Friday, November 2, 2012

PCA in the ED is Brilliant and Horrible


Management of acute pain in the Emergency Department is frequently inadequate.  Considering the practice environment, the ebb and flow of workload, and the heterogenous presentations, this is not surprising.  On the inpatient side of things, many patients with acute, severe pain receive patient-controlled analgesia.  So, this is a randomized, controlled trial of PCA vs. conventional, untitrated boluses in the ED.

And, they were successful in demonstrating significant trends towards better, faster pain control and increased patient satisfaction with the PCA.  Both groups received the same total amount of morphine, but the dynamics by which patients were able to self-titrate their pain control resulted in improved pain relief.

Unfortunately, there are some flaws with this study.  This multi-center study only managed to enroll 96 patients in a one-year timeframe – probably the number we could aggressively enroll at my institution in a week.  There is no mention of adverse events – which is significant, because PCA medication variances are renowned on the inpatient side as significant sources of morbidity.  And, finally, they don't measure any of the other operational variables that are important – cost, time to set up, etc.

Patient-controlled analgesia may yet have a role in the ED – and studies like this help keep the flame alive – but significant hurdles remain.

"A Randomized Controlled Trial of Patient-Controlled Analgesia Compared with Boluses of Analgesia for the Control of Acute Traumatic Pain in the Emergency Department"
www.ncbi.nlm.nih.gov/pubmed/23068783

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