilman
- University of British Columbia, Faculty of Medicine, Vancouver, BC, Canada
- Interior Health Authority, Kelowna, BC, Canada
| | - Nick Balfour
- University of British Columbia, Faculty of Medicine, Vancouver, BC, Canada
- Interior Health Authority, Kelowna, BC, Canada
| | - Kirk McCarroll
- University of British Columbia, Faculty of Medicine, Vancouver, BC, Canada
- Interior Health Authority, Kelowna, BC, Canada
| | - Shauna Speers
- British Columbia Emergency Health Services, Saanichton, BC, Canada
| | - Devin Harris
- University of British Columbia, Faculty of Medicine, Vancouver, BC, Canada
- Interior Health Authority, Kelowna, BC, Canada
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Althagafi SM, Hughes JA. Identifying the relationship between patient-reported outcomes and treatment with opiates in the adult emergency department - A cross-sectional study. Int Emerg Nurs 2022; 62:101152. [PMID: 35245729 DOI: 10.1016/j.ienj.2022.101152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/09/2022] [Accepted: 01/31/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Suhair M Althagafi
- School of Nursing, Queensland University of Technology, Brisbane, Australia; College of Nursing, Umm AlQura University, Makkah, Saudi Arabia
| | - James A Hughes
- School of Nursing, Queensland University of Technology, Brisbane, Australia.
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Su C, Ren X, Wang H, Ding X, Guo J. Changing Pain Management Strategy from Opioid-Centric towards Improve Postoperative Cognitive Dysfunction with Dexmedetomidine. Curr Drug Metab 2021; 23:57-65. [PMID: 34791997 DOI: 10.2174/1389200222666211118115347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/21/2021] [Accepted: 09/23/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study was aimed to investigate the effectiveness of dexmedetomidine (DEX) on improving the level of pain and disability to find out the possible correlation between psychological factors with pain management satisfaction and physical function in patients with femoral neck fractures. METHODS One hundred twenty-four adult patients with stable femoral neck fractures (type I and II, Garden classification) who underwent internal fixation, were prospectively enrolled including 62 patients in the DEX group and 62 patients in the control group. The magnitude of disability using Harris Hip Score, Postoperative Cognitive Dysfunction (POCD) using Mini-Mental State Examination (MMSE score), Quality of Recovery (QoR-40), pain-related anxiety (PASS-20), pain management and pain catastrophizing scale (PCS) were recorded on the first and second day after surgery. RESULTS The DEX group on the first and second days after surgery exhibited higher quality of recovery scores, greater satisfaction with pain management, low disability scores, less catastrophic thinking, lower pain anxiety, greater mini mental state examination scores and less opioid intake and the differences were statistically significant compared with the control group (P<0.001). Emergence agitation and incidence of POCD were significantly less in the DEX group (P<0.001). Decreased disability was associated with less catastrophic thinking and lower pain anxiety, but not associated with more opioid intake (P<0.001). Higher QoR-40 scores had a negative correlation with more catastrophic thinking and more opioid intake (P<0.001). Greater satisfaction with pain management was correlated with less catastrophic thinking and less opioid intake (P<0.001). CONCLUSION Using DEX as an adjunct to anesthesia could significantly improve postoperative cognitive dysfunction and the quality of recovery and these improvements were accompanied by decrease in pain, emergence agitation, and opioid consumption by DEX administration. Since pain relief and decreased disability were not associated with prescribing greater amounts of opioid intake in the patients, improving psychological factors, including reducing catastrophic thinking or self-efficacy about pain, could be a more effective strategy to reduce pain and disability, meanwhile reducing opioid prescription in the patients. Our findings showed that DEX administration is safe sedation with anti-inflammatory, analgesic and antiemetic effects and it could help change pain management strategy from opioid-centric towards improved postoperative cognitive dysfunction.
