Longitudinal Trends in the Treatment of Abdominal Pain in an Academic Emergency Department

Background

Abdominal pain is a top chief complaint of patients presenting to Emergency Departments (ED). Historically, uncertainty surrounded correct management. Evidence has shown adequate analgesia does not obscure the diagnosis, making it the standard of care.

Objective

We sought to evaluate trends in treatment of abdominal pain in an academic ED during a 10-year period.

Methods

We prospectively evaluated a convenience sample of patients in an urban academic tertiary care hospital ED from September 2000 through April 2010. Adult patients presenting with a chief complaint of abdominal pain were included in this study. Analgesic administration rates and times, pain scores, and patient satisfaction at discharge were analyzed to evaluate trends by year.

Results

There were 2,646 patients presenting with abdominal pain who were enrolled during the study period. Rates of analgesic administration generally increased each year from 39.9% in 2000 to 65.5% in 2010 (p value for trend <0.001). Similarly, time to analgesic administration generally decreased by year, from 116 min in 2000 to 81 min in 2009 (p < 0.001). There was no improvement in mean pain scores at discharge by year (p = 0.27) and 48% of patients during the 10-year period still reported moderate to severe pain at discharge. Patient satisfaction with pain treatment increased from a score of 7.1 to 9.0 during the study period (p < 0.005), following the trend of increase in analgesic administration.

Conclusions

In patients presenting to the ED with abdominal pain, analgesia administration increased and time to medication decreased during the 10-year period. Despite overall improvements in satisfaction, significant numbers of patients presenting with abdominal pain still reported moderate to severe pain at discharge.     

Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain

Objectives:  Oligoanalgesia for acute abdominal pain historically has been attributed to the provider's fear of masking serious underlying pathology. The authors assessed whether a gender disparity exists in the administration of analgesia for acute abdominal pain.
Methods:  This was a prospective cohort study of consecutive nonpregnant adults with acute nontraumatic abdominal pain of less than 72 hours' duration who presented to an urban emergency department (ED) from April 5, 2004, to January 4, 2005. The main outcome measures were analgesia administration and time to analgesic treatment. Standard comparative statistics were used.
Results:  Of the 981 patients enrolled (mean age ± standard deviation [SD] 41 ± 17 years; 65% female), 62% received any analgesic treatment. Men and women had similar mean pain scores, but women were less likely to receive any analgesia (60% vs. 67%, difference 7%, 95% confidence interval [CI] = 1.1% to 13.6%) and less likely to receive opiates (45% vs. 56%, difference 11%, 95% CI = 4.1% to 17.1%). These differences persisted when gender-specific diagnoses were excluded (47% vs. 56%, difference 9%, 95% CI = 2.5% to 16.2%). After controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes).
Conclusions:  Gender bias is a possible explanation for oligoanalgesia in women who present to the ED with acute abdominal pain. Standardized protocols for analgesic administration may ameliorate this discrepancy.     

A Randomized Clinical Trial of Analgesia in Children with Acute Abdominal Pain

OBJECTIVE: To evaluate the effects of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain. METHODS: A randomized, double-blind, placebo-controlled clinical trial was conducted at an emergency department of a tertiary care children's hospital. Children aged 5-18 years with abdominal pain of < or =5 days' duration, pain score > or =5 on a 0-10 visual analog scale, and need for surgical evaluation were eligible. Following the initial assessment, patients were randomized to receive either 0.1 mg/kg morphine or an equal volume of saline. The pediatric emergency medicine physician and surgical consultant independently recorded the areas of tenderness to palpation and percussion, and their diagnoses before the study medication and 15 to 30 minutes later. RESULTS: Sixty patients were enrolled, and 29 received morphine and 31 received saline. The demographic characteristics between the two groups were similar. The median reduction of pain score between the two study groups was 2 (95% CI = 1 to 4; p = 0.002). There was no significant change in the areas of tenderness in both study groups. Children with surgical conditions had persistent tenderness to palpation and/or percussion. There was no significant change in the diagnostic accuracy between the study groups and between the physician groups. All patients requiring laparotomy were identified and no significant complication was noted in the morphine group. CONCLUSIONS: Intravenous morphine provides significant pain reduction to children with acute abdominal pain without adversely affecting the examination, and morphine does not affect the ability to identify children with surgical conditions.     

