Comparative Effectiveness of Patient-Controlled Analgesia for Treating Acute Pain in the Emergency Department - 22/11/17
, Angela M. Mills, MD c, Andrew K. Chang, MD, MS d, Deborah White, MD a, Andrew Restivo, MD a, Shaun Persaud, MS a, Clyde B. Schechter, MD, MA b, E. John Gallagher, MD a, Adrienne J. Birnbaum, MD, MS aAbstract |
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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| Please see page 810 for the Editor’s Capsule Summary of this article. |
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| Dr. Chang is currently affiliated with Albany Medical Center, Albany, NY. |
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| Supervising editor: Donald M. Yealy, MD |
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| Author contributions: PEB and AJB conceived the study, designed the trial, and obtained research funding. AMM, AKC, AR, and SP supervised the conduct of the trial and data collection at each site. CS provided statistical advice and PEB analyzed the data. EJG provided consultation and guidance on study design and the ongoing functioning of the study. PEB drafted the manuscript, and all authors contributed substantially to its revision. PEB takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). Drs. Bijur, Birnbaum, Schechter, and Mr. Persaud were supported by a grant from the National Institute of Nursing Research (NINR) (1R01NR013980). |
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| Trial registration number: NCT01775371 |
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| The NINR had no role in determination of study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication. |
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| A podcast for this article is available at www.annemergmed.com. |
Vol 70 - N° 6
P. 809 - décembre 2017 Retour au numéro
Article précédent
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