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Affiliation(s)
- Chunhong Su
- Department of Pain, Lanzhou University Second Hospital, Lanzhou, Gansu. China
| | - Xiaojun Ren
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou, Gansu. China
| | - Hongpei Wang
- Department of Pain, Lanzhou University Second Hospital, Lanzhou, Gansu. China
| | - Xiaomei Ding
- Department of Pain, Lanzhou University Second Hospital, Lanzhou, Gansu. China
| | - Jian Guo
- Department of Pain, Lanzhou University Second Hospital, Lanzhou, Gansu. China
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Papa L, Maguire L, Bender M, Boyd M, Patel S, Samcam I. Patient controlled analgesia for the management of acute pain in the emergency department: A systematic review. Am J Emerg Med 2021; 51:228-238. [PMID: 34775197 DOI: 10.1016/j.ajem.2021.10.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The most common presenting complaint to the emergency department (ED) is pain. Several studies have shown that a large proportion of ED patients either receive no or sub-optimal analgesia. Patient-controlled analgesia (PCA) pumps used in the post-operative setting has shown to decrease total opioid consumption and has increased patient and nurse satisfaction. OBJECTIVE The purpose of this systematic review was to evaluate clinical trials that have used PCAs in the ED setting, to evaluate safety and efficacy as well as patient and healthcare provider experience. METHODS A search of PubMed, MEDLINE, and the Cochrane Database was conducted using the MESH search terms emergency department, patient-controlled analgesia, and acute pain up to September 2021. These terms were searched in all fields of publication and were limited to the English-language articles, clinical "human" studies, and studies that included the use of patient-controlled analgesia in the setting of the emergency department. RESULTS The search initially identified 227 potentially relevant articles and a total of 10 studies met criteria for inclusion. ED use of PCA therapy was associated with increased patient satisfaction, decreased pain scores, and an overall increase in opioid consumption. CONCLUSION The quality, the differences in study methods and outcome measures used, and heterogeneity of the studies performed to date do not provide adequate evidence to support its widespread use in the ED. Well-designed studies conducted in the ED are still needed to evaluate the ideal patient population to whom these PCAs may provide the most benefit as well as a robust cost-analysis to ensure feasibility of use in the future.
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Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 W Underwood, Orlando, FL 32806, United States of America; Department of Neurology and Neurosurgery, McGill University, 3801 Rue University, Montreal, Quebec H3A 2B4, Canada.
| | - Lindsay Maguire
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 W Underwood, Orlando, FL 32806, United States of America
| | - Mark Bender
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 W Underwood, Orlando, FL 32806, United States of America
| | - Michael Boyd
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 W Underwood, Orlando, FL 32806, United States of America
| | - Sagar Patel
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 W Underwood, Orlando, FL 32806, United States of America
| | - Ivan Samcam
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 W Underwood, Orlando, FL 32806, United States of America
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Wong A, Potter J, Brown NJ, Chu K, Hughes JA. Patient-Reported outcomes of pain care research in the adult emergency department: A scoping review. Australas Emerg Care 2020; 24:127-134. [PMID: 33187935 DOI: 10.1016/j.auec.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
Despite more than 30 years of research, pain in the emergency department (ED) setting is frequently undertreated. EDs prioritise process measures that often have tenuous links to patient-reported outcomes. However, process measures, such as time to the administration of first analgesic medication, are neither direct objective measures of analgesia nor appropriate surrogate markers of pain relief. Since pain is a subjective symptom that lacks an objective measure, pain research in any clinical environment, including EDs, should rely upon patient-reported outcomes. This scoping review examined patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) of pain care in the adult emergency department at the micro, meso and macro-level over the last ten years. We reviewed pain care research conducted on adults in EDs over the last ten years and identified 57 articles using 14 patient-reported outcomes of pain care falling into five broad areas, most without validation or adaption to the ED setting. Despite efforts made to incorporate PROs and PROMs into acute pain care research in the ED over the last ten years, there is still no gold-standard PROM in widespread use. We recommend the adaptation of existing tools with rigorous validation in ED populations.
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Affiliation(s)
- Alixandra Wong
- Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Joseph Potter
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Logan Hospital, Meadowbrook, Australia
| | - Nathan J Brown
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Kevin Chu
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
| | - James A Hughes
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Australia.