Changing Opioid Use for Right Lower Quadrant Abdominal Pain in the Emergency Department

Objectives: To compare the use of opioid analgesia in the treatment of emergency department patients with acute right lower quadrant (RLQ) abdominal pain between 1998 and 2003 and to explore the relationship between opioid use and abdominal computed tomography (CT) scanning. Methods: This was a retrospective cohort study of patients presenting in 1998 and 2003 to an urban emergency department with a triage complaint of RLQ pain. The authors abstracted use and timing of abdominal CT scanning and opioid analgesia. Other predictor variables were patient demographics. Risk ratio for receiving opioids with CT scan versus without CT scan, stratifying by year, were calculated. Proportional‐hazards analysis was used to control for time in the emergency department. Results: Of the 187 patients seen in 1998, 38 (20%) underwent CT scanning and 43 (23%) received opioids. Of the 137 patients seen in 2003, 77 (56%) underwent CT scanning and 72 (53%) received opioids. In 1998, the risk ratio for receiving opioids in patients who underwent CT scanning (vs. without) was 3.7 (95% confidence interval [CI] = 2.3 to 6.1); in 2003, it was 1.5 (95% CI = 1.0 to 2.1). Opioids were overwhelmingly given before CT scanning in those patients who received both (81% in 1998 and 98% in 2003). The mean time to administration of the first opioid dose in 1998 was 155 minutes and in 2003 was 94 minutes. The proportional‐hazards analysis confirmed a strong association between CT scanning and opioid administration in 1998 (relative hazard, 2.7; 95% CI = 1.5 to 5.1) and substantial attenuation of the association in 2003 (relative hazard, 1.3; 95% CI = 0.8 to 2.1). The hospitalization rate was not significantly different in 2003 (33%) versus 1998 (27%) (p = 0.28). The risk ratio of receiving opioids in admitted patients was 2.8 (95% CI = 1.7 to 4.6) in 1998 and 2.0 (95% CI = 1.5 to 2.7) in 2003. Conclusions: Opioid administration to patients with RLQ pain has dramatically increased between 1998 and 2003. During these five years, the number of patients receiving opioids more than doubled and the time to first administration of opioids decreased by one hour. The authors show that this cannot be attributed to an increased use of CT scanning.     

Accelerated stability model for predicting shelf-life

Second- and higher-order degradation reactions sometimes cannot be approximated with linear or exponential relationships and need to be appropriately modeled. Events above the COULTER HmX Analyzer white blood cell (WBC) counting threshold were recorded for the HmX PAK reagent system stored at five elevated temperatures. An accelerated stability model for a second-degree polynomial degradation pattern was used. The shelf-life of the reagent, along with 95% lower bound confidence intervals, is predicted using the same pattern of degradation as well as the Arrhenius approximation. Experiments indicated that the degradation of the HmX PAK reagent occurred in two phases, the lag phase and the degradation phase, in all tested temperatures. The phase durations are temperature-dependent, and the Arrhenius approximation is appropriate (P=0.639). The degradation of the reagent during the lag phase was experimentally undetectable. Changes of the reagent were nonsignificant for a predicted period of 164 days at 25 degrees C. The rate of degradation increased significantly later on during the degradation phase. The lower bound of the 95% confidence interval of this prediction indicated that it would take at least 326 days before the HmX PAK reagent would have any performance issue related to aging at storage temperature.     

Transversus Abdominis Block: Clinical Uses,Side Effects,and Future Perspectives

Poorly controlled acute pain during the postoperative setting after abdominal surgery can be detrimental to the patient. Current pain management practices for the postoperative abdominal surgery patient rely heavily on opioids, which are associated with many unwanted side effects. Recently, interest surrounding regional anesthesia has been growing owing to its demonstrated efficacy and safety outcomes. More specifically, the transversus abdominis plane (TAP) block procedure has attracted attention owing to its ability to successfully block peripheral pain signaling in the abdomen, its ease of use, few complications, and its greater acceptability. A majority of the studies published has demonstrated the successful reduction in pain in many abdominal surgical procedures using local anesthetics during the TAP block. However, the short duration of the pain block causes the patient to still rely on other analgesics throughout the additional postoperative days. Preliminary studies using continuous infusion catheters placed in the TAP has been one of the ways to prolong the nerve block in the abdomen; however, technical and operational issues currently limit the widespread adoption of this method. In this review, current studies will be presented and summarized to update the field on the potential benefits of the TAP block procedure, in addition to providing insight into the future direction of the drugs that could be used for TAP block.     

