General and Emergency Surgery, Department of Surgery, University of L'Aquila, Italy.
Int J Surg. 2013;11(9):847-52. doi: 10.1016/j.ijsu.2013.08.005. Epub 2013 Aug 22.
The safety of early analgesia in patients suspected to have acute appendicitis (AA) is still controversial.
Double blind randomized clinical trials comparing patients receiving or not receiving opiates for early analgesia in suspected AA were selected for meta-analysis according to PRISMA guidelines. Primary outcomes were the number of patients with AA confirmed by histology and the number of patients undergoing surgical intervention. Secondary outcomes were missed diagnoses, false positive AA and complication rate. Effect sizes were calculated using a Mantel-Haenszel fixed effects model.
Previously published papers mostly analyzed surrogate end-points such as physician's confidence about the diagnosis or the alteration of clinical signs, subjective parameters dependent on personal perception. Our article focused on clinical outcome and specifically investigated those potentially related to AA instead of unspecified abdominal pain. Opiate administration did not have an impact on the number of histologically proven AA (OR = 1.196 [0.875-1.635]; P = 0.261). Differences in appendectomy rates were only slightly above the threshold for statistical significance (OR = 1.350 [0.966-1.887]; P = 0.079), suggesting that analgesia might influence the treatment approach. On the other hand missed diagnoses (OR = 0.509 [0.087-2.990]; P = 0.455) and false positive AA (OR = 1.071 [0.596-1.923]; P = 0.818) ascertained by histologic examination were unaffected, so diagnostic accuracy was retained. Safety was not compromised by opiates, as the difference in complication rates did not reach statistical significance (OR = 0.615 [0.217-1.748]; P = 0.372).
Early analgesia with opiates in suspected AA might influence the approach to treatment, but does not appear to alter diagnostic accuracy or surgical outcome. To support our findings, further trials on larger sample sizes from different age groups and both genders are needed.
在疑似急性阑尾炎（AA）患者中早期镇痛的安全性仍存在争议。
根据 PRISMA 指南，选择比较疑似 AA 患者接受或不接受阿片类药物早期镇痛的双盲随机临床试验进行荟萃分析。主要结局是通过组织学证实的 AA 患者数量和接受手术干预的患者数量。次要结局是漏诊、假阳性 AA 和并发症发生率。使用 Mantel-Haenszel 固定效应模型计算效应大小。
之前发表的论文主要分析了替代终点，如医生对诊断的信心或临床体征的改变，以及依赖个人感知的主观参数。我们的文章侧重于临床结果，特别是调查了那些与 AA 相关而不是未指明的腹痛有关的结果。阿片类药物给药对组织学证实的 AA 数量没有影响（OR = 1.196 [0.875-1.635]；P = 0.261）。阑尾切除术率的差异仅略高于统计学意义的阈值（OR = 1.350 [0.966-1.887]；P = 0.079），表明镇痛可能影响治疗方法。另一方面，通过组织学检查确定的漏诊（OR = 0.509 [0.087-2.990]；P = 0.455）和假阳性 AA（OR = 1.071 [0.596-1.923]；P = 0.818）不受影响，因此保留了诊断准确性。阿片类药物的使用并没有降低安全性，因为并发症发生率的差异没有达到统计学意义（OR = 0.615 [0.217-1.748]；P = 0.372）。
在疑似 AA 患者中早期使用阿片类药物镇痛可能会影响治疗方法，但似乎不会改变诊断准确性或手术结果。为了支持我们的发现，需要在不同年龄组和性别中进行更大规模的试验。