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Schultz H, Abrahamsen L, Rekvad LE, Skræp U, Schultz Larsen T, Möller S, Tecedor UK, Qvist N. Patient-controlled oral analgesia at acute abdominal pain: A before-and-after intervention study of pain management during hospital stay. Appl Nurs Res 2019; 46:43-49. [PMID: 30853075 DOI: 10.1016/j.apnr.2019.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/30/2018] [Accepted: 02/10/2019] [Indexed: 01/24/2023]
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Abstract
PURPOSE OF REVIEW The purpose of the study is to evaluate and analyze the role of both opioid and non-opioid analgesics in the emergency department (ED). RECENT FINDINGS Studies have shown that the implementation of opioid-prescribing policies in the ED has the potential to reduce the opioid addiction burden. Clinical studies point to inconsistencies in providers' approach to pain treatment. In this review, we discuss specific aspects of opioid utilization and explore alternative non-opioid approaches to pain management. Pain is the most common reason patients present to the ED. As such, emergency medicine (EM) providers must be well versed in treating pain. EM providers must be comfortable using a wide variety of analgesic medications. Opioid analgesics, while effective for some indications, are associated with significant adverse effects and abuse potential. EM providers should utilize opioid analgesics in a safe and rational manner in an effort to combat the opioid epidemic and to avoid therapeutic misadventures. EM providers should be aware of all of their therapeutic options, e.g., opioid and non-opioid, in order to provide effective analgesia for their patients, while avoiding adverse effects and minimizing the potential for misuse.
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Casamayor M, DiDonato K, Hennebert M, Brazzi L, Prosen G. Administration of intravenous morphine for acute pain in the emergency department inflicts an economic burden in Europe. Drugs Context 2018; 7:212524. [PMID: 29675049 PMCID: PMC5898605 DOI: 10.7573/dic.212524] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/13/2018] [Accepted: 03/15/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Acute pain is among the leading causes of referral to the emergency department (ED) in industrialized countries. Its management mainly depends on intensity. Moderate-to-severe pain is treated with intravenous (IV) administered opioids, of which morphine is the most commonly used in the ED. We have estimated the burden of IV administration of morphine in the five key European countries (EU5) using a micro-costing approach. SCOPE A structured literature review was conducted to identify clinical guidelines for acute pain management in EU5 and clinical studies conducted in the ED setting. The data identified in this literature review constituted the source for all model input parameters, which were clustered as analgesic (morphine), material used for IV morphine administration, nurse workforce time and management of morphine-related adverse events and IV-related complications. FINDINGS The cost per patient of IV morphine administration in the ED ranges between €18.31 in Spain and €28.38 in Germany. If costs associated with the management of morphine-related adverse events and IV-related complications are also considered, the total costs amount to €121.13-€132.43. The main driver of those total costs is the management of IV-related complications (phlebitis, extravasation and IV prescription errors; 73% of all costs) followed by workforce time (14%). CONCLUSIONS IV morphine provides effective pain relief in the ED, but the costs associated with the IV administration inflict an economic burden on the respective national health services in EU5. An equally rapid-onset and efficacious analgesic that does not require IV administration could reduce this burden.