The Association between Emergency Department Crowding and Analgesia Administration in Acute Abdominal Pain Patients

Objectives:  The authors assessed the effect of emergency department (ED) crowding on the nontreatment and delay in treatment for analgesia in patients who had acute abdominal pain.
Methods:  This was a secondary analysis of prospectively enrolled nonpregnant adult patients presenting to an urban teaching ED with abdominal pain during a 9-month period. Each patient had four validated crowding measures assigned at triage. Main outcomes were the administration of and delays in time to analgesia. A delay was defined as waiting more than 1 hour for analgesia. Relative risk (RR) regression was used to test the effects of crowding on outcomes.
Results:  A total of 976 abdominal pain patients (mean [±standard deviation] age = 41 [±16.6] years; 65% female, 62% black) were enrolled, of whom 649 (67%) received any analgesia. Of those treated, 457 (70%) experienced a delay in analgesia from triage, and 320 (49%) experienced a delay in analgesia after room placement. After adjusting for possible confounders of the ED administration of analgesia (age, sex, race, triage class, severe pain, final diagnosis of either abdominal pain not otherwise specified or gastroenteritis), increasing delays in time to analgesia from triage were independently associated with all four crowding measures, comparing the lowest to the highest quartile of crowding (total patient-care hours RR = 1.54, 95% confidence interval [CI] = 1.32 to 1.80; occupancy rate RR = 1.64, 95% CI = 1.42 to 1.91; inpatient number RR = 1.57, 95% CI = 1.36 to 1.81; and waiting room number RR = 1.53, 95% CI = 1.31 to 1.77). Crowding measures were not associated with the failure to treat with analgesia.
Conclusions:  Emergency department crowding is associated with delays in analgesic treatment from the time of triage in patients presenting with acute abdominal pain.     

早期镇痛对急腹症诊疗影响的Meta分析

目的：探讨早期镇痛对急腹症诊疗准确性的影响。方法：计算机检索Pubmed、Embase、Cochrane database、CBM、CNKI、万方数据库,查找所有关于早期镇痛对急腹症诊治影响的随机对照实验（RCT）,检索时限为建库至2013-09-30。按纳入排除标准再由两人独立进行RCT筛选、资料提取及质量评价。最后再应用Rev-Man5．2软件进行Meta分析。结果：在急腹症的腹部体格检查上,纳入7个随机对照研究,镇痛组381名患者,对照组350名患者,结果显示应用镇痛药并没有增加腹部体格检查的风险性,其相对危险度（RR）为0．90[95％CI（0．80,1．02）]。在急腹症疾病诊断的敏感性上,纳入9个随机对照研究,镇痛组574名患者,对照组520名患者,结果同样显示应用镇痛药没有增加诊断准确性的风险性,其RR为1．03E95％CI（0．90,1．08）]。结论：早期镇痛对于急腹症的体格检查及疾病的诊疗上并没有显著的影响。     

Operator confidence correlates with more accurate abdominal ultrasounds by emergency medicine residents

The purpose of this study was to assess whether greater operator confidence correlates with more accurate focused abdominal ultrasounds (FAUS) by residents. This was a prospective study of novice residents performing FAUS in patients with abdominal pain. FAUS included focused assessment with sonography for trauma, gall bladder, renal, and aortic examinations. Residents answered the question, “How confident are you of your findings?” using a visual scale from 1 (doubtful) to 5 (certain). The results of the resident-performed FAUS were compared to subsequent criterion evaluations. Thirty-eight residents with an average experience of 27 (95% confidence interval [CI] 18–36) prior US examinations evaluated 504 patients. Greater operator confidence correlated with improved accuracy of FAUS (R² = 0.858, p = 0.0369). Sensitivity and specificity were 14% (95% CI 4–37 %) and 71% (95% CI 48–88 %) with a confidence level of 2/5 but 85% (95% CI 73–93 %) and 100% (95% CI 97–100 %) with a confidence level of 5/5. Greater operator confidence correlates with improved accuracy in FAUS. This should be considered in the development of training guidelines.     

