Opiates in Acute Abdomen RCE


Question: “Do opiates affect the clinical evaluation of patients with acute abdominal pain?”

Original Citation JAMA, October 11, 2006 – Vol 296, No. 14 pp 1764-1774

Bottom Line

• Opiate administration changes the physical exam findings but not the clinical outcome. Clinical examination alone rarely diagnoses surgical abdomen. It is a generally accepted view that history alone provides most of the crucial information necessary for a diagnosis. It is a rarity for all but unstable patients to go to the OR without first stopping at the CT. Abdominal imaging has decreased the emphasis in practice on the physical examination as a decision-making tool for patients with acute abdominal pain.

SORT Grade of Recommendation: Level B – Lower quality trials or inconsistent findings

Updated Search Findings: Additional article supports above findings and makes similar summary points.

Comments/Hints/Suggestions

“A 1999 survey showed 69% of general surgeons preferred that pain medication not be administered before they could examine the patient in the belief that analgesia could impair the accuracy of diagnosis by obscuring physical examination findings. Most emergency medicine physicians still defer analgesia until after surgical evaluation…”

“Articles in the RCE series generally address the degree to which specific components of the clinical examination allow clinicians to rule in or rule out target diagnoses, including conditions that present as an “acute abdomen”… However, the diagnosis of the patient experiencing abdominal pain is rarely certain, and the initial examining physician is usually not the surgeon responsible for the operative decision.”

“While giving opiates to patients with acute abdominal pain appears to alter the physical examination, the use of opiates leads to virtually no increase in incorrect management decisions.”

“We examined the effects of opiates on the clinical examination of patients with abdominal pain and also evaluated the effect of opiates on the operative decision, to determine the impact of changes in the examination.”

The most common analgesic regimen was 0.05-0.1mg/kg IV morphine with a max dose (where specified) of 5-20mg.

Patient Group

RR of Physical Diagnosis Change*

RR of Management error**

Adults

2.22%; 95% CI 0.91% to 5.40%

+0.3%; 95% CI –4.1% to 4.7%

Pediatric

2.11%; 95% CI 0.60% to 7.35%

-0.8%; 95% CI –8.6% to 6.9%

Combined

2.13%; 95% CI 1.14 to 3.98

+0.1%; 95% CI –3.6% to 3.8%

* Statistically significant change in physical examination findings after administration of opiate.

** Delay of necessary surgery or performance of unnecessary surgery.

Studies description

Inclusion criteria: MEDLINE search through May 2006. EMBASE and hand searches of article bibliographies to identify placebo-controlled randomized trials of opiate analgesia reporting changes in history, physical examination findings, or diagnostic errors.

Search Date: May 2006

Number Found and Reviewed: 9 adult trials, 3 pediatric.

Quality/Limitations: Small sample size, inconsistent blinding of examiner and of outcomes analysis. Several trials included which did not find a significant reduction in pain scores following administration of medication. Some studies used non-standard (non-morphine) medications (e.g., buprenorphine, papveretum, fentanyl).

Gold Standards: Patient pain-scale reporting for analgesia, operative findings for diagnosis of surgical abdomen.

Updated SearchDate: February 2007

Article: Ann Emerg Med. 2006 Aug;48(2):161-3

Description: “Randomized Clinical Trial of Morphine in Acute Abdominal Pain”

Findings : Administration of could lead to as much as a 12% difference in diagnostic accuracy, equally favoring opioid or placebo. However, the data is most consistent with the inference that morphine safely provides analgesia without impairing clinically important diagnostic accuracy.

Critique: Well done study, great incorporation of previous studies into discussion.

Level of Evidence : Level 2. Patient outcome oriented, but small (n=153)

Fit: Excellent fit.

Reviewed by: Joseph Pye, MD Date Feb 21, 2007


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