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Affiliation(s)
| | - Karen DiDonato
- AcelRx, 351 Galveston Drive, Redwood City, CA 94063, USA
| | | | - Luca Brazzi
- Department of Surgical Science, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - Gregor Prosen
- Centre for Emergency Medicine, Community Health Center, Maribor, Slovenia
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Madsen SB, Qvist N, Möller S, Schultz H. Patient-controlled oral analgesia for acute abdominal pain: A before-and-after intervention study on pain intensity and use of analgesics. Appl Nurs Res 2018; 40:110-115. [PMID: 29579484 DOI: 10.1016/j.apnr.2018.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/10/2018] [Accepted: 01/19/2018] [Indexed: 11/19/2022]
Abstract
AIM To compare the use of patient-controlled oral analgesia with nurse-controlled analgesia for patients admitted to hospital with acute abdominal pain. The primary outcome measure was pain intensity. The secondary outcome measures were the use of analgesics and antiemetics. BACKGROUND Inadequate pain management of patients with acute abdominal pain can occur during hospital admission. Unrelieved acute pain can result in chronic pain, stroke, bleeding and myocardial ischemia. METHODS A before-and-after intervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected from medical charts and analyzed using chi-squared and Kruskal-Wallis tests. RESULTS A total of 170 patients were included. The median pain intensity score, using the numeric ranking scale, was 2.5 and 2 on Day 2 (p = 0.10), 2 and 2 on Day 3 (p = 0,40), 2.5 and 0 on Day 4 (p = 0.10), 2 and 0 on Day 5 (p = 0.045) in the control and intervention group, respectively. The percentage of patients receiving analgesics was 93 and 86 on Day 2 (p = 0.20), 91 and 75 on Day 3 (p = 0.02), 89 and 67 on Day 4 (p = 0.009) and 80 and 63 on Day 5 (p = 0.39). The use of antiemetics was similar in the two groups. CONCLUSION Patient-controlled oral analgesia significantly reduced the numerical ranking pain scale score on Day 5 and the consumption of analgesics on Days 3 and 4 after hospital admission. Patient-controlled oral analgesia is feasible as pain management for patients, but only with minor impact on experienced pain intensity and use of analgesics.
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Affiliation(s)
- Sandra Bruun Madsen
- Research Unit of Clinical Pharmacology and Pharmacy, University of Southern Denmark, J. B. Winsløws Vej 19, 2, 5000 Odense C, Denmark.
| | - Niels Qvist
- Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense C, Denmark; Surgical Department, Odense University Hospital, Sdr. Boulevard 4, 5000 Odense C, Denmark.
| | - Sören Möller
- Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense C, Denmark; OPEN - Odense Patient data Explorative Network, Odense University Hospital, Denmark.
| | - Helen Schultz
- Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense C, Denmark; OPEN - Odense Patient data Explorative Network, Odense University Hospital, Denmark; Surgical Department, Odense University Hospital, Sdr. Boulevard 4, 5000 Odense C, Denmark.
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12
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Bijur PE, Mills AM, Chang AK, White D, Restivo A, Persaud S, Schechter CB, Gallagher EJ, Birnbaum AJ. Comparative Effectiveness of Patient-Controlled Analgesia for Treating Acute Pain in the Emergency Department. Ann Emerg Med 2017; 70:809-818.e2. [PMID: 28601270 DOI: 10.1016/j.annemergmed.2017.03.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 03/23/2017] [Accepted: 03/27/2017] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We assess the effectiveness of patient-controlled analgesia in the emergency department (ED). We hypothesized that decline in pain intensity from 30 to 120 minutes after initial intravenous opioid administration is greater in patients receiving morphine by patient-controlled analgesia compared with usual care and would differ by a clinically significant amount. METHOD This was a pragmatic randomized controlled trial of patient-controlled analgesia and usual care (opioid and dose at physician's discretion) in 4 EDs. Entry criteria included age 18 to 65 years and acute pain requiring intravenous opioids. The primary outcome was decline in numeric rating scale pain score 30 to 120 minutes postbaseline. Secondary outcomes included satisfaction, time to analgesia, adverse events, and patient-controlled analgesia pump-related problems. We used a mixed-effects linear model to compare rate of decline in pain (slope) between groups. A clinically significant difference between groups was defined as a difference in slopes equivalent to 1.3 numeric rating scale units. RESULTS Six hundred thirty-six patients were enrolled. The rate of decline in pain from 30 to 120 minutes was greater for patients receiving patient-controlled analgesia than usual care (difference=1.0 numeric rating scale unit; 95% confidence interval [CI] 0.6 to 1.5; P<.001) but did not reach the threshold for clinical significance. More patients receiving patient-controlled analgesia were satisfied with pain management (difference=9.3%; 95% CI 3.3% to 15.1%). Median time to initial analgesia was 15 minutes longer for patient-controlled analgesia than usual care (95% CI 11.4 to 18.6 minutes). There were 7 adverse events in the patient-controlled analgesia group and 1 in the usual care group (difference=2.0%; 95% CI 0.04% to 3.9%), and 11 pump-programming errors. CONCLUSION The findings of this study do not favor patient-controlled analgesia over usual ED care for acute pain management.