开展镇痛教育对腹腔手术患者镇痛认知度及术后镇痛需求的影响

目的通过镇痛知识教育提高患者对术后镇痛的认知度，改善术后镇痛需求，有效控制术后疼痛。方法将168例择期腹腔手术患者按入院先后顺序随机分为实施镇痛教育组（观察组）和未实施镇痛教育组（对照组）各84例。对照组由责任护士在患者入院后一对一实施常规疼痛健康教育。观察组在对照组的基础上增加镇痛知识教育，统一教育内容，包括术后镇痛的临床意义、术后常用镇痛方法、镇痛方法优缺点、术后镇痛注意事项、止痛药的不良反应、』临床使用止痛药的常见误区，术前1d再次复述巩固教育内容。术前1d由责任护士用同一指导语进行问卷调查，评估患者对术后镇痛的认知度，术后2d内由责任护士询问和记录每位患者的不同镇痛需求。结果两组患者对镇痛的认知情况比较差异具有统计学意义。观察组患者对镇痛的临床意义、术后常用镇痛方法、镇痛方法优缺点、术后镇痛注意事项、使用止痛药的常见误区等知识的了解多于对照组（P〈0．005）。两组患者术后不同镇痛需求比较差异具有统计学意义，试验组患者术后使用PCA镇痛例数、肌内注射杜冷丁镇痛和口服止痛药的例数明显多于对照组（P〈0．005）。结论开展镇痛知识教育能显著提高患者对镇痛的认知度，提高患者术后镇痛的接受程度，改善患者术后镇痛需求，有效控制术后疼痛。     

Etiology of non-traumatic acute abdomen in pediatric emergency departments

Acute abdominal pain is a common complaint in pediatric emergency departments. A complete evaluation is the key factor approaching the disease and should include the patient’s age, any trauma history, the onset and chronicity of the pain, the related symptoms and a detailed physical examination. The aim of this review article is to provide some information for physicians in pediatric emergency departments, with the age factors and several causes of non-traumatic acute abdominal pain. The leading causes of acute abdominal pain are divided into four age groups: infants younger than 2 years old, children 2 to 5, children 5 to 12, and children older than 12 years old. We review the information about acute appendicitis, intussusception, Henoch-Schönlein purpura, infection, Meckel’s diverticulum and mesenteric adenitis. In conclusion, the etiologies of acute abdomen in children admitted to the emergency department vary depending on age. A complete history and detailed physical examination, as well as abdominal imaging examinations, could provide useful information for physicians in the emergency department to narrow the differential diagnosis of abdominal emergencies and give a timely treatment.     

Postoperative pain control - the impact of an acute pain team

A two year prospective audit of the severity of postoperative pain and sedation in 1,781 patients receiving either patient controlled or epidural infusion analgesia (PCA or EIA) is presented. The introduction of an acute pain team (APT) led to sequential changes in procedures and policies, including nurse prescribing. The percentage of patients with moderate to severe pain fell from 35 to 11% for PCA and 35 to 22% for EIA following the introduction of the APT.     

105例学龄儿童再发性腹痛的调查分析

目的调查学龄儿童再发性腹痛（recurrent abdominal pain,RAP）胃镜下表现,并分析RAP病因,探讨护理对策。方法对105例RAP学龄儿童行电子胃镜检查,钳取胃窦黏膜活组织行快速尿素酶检测。根据镜检结果判断上消化道疾病与幽门螺旋杆菌（Helicobacter Pylori HP）感染的关系,结合病史找出其疾病的诱发因素,制定个性化的护理措施。结果105例儿童均顺利完成胃镜检查,胃镜下病变检出率为97．14％,HP感染率为41．90％。所有患儿经精心治疗和护理后复诊,症状基本消失,其中2例十二指肠溃疡患儿6个月后胃镜复查提示已治愈。结论上消化道疾患是学龄儿童RAP的主要病因;HP感染是上消化道疾病的重要致病因素;而学习压力过大精神紧张和无规律饮食是学龄儿童上消化道疾病的诱发因素。有效的护理能及早发现疾病,规范治疗程序和减少诱发因素。     

