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Comparative Effectiveness of Patient-Controlled Analgesia for Treating Acute Pain in the Emergency Department
Bijur PE, Millis AM, Chang AK, et al. Ann Emerg Med. 2017; 70: 809-18.
Study Question: Does patient-controlled analgesia (PCA) in the emergency department (ED) reduce pain scores more effectively than usual care?
Study Description: This multicenter, randomized trial included patients treated with PCA or usual IV opioids between April 2013 and February 2016. The PCA group consisted of a loading dose of morphine 0.1 mg/kg, demand dose of 1 mg with a lockout every 6 minutes, and physician-managed supplementation. Pertinent exclusion criteria were chronic opioid use, opioid use within 24 hours, chronic pain, COPD or sleep apnea, and renal dysfunction. The primary endpoint was rate of pain decline from 30 to 120 minutes after the initial dose. Secondary endpoints included patient satisfaction, preference for same pain management strategy in future, and need for additional analgesics at 120 minutes.
Results: A total of 636 patients were included (n=306 PCA, n=330 usual care). The majority of patients had nontraumatic abdominal pain and a baseline pain score of > 7. The mean total dose of opioid received was doubled in the PCA group (12 mg vs. 6.1 mg morphine equivalents). The rate of decline in pain from 30 to 120 minutes was greater in the PCA group with a difference of 1 numeric rating score unit (p < 0.001); however, did not reach the a prioiri-defined threshold set at 1.3 for clinical significance. More patients were satisfied with pain management in the PCA group (87.9% vs. 78.6%). Side effects were similar between groups. Pump-programming errors were reported in 11 patients.
Conclusion(s): Patients receiving PCA compared to usual care in the ED did not experience a clinically significant difference in effectiveness of acute pain management.
Perspective: This study suggests PCA as a potential option in the ED, providing a less labor-intensive pain management method but at the risk of more adverse events, pump-programming errors, and increased opioid consumption. The cost-effectiveness of using PCA in the ED warrants investigation.