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Affiliation(s)
- Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY.
| | - Angela M Mills
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew K Chang
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Deborah White
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Andrew Restivo
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Shaun Persaud
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Adrienne J Birnbaum
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
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13
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Doleman B, Williams JP. Patient controlled analgesia: effective and cost-effective management of acute pain within the Emergency Department? Anaesthesia 2017; 72:935-939. [PMID: 28555748 DOI: 10.1111/anae.13893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- B Doleman
- Department of Surgery and Anaesthesia, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - J P Williams
- Department of Surgery and Anaesthesia, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
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Pritchard C, Smith JE, Creanor S, Squire R, Barton A, Benger J, Cocking L, Ewings P, Rockett M. The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital. Anaesthesia 2017; 72:953-960. [PMID: 28547753 DOI: 10.1111/anae.13932] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2017] [Indexed: 11/30/2022]
Abstract
The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.
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Affiliation(s)
- C Pritchard
- NIHR Research Design Service, South West, UK
| | - J E Smith
- Department of Anaesthesia, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
| | - S Creanor
- Department of Medical Statistics, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - R Squire
- Emergency Department, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
| | - A Barton
- NIHR Research Design Service, South West, UK
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - L Cocking
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - P Ewings
- NIHR Research Design Service, South West, UK
| | - M Rockett
- Department of Anaesthesia, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
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15
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Palmer PP, Walker JA, Patanwala AE, Hagberg CA, House JA. Cost of Intravenous Analgesia for the Management of Acute Pain in the Emergency Department is Substantial in the United States. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2017; 5:1-15. [PMID: 37664687 PMCID: PMC10471413 DOI: 10.36469/9793] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background: Pain is a leading cause of admission to the emergency department (ED) and moderate-to-severe acute pain in medically supervised settings is often treated with intravenous (IV) opioids. With novel noninvasive analgesic products in development for this indication, it is important to assess the costs associated with IV administration of opioids. Materials and Methods: A retrospective observational study of data derived from the Premier database was conducted. All ED encounters of adult patients treated with IV opioids during a 2-year time period, who were charged for at least one IV opioid administration in the ED were included. Hospital reported costs were used to estimate the costs to administer IV opioids. Results: Over a 24 month-period, 7.3 million encounters, which included the administration of IV opioids took place in 614 US EDs. The mean cost per encounter of IV administration of an initial dose of the three most frequently prescribed opioids were: morphine $145, hydromorphone $146, and fentanyl $147. The main driver of the total costs is the cost of nursing time and equipment cost to set up and maintain an IV infusion ($140 ± 60). Adding a second dose of opioid, brings the average costs to $151-$154. If costs associated with the management of opioid-related adverse events and IV-related complications are also added, the total costs can amount to $269-$273. Of these 7.3 million encounters, 4.3 million (58%) did not lead to hospital admission of the patient and, therefore, the patient may have only required an IV catheter for opioid administration. Conclusions: IV opioid use in the ED is indicated for moderate-to-severe pain but is associated with significant costs. In subjects who are discharged from the ED and may not have required an IV for reasons other than opioid administration, rapid-onset analgesics for moderate-to-severe pain that do not require IV administration could lead to direct cost reductions and improved care.
