Bijur Polly E, Mills Angela M, Chang Andrew K, White Deborah, Restivo Andrew, Persaud Shaun, Schechter Clyde B, Gallagher E John, Birnbaum Adrienne J
Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY.
Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Ann Emerg Med. 2017 Dec;70(6):809-818.e2. doi: 10.1016/j.annemergmed.2017.03.064.
We assess the effectiveness of patient-controlled analgesia in the emergency department (ED). We hypothesized that decline in pain intensity from 30 to 120 minutes after initial intravenous opioid administration is greater in patients receiving morphine by patient-controlled analgesia compared with usual care and would differ by a clinically significant amount.
This was a pragmatic randomized controlled trial of patient-controlled analgesia and usual care (opioid and dose at physician's discretion) in 4 EDs. Entry criteria included age 18 to 65 years and acute pain requiring intravenous opioids. The primary outcome was decline in numeric rating scale pain score 30 to 120 minutes postbaseline. Secondary outcomes included satisfaction, time to analgesia, adverse events, and patient-controlled analgesia pump-related problems. We used a mixed-effects linear model to compare rate of decline in pain (slope) between groups. A clinically significant difference between groups was defined as a difference in slopes equivalent to 1.3 numeric rating scale units.
Six hundred thirty-six patients were enrolled. The rate of decline in pain from 30 to 120 minutes was greater for patients receiving patient-controlled analgesia than usual care (difference=1.0 numeric rating scale unit; 95% confidence interval [CI] 0.6 to 1.5; P<.001) but did not reach the threshold for clinical significance. More patients receiving patient-controlled analgesia were satisfied with pain management (difference=9.3%; 95% CI 3.3% to 15.1%). Median time to initial analgesia was 15 minutes longer for patient-controlled analgesia than usual care (95% CI 11.4 to 18.6 minutes). There were 7 adverse events in the patient-controlled analgesia group and 1 in the usual care group (difference=2.0%; 95% CI 0.04% to 3.9%), and 11 pump-programming errors.
The findings of this study do not favor patient-controlled analgesia over usual ED care for acute pain management.
我们评估了急诊科患者自控镇痛（PCA）的有效性。我们假设，与常规治疗相比，接受吗啡PCA治疗的患者在初始静脉注射阿片类药物后30至120分钟疼痛强度的下降幅度更大，且在临床上有显著差异。
这是一项在4个急诊科进行的关于PCA与常规治疗（阿片类药物及剂量由医生决定）的实用随机对照试验。入选标准包括年龄在18至65岁之间以及需要静脉注射阿片类药物治疗的急性疼痛。主要结局是基线后30至120分钟数字评分量表疼痛评分的下降情况。次要结局包括满意度、镇痛起效时间、不良事件以及与PCA泵相关的问题。我们使用混合效应线性模型比较两组之间疼痛下降率（斜率）。两组之间具有临床意义的差异定义为斜率差异相当于1.3个数字评分量表单位。
共纳入636例患者。接受PCA治疗的患者在30至120分钟的疼痛下降率高于常规治疗（差异=1.0个数字评分量表单位；95%置信区间[CI]0.6至1.5；P<0.001），但未达到临床意义的阈值。更多接受PCA治疗的患者对疼痛管理感到满意（差异=9.3%；95%CI 3.3%至15.1%）。PCA治疗组初始镇痛的中位时间比常规治疗长15分钟（95%CI 11.4至18.6分钟）。PCA组有7例不良事件，常规治疗组有1例（差异=2.0%；95%CI 0.04%至3.9%），以及11例泵编程错误。
本研究结果不支持在急性疼痛管理中PCA优于急诊科常规治疗。