术后疼痛管理新进展

术后疼痛管理的新理念包括多模式镇痛、超前镇痛和个体化镇痛,目前国外的术后疼痛管理完成了从以麻醉医生为主体到以护士为主体的转变,术后疼痛评估常态化、常规化,同时将个人数字助理（PDA)用于术后镇痛随访,使用无线远程镇痛监控系统进行术后疼痛管理。这些措施有效地提高了术后镇痛的效果,并实现了个体化的术后疼痛管理,提高了患者对术后镇痛的满意度,减少了医护人员的工作量,提高了工作效率。     

A Randomized-Controlled Study of Intrathecal Versus Epidural Thoracic Analgesia in Patients Undergoing Abdominal Cancer Surgery

BACKGROUND: We sought to determine the effectiveness of continuous intrathecal thoracic analgesia (ITA) in comparison with continuous epidural thoracic analgesia (ETA) for the management of postoperative pain after abdominal cancer surgery in a randomised controlled study. MATERIALS AND METHODS: Catheters were inserted at T8-10 level for both techniques. Sixty patients were randomized to receive ITA providing levobupivacaine 0.25%, at 0.5-0-7 ml/h, associated with a single bolus of morphine 0.15 mg, or ETA with levobupivacaine 0.25% 4-6 ml/h and a single bolus of epidural morphine 2-3 mg. Data were collected before discharging from recovery room to the surgical ward, 1, 2, 3, 8, 12, 24 h, and 48 h after operation. The primary outcome was pain intensity evaluation. Postoperative morphine consumption, hemodynamics, fluids, and blood losses for the first postoperative 48 h, surgical outcome, hospital stay, and complications were also collected. RESULTS: Pain intensity at rest mean values ranged from 1.12 to 1.44 and from 1.04 to 1.20 in ITA group and ETA group, respectively. Dynamic pain intensity mean values ranged from 1.28 to 1.70 and from 1.16 to 1.80 in ITA group and ETA group, respectively. No significant differences were found between the two groups. Total amount morphine consumption was minimal in both groups, 4.4 mg (+/-2.9) and 3.1 mg (+/-2.4), for ITA and ETA groups, respectively. There were no severly sedated patients. Hemodynamic variables, diuresis, amounts of fluids, and red cell transfusion were equivalent between the groups. No important technical complications were reported in both groups and postoperative surgical complications were not related to the examined techniques. CONCLUSION: ITA and ETA produced the same levels of analgesia, without relevant complications.     

Overview of current development in patient-controlled analgesia

Over the past two decades, numerous trials have assessed the safety and efficacy of patient-controlled analgesia (PCA). Advantages over conventional parenteral narcotics reported from these trials include equivalent to superior pain relief, superior patient satisfaction, decreased sedation and anxiety, faster return to normal functional status, and reduction in nursing time and hospitalization. The majority of these trials have been conducted in the postoperative patient population. In the mid to late 1980s, interest arose in applying PCA technology to the management of cancer pain. Factors that served as an impetus for the use of PCA in cancer pain included favorable reports from the postoperative setting and the often-cited statistics regarding the magnitude of the cancer pain problem. Advances in PCA technology coupled with advances in vascular access technology that allow the placement of long-term ports and catheters to facilitate intravenous, epidural, or intrathecal administration of opioid analgesics have made the applicability of PCA in ambulatory cancer patients an attractive option. The greatest break-through in PCA technology came with the introduction of devices making it possible to choose between intermittent (demand bolus) and continuous administration (continuous infusion) or both intermittent and continuous modes. A comparison of these types of PCA devices is described. The limitations of the literature involving PCA therapy in cancer patients make it difficult to identify optimal patient selection criteria, PCA administration schedules, drug selection and dosing, and optimal route of administration. The current status and pertinent issues related to these topics are addressed.Presented as an invited lecture at the 6th International Symposium: Supportive Care in Cancer, New Orleans, La., USA, 2–5 March 1994