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Analgesia in the emergency department: a GRADE-based evaluation of research evidence and recommendations for practice.

Lipp C, Dhaliwal R, Lang E - Crit Care (2013)

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The prevalence of pain as the presenting complaint of patients seeking emergency department (ED) care ranges from 38% to as high as 78%... As a result, evidence-based use of analgesics should be a foundational skill of emergency physicians... Notwithstanding the prevalence of pain in the ED, many patients often report that their pain was not properly treated... Subsequently each question compares two specific management strategies (intervention and comparison)... Finally, we defined important patient oriented outcomes (e.g., change in pain) as well as any adverse effects of the medication or other safety concerns... These seven clinically-based PICO questions compared analgesics (morphine, fentanyl, hydromorphone, non-steroidal anti-inflammatory drugs [NSAIDs], codeine, oxycodone) commonly used in the management of adult acute pain in the ED... The time frame used to assess change in pain varied from 30 minutes to two hours, depending on the medication route of administration... Secondary patient-oriented outcomes included serious adverse events, patient satisfaction, and side effects... The same reviewer assessed the full text articles and determined that 14 of the 26 offered quantitative results that could be analyzed using the GRADE-pro software... The remaining 12 articles were excluded because they did not compare both drugs assessed in a PICO question, compared analgesics not addressed in the seven PICO questions (such as acetaminophen alone), used unconventional medication dosing, used non-validated pain measurement scales, and/or unusual study designs... Similar SoF tables were developed for each PICO question... Overall, the grading process supported the use of intravenous hydromorphone and fentanyl as superior to intravenous morphine for rapid and effective pain relief (weak recommendation, moderate quality evidence)... These evidence-based guidelines have the potential to not only impact on patient morbidity, but also on health care costs and ED efficiency... As health care professionals with the role of treating emergent health problems, it is crucial that all emergency physicians have up-to-date, evidence-based knowledge to adequately treat acute pain.

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Suggested approach to acute pain in the emergency department. NSAID: non-steroidal anti-inflammatory drug; IV: intravenous.
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Figure 1: Suggested approach to acute pain in the emergency department. NSAID: non-steroidal anti-inflammatory drug; IV: intravenous.

Mentions: Using the GRADE framework, we have synthesized and evaluated the medical literature surrounding analgesia delivery in the adult ED and developed clear and actionable recommendations for analgesic use based on graded recommendations. Despite using a thorough, systematic approach to reviewing the literature on each PICO question we identified only 14 articles that met our inclusion criteria. However, although the number of studies used to make our recommendations may seem low, our recommendations take into consideration the quality of evidence of the studies. Pragmatic derivations of the seven PICO questions, their recommendations, and the rationale for these recommendations are listed in Table 4[28-41]. Furthermore, we also developed a flow-chart as a suggested approach to analgesia in the ED (Figure 1).


Analgesia in the emergency department: a GRADE-based evaluation of research evidence and recommendations for practice.

Lipp C, Dhaliwal R, Lang E - Crit Care (2013)

Suggested approach to acute pain in the emergency department. NSAID: non-steroidal anti-inflammatory drug; IV: intravenous.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3672477&req=5

Figure 1: Suggested approach to acute pain in the emergency department. NSAID: non-steroidal anti-inflammatory drug; IV: intravenous.
Mentions: Using the GRADE framework, we have synthesized and evaluated the medical literature surrounding analgesia delivery in the adult ED and developed clear and actionable recommendations for analgesic use based on graded recommendations. Despite using a thorough, systematic approach to reviewing the literature on each PICO question we identified only 14 articles that met our inclusion criteria. However, although the number of studies used to make our recommendations may seem low, our recommendations take into consideration the quality of evidence of the studies. Pragmatic derivations of the seven PICO questions, their recommendations, and the rationale for these recommendations are listed in Table 4[28-41]. Furthermore, we also developed a flow-chart as a suggested approach to analgesia in the ED (Figure 1).

View Article: PubMed Central - HTML - PubMed

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

The prevalence of pain as the presenting complaint of patients seeking emergency department (ED) care ranges from 38% to as high as 78%... As a result, evidence-based use of analgesics should be a foundational skill of emergency physicians... Notwithstanding the prevalence of pain in the ED, many patients often report that their pain was not properly treated... Subsequently each question compares two specific management strategies (intervention and comparison)... Finally, we defined important patient oriented outcomes (e.g., change in pain) as well as any adverse effects of the medication or other safety concerns... These seven clinically-based PICO questions compared analgesics (morphine, fentanyl, hydromorphone, non-steroidal anti-inflammatory drugs [NSAIDs], codeine, oxycodone) commonly used in the management of adult acute pain in the ED... The time frame used to assess change in pain varied from 30 minutes to two hours, depending on the medication route of administration... Secondary patient-oriented outcomes included serious adverse events, patient satisfaction, and side effects... The same reviewer assessed the full text articles and determined that 14 of the 26 offered quantitative results that could be analyzed using the GRADE-pro software... The remaining 12 articles were excluded because they did not compare both drugs assessed in a PICO question, compared analgesics not addressed in the seven PICO questions (such as acetaminophen alone), used unconventional medication dosing, used non-validated pain measurement scales, and/or unusual study designs... Similar SoF tables were developed for each PICO question... Overall, the grading process supported the use of intravenous hydromorphone and fentanyl as superior to intravenous morphine for rapid and effective pain relief (weak recommendation, moderate quality evidence)... These evidence-based guidelines have the potential to not only impact on patient morbidity, but also on health care costs and ED efficiency... As health care professionals with the role of treating emergent health problems, it is crucial that all emergency physicians have up-to-date, evidence-based knowledge to adequately treat acute pain.

Show MeSH
Related in: MedlinePlus