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Affiliation(s)
| | - Judith A Walker
- QuintilesIMS, Alba Campus, Rosebank, Livingston, West Lothian, UK
| | - Asad E Patanwala
- Department of Pharmacy Practice and Science College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Carin A Hagberg
- Department of Anesthesiology, UTHealth The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
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The Safe and Rational Use of Analgesics: Opioid Analgesics. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Smith JE, Rockett M, Creanor S, Squire R, Hayward C, Ewings P, Barton A, Pritchard C, Eyre V, Cocking L, Benger J. PAin SoluTions In the Emergency Setting (PASTIES)--patient controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial. BMJ 2015; 350:h3147. [PMID: 26094712 PMCID: PMC4476026 DOI: 10.1136/bmj.h3147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine whether patient controlled analgesia (PCA) is better than routine care in providing effective analgesia for patients presenting to emergency departments with moderate to severe non-traumatic abdominal pain. DESIGN Pragmatic, multicentre, parallel group, randomised controlled trial SETTING Five English hospitals. PARTICIPANTS 200 adults (66% (n=130) female), aged 18 to 75 years, who presented to the emergency department requiring intravenous opioid analgesia for the treatment of moderate to severe non-traumatic abdominal pain and were expected to be admitted to hospital for at least 12 hours. INTERVENTIONS Patient controlled analgesia or nurse titrated analgesia (treatment as usual). MAIN OUTCOME MEASURES The primary outcome was total pain experienced over the 12 hour study period, derived by standardised area under the curve (scaled from 0 to 100) of each participant's hourly pain scores, captured using a visual analogue scale. Pre-specified secondary outcomes included total morphine use, percentage of study period in moderate or severe pain, percentage of study period asleep, length of hospital stay, and satisfaction with pain management. RESULTS 196 participants were included in the primary analyses (99 allocated to PCA and 97 to treatment as usual). Mean total pain experienced was 35.3 (SD 25.8) in the PCA group compared with 47.3 (24.7) in the treatment as usual group. The adjusted between group difference was 6.3 (95% confidence interval 0.7 to 11.9). Participants in the PCA group received significantly more morphine (mean 36.1 (SD 22.4) v 23.6 (13.1) mg; mean difference 12.3 (95% confidence interval 7.2 to 17.4) mg), spent less of the study period in moderate or severe pain (32.6% v 46.9%; mean difference 14.5% (5.6% to 23.5%)), and were more likely to be perfectly or very satisfied with the management of their pain (83% (73/88) v 66% (57/87); adjusted odds ratio 2.56 (1.25 to 5.23)) in comparison with participants in the treatment as usual group. CONCLUSIONS Significant reductions in pain can be achieved by PCA compared with treatment as usual in patients presenting to the emergency department with non-traumatic abdominal pain. Trial registration European Clinical Trials Database EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280.
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Affiliation(s)
- Jason E Smith
- Derriford Hospital, Plymouth PL6 8DH, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Medical Directorate, Birmingham, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mark Rockett
- Derriford Hospital, Plymouth PL6 8DH, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Siobhan Creanor
- Centre for Biostatistics, Bioinformatics and Biomarkers, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Chris Hayward
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | | | | | - Victoria Eyre
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Laura Cocking
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Smith JE, Rockett M, S SC, Squire R, Hayward C, Ewings P, Barton A, Pritchard C, Eyre V, Cocking L, Benger J. PAin SoluTions In the Emergency Setting (PASTIES)--patient controlled analgesia versus routine care in emergency department patients with pain from traumatic injuries: randomised trial. BMJ 2015; 350:h2988. [PMID: 26094763 PMCID: PMC4476025 DOI: 10.1136/bmj.h2988] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To determine whether patient controlled analgesia (PCA) is better than routine care in patients presenting to emergency departments with moderate to severe pain from traumatic injuries. DESIGN Pragmatic, multicentre, parallel group, randomised controlled trial. SETTING Five English hospitals. PARTICIPANTS 200 adults (71% (n = 142) male), aged 18 to 75 years, who presented to the emergency department requiring intravenous opioid analgesia for the treatment of moderate to severe pain from traumatic injuries and were expected to be admitted to hospital for at least 12 hours. INTERVENTIONS PCA (n = 99) or nurse titrated analgesia (treatment as usual; n = 101). MAIN OUTCOME MEASURES The primary outcome was total pain experienced over the 12 hour study period, derived by standardised area under the curve (scaled from 0 to 100) of each participant's hourly pain scores, captured using a visual analogue scale. Pre-specified secondary outcomes included total morphine use, percentage of study period in moderate/severe pain, percentage of study period asleep, length of hospital stay, and satisfaction with pain management. RESULTS 200 participants were included in the primary analyses. Mean total pain experienced was 47.2 (SD 21.9) for the treatment as usual group and 44.0 (24.0) for the PCA group. Adjusted analyses indicated slightly (but not statistically significantly) lower total pain experienced in the PCA group than in the routine care group (mean difference 2.7, 95% confidence interval -2.4 to 7.8). Participants allocated to PCA used more morphine in total than did participants in the treatment as usual group (mean 44.3 (23.2) v 27.2 (18.2) mg; mean difference 17.0, 11.3 to 22.7). PCA participants spent, on average, less time in moderate/severe pain (36.2% (31.0) v 44.1% (31.6)), but the difference was not statistically significant. A higher proportion of PCA participants reported being perfectly or very satisfied compared with the treatment as usual group (86% (78/91) v 76% (74/98)), but this was also not statistically significant. CONCLUSIONS PCA provided no statistically significant reduction in pain compared with routine care for emergency department patients with traumatic injuries. Trial registration European Clinical Trials Database EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280.
