Patient controlled analgesia (PCA) can be used effectively in emergency department patients dealing with moderate or severe pain, according to results of the Pain Solutions in the Emergency Setting (PASTIES) studies (here and here).
The trials showed significant improvement in pain control in patients with nontraumatic abdominal pain who received PCA over nurse titrated analgesia, and a small but not statistically significant improvement in pain control in trauma patients. Patients who received PCA were much more satisfied with their care.
“Patient controlled analgesia is used to good effect in other areas of the hospital, but not typically in emergency patients,” Jason E. Smith, MBBS, MSc, consultant in emergency medicine at Derriford Hospital in Plymouth, United Kingdom, told Reuters Health by email.
The U.K.-based PASTIES research team conducted two pragmatic, multicenter parallel group randomized controlled trials, enrolling 200 adults with acute nontraumatic abdominal pain in one study and 200 adults with acute traumatic injury in the other study.
The studies included only patients who needed boluses of morphine, titrated and given by a nurse in the ED, and were expected to stay in the hospital for at least 12 hours. “We looked at pain over a 12-hour period—the first study to look at this vulnerable period between emergency care and inpatient care,” Dr. Smith said. Participants in each study were randomly allocated to PCA or nurse-titrated analgesia (usual care).
In the nontraumatic abdominal pain patients, the PCA group reported significantly less pain overall than the usual care group. The PCA group spent 14.5 percent less time in moderate or severe pain over 12 hours, received significantly more morphine (mean difference 12.3 mg), and had about a 2.5-fold increase in the likelihood of being very or completely satisfied with their pain management.
In the acute traumatic injury patients, pain scores were also lower and satisfaction scores higher with PCA, but the differences failed to reach statistical significance relative to usual care.
In an editorial in the BMJ, Fiona Lecky, MB ChB, MSc, PhD, clinical professor of emergency medicine at the University of Sheffield, United Kingdom, said, “The inconsistent results could be due to differing pain mechanisms in the two populations (visceral in abdominal pain, somatic in acute traumatic injury), a type 2 error in the study of acute traumatic injury (whereby the study failed to find an existing difference between treatments owing to methodological factors such as low power), or type 1 error in the abdominal pain study (whereby the study found a difference where none existed).”
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One Response to “Patient-Controlled Analgesia Works in the Emergency Department”
July 26, 2015
John CastleI’m a 67 y/o WM PA. I have chronic pain from my 35 years of Naval service which included years of “humping” with the Marines. As a result of the above, I’m a “chronic pain” patient with a lot of spinal DJD. I also have had contact with the medical system as an acute pain patient for myself, and my wife just had a C-section. In all of these encounters it appears to me that we have more of a pain control problem than just using a PCA in the ER.
For twenty (20) years I have been on Tramadol prn for “break through” arthritis pain. I was never an “addict” until the FDA made tramadol a controlled medication. Now I can only get tramadol by “doctor shopping.” And everyone wants to send me for “injections” to protect themselves, and the injections have a checkered perception based on mixed results on studies of their efficacy.
I had an acute prostatitis a few weeks ago. I could ONLY get tramadol for that pain, since the urgent care clinic didn’t carry triplicates and couldn’t give me anything “stronger.” Tylenol #3 wasn’t even offered. To directly ask for something stronger put me at risk of being identified as a “drug seeker,” and that medical record was available to the entire medical center, including to my bosses. It was a risk I was unwilling to take.
My wife just had a C-section. The OB dept didn’t have triplicates and so could only give her Tylenol #3, a condition for which for many years a woman would get a hydrocodone or Percocet RX.
For years we’ve endured EBM that said we weren’t providing our patients enough pain control, thus the irritating evolution of asking 4 y/o children their pain level from 1-10 with a happy face schema to help them describe it. Now it doesn’t matter because the Schedule of controlled drugs now controls our medicine and EBM doesn’t matter.
I remember when my attending at Naval Medical Center San Diego bawled me out for not giving a few Vicodin to a patient to keep them from lodging a complaint against us and thus hurting our quality scores. We as practitioners are continually complaining about the “drug seeker.” Now we can’t even control real pain in patients because the feds control our practice. And as a PA I am dedicated to practicing within the parameters of my supervising physician. If he/she is a wimp and afraid of the feds, the patient suffers.
Physicians — any answers?
Blessings.