Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain

Abstract

Background: The question of whether it is safe to provide analgesia for patients with undifferentiated acute abdominal pain is marked by longstanding controversy over the possible masking of physical findings. The goal of this review is to assess the pertinent studies.Method: A Medline search was performed in April 2002, using the terms 'analgesia', 'abdominal pain', 'acute abdomen' and 'morphine'. Other articles were identified using the bibliographies of papers found through Medline. All articles reporting clinical trials of analgesia and its effects on diagnosis or physical examination were reviewed.Results: A total of eight trials (one reported only as an abstract) were identified. Because of significant disparity in trial design, no formal analysis such as meta-analysis was performed. However, detailed review of the trials revealed a striking consistency in results. In no study was there an association between analgesia and diagnostic impairment or dangerous masking of the findings of physical examination. Conclusion:The literature addressing early pain relief for abdominal pain is characterized by weaknesses, but there is a common theme suggesting that analgesia is safe. Pending further research, which should address some of the shortcomings of extant studies, a practice of judicious provision of analgesia appears safe, reasonable and in the best interests of patients in pain.

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments

“…38 Still, we believe that 14% remains unacceptably high; ample evidence currently supports the pre-diagnostic administration of analgesia. 13,14,[39][40][41][42][43][44][45][46] Furthermore, although the proportion of respondents withholding analgesia due to the belief it may mask a surgical diagnosis is significantly lower than reported in other studies, it still portends a delayed approach to providing analgesia in children with abdominal pain and emphasizes the need for wider knowledge translation. Although the majority of respondents indicated they would provide analgesia in an appendicitis scenario (and AAP recommends to provide systemic opioids for severe pain 40 ), less than two-thirds of survey respondents reported a willingness to provide intravenous opioids, despite a pain score of 8 out of 10.…”

Management of Pain in the Emergency Department

“…It is undoubtedly the case that severe pain can create barriers to obtaining an adequate history and physical exam, and also that removal of these barriers by pain relief can facilitate better patient care [3,8]. The risks of analgesia should always be kept in mind, but a fair risk/benefit assessment should include the potential upside to making patients more comfortable.…”

“…Analgesia in the setting of undifferentiated abdominal pain has long been an area for controversy; the idea is that "covering the physical findings" will worsen outcomes [8,214]. Fortunately, there are sufficient data refuting this idea-an idea based upon historical cautions formulated due to problems with large opioid doses in the preradiology era-that the question has been answered to a reasonable degree of certainty [179,[215][216][217][218][219][220][221][222][223][224][225][226].…”

Introduction and general approach to pain

“…It is now standard care to provide analgesia for patients with undifferentiated abdominal pain while performing necessary investigations. 7 New frontiers, such as nurse-initiated analgesics while the patient is in triage or with the use of delegated acts, are growing rapidly. [8][9][10][11] Patients in many EDs are now routinely provided topical or local anesthesia for simple (yet painful)…”

“…Perhaps most importantly, the absence of such signs does not exclude the experience of pain. [6][7][8][9][10] The very idea of quantifying pain is somewhat controversial. Germaine to the debate is a nineteenth century contention made by William Thomson (Lord Kelvin) that worthy knowledge should be quantifiable in the form of…”