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Affiliation(s)
- Jason E Smith
- Derriford Hospital, Plymouth PL6 8DH, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Medical Directorate, Birmingham, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mark Rockett
- Derriford Hospital, Plymouth PL6 8DH, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Siobhan Creanor S
- Centre for Biostatistics, Bioinformatics and Biomarkers, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Chris Hayward
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | | | | | - Victoria Eyre
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Laura Cocking
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Abstract
This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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20
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Xia S, Choe D, Hernandez L, Birnbaum A. Does Initial Hydromorphone Relieve Pain Best if Dosing Is Fixed or Weight Based? Ann Emerg Med 2014; 63:692-8.e4. [DOI: 10.1016/j.annemergmed.2013.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 09/24/2013] [Accepted: 10/04/2013] [Indexed: 11/29/2022]
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Abstract
This paper is the thirty-fifth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2012 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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22
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Abstract
Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.
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Smith JE, Rockett M, Squire R, Hayward CJ, Creanor S, Ewings P, Barton A, Pritchard C, Benger JR. PAin SoluTions In the Emergency Setting (PASTIES); a protocol for two open-label randomised trials of patient-controlled analgesia (PCA) versus routine care in the emergency department. BMJ Open 2013; 3:bmjopen-2013-002577. [PMID: 23418302 PMCID: PMC3586149 DOI: 10.1136/bmjopen-2013-002577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Pain is the commonest reason that patients present to an emergency department (ED), but it is often not treated effectively. Patient controlled analgesia (PCA) is used in other hospital settings but there is little evidence to support its use in emergency patients. We describe two randomised trials aiming to compare PCA to nurse titrated analgesia (routine care) in adult patients who present to the ED requiring intravenous opioid analgesia for the treatment of moderate to severe pain and are subsequently admitted to hospital. METHODS AND ANALYSIS Two prospective multi-centre open-label randomised trials of PCA versus routine care in emergency department patients who require intravenous opioid analgesia followed by admission to hospital; one trial involving patients with traumatic musculoskeletal injuries and the second involving patients with non-traumatic abdominal pain. In each trial, 200 participants will be randomised to receive either routine care or PCA, and followed for the first 12 h of their hospital stay. The primary outcome measure is hourly pain score recorded by the participant using a visual analogue scale (VAS) over the 12 h study period, with the primary statistical analyses based on the area under the curve of these pain scores. Secondary outcomes include total opioid use, side effects, time spent asleep, patient satisfaction, length of hospital stay and incremental cost effectiveness ratio. ETHICS AND DISSEMINATION The study is approved by the South Central-Southampton A Research Ethics Committee (REC reference 11/SC/0151). Data collection will be completed by August 2013, with statistical analyses starting after all final data queries are resolved. Dissemination plans include presentations at local, national and international scientific meetings held by relevant Colleges and societies. Publications should be ready for submission during 2014. A lay summary of the results will be available to study participants on request, and disseminated via a publically accessible website. REGISTRATION DETAILS The study is registered with the European Clinical Trials Database (EudraCT Number: 2011-000194-31) and is on the ISCRTN register (ISRCTN25343280).
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Affiliation(s)
- Jason E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| | - Mark Rockett
- Department of Anaesthesia and Pain Medicine, Derriford Hospital, Plymouth, UK
| | | | | | - Siobhan Creanor
- Centre for Health and Environmental Statistics, University of Plymouth, Plymouth, UK
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