Skip to main content Accessibility help
×
Home

Pain management of acute appendicitis in Canadian pediatric emergency departments

  • Andrea L. Robb (a1), Samina Ali (a2) (a3), Naveen Poonai (a4), Graham C. Thompson (a1) (a5) and the Pediatric Emergency Research Canada (PERC) Appendicitis Study Group...

Abstract

Objectives

Children with suspected appendicitis are at risk for suboptimal pain management. We sought to describe pain management patterns for suspected appendicitis across Canadian pediatric emergency departments (PEDs).

Methods

A retrospective medical record review was undertaken at 12 Canadian PEDs. Children ages 3 to 17 years who were admitted to the hospital in February or October 2010 with suspected appendicitis were included. Patients were excluded if partially assessed or treated at another hospital. Data were abstracted using a study-specific, standardized electronic data extraction tool. The primary outcome was the proportion of children who received analgesia while in the emergency department (ED). Secondary outcomes included the proportion of children receiving intravenous (IV) morphine and the timing of analgesic provision.

Results

A total of 619 health records were abstracted; mean (SD) patient age was 11.4 (3.5) years. Sixty-one percent (381/616) of patients received analgesia in the ED; 42.8% (264/616) received IV morphine. Other analgesic agents provided included oral acetaminophen (23.5% [145/616]) and oral ibuprofen (5.8% [36/616]). The median (IQR) initial dose of IV morphine was 0.06 (0.04, 0.09) mg/kg. The median (IQR) time from triage to the initial dose of analgesia was 196 (101, 309.5) minutes. Forty-three percent (117/269) of children receiving analgesia received the initial dose following surgical consultation; 43.7% (121/277) received their first analgesic after abdominal ultrasound was performed.

Conclusions

Suboptimal and delayed analgesia remains a significant issue for children with suspected appendicitis in Canadian PEDs. This suggests a role for multidimensional knowledge translation interventions and care protocols to improve timely access to analgesia.

Objectif

Le soulagement de la douleur causée par une appendicite présumée chez les enfants risque d’être insuffisant. L’étude visait à décrire différentes formes de traitement de la douleur causée par une appendicite présumée dans les services des urgences pédiatriques (SUP) partout au Canada.

Méthode

Il s’agit d’un examen rétrospectif de dossiers médicaux, mené dans 12 SUP au Canada. Ont participé à l’étude des enfants âgés de 3 à 17 ans, qui avaient été hospitalisés en février ou en octobre 2010 pour une appendicite présumée. Les enfants qui avaient été évalués ou traités en partie dans un autre hôpital ont été écartés. Les données recueillies ont été résumées à l’aide d’un outil électronique d’extraction uniforme de données et propre à l’étude. Le principal critère d’évaluation consistait en la proportion d’enfants soumis à un traitement analgésique pendant leur séjour au SUP. Les critères secondaires d’évaluation comprenaient la proportion d’enfants ayant reçu de la morphine par voie intraveineuse (i.v.) ainsi que le moment de l’administration des analgésiques.

Résultats

Il y a eu 619 résumés de dossiers médicaux; la moyenne d’âge (écart type) était de 11,4 ans (3,5 ans). Soixante et un pour cent (381/616) des enfants ont reçu un traitement analgésique au SUP, et 42,8 % (264/616) ont reçu de la morphine i.v. D’autres analgésiques ont été administrés, notamment l’acétaminophène par voie orale (23,5 %; 145/616) et l’ibuprofène par voie orale (5,8 %; 36/616). La dose initiale médiane (intervalle interquartile [IIQ]) de morphine i.v. était de 0,06 mg/kg (0,04 - 0,09). Le temps écoulé médian (IIQ) depuis le triage jusqu’à la première dose d’analgésique était de 196 minutes (101 - 309,5). Parmi les enfants soumis à un traitement analgésique, 43 % (117/269) ont reçu la première dose de médicament après la consultation en chirurgie et 43,7 % (121/277), après l’échographie abdominale.

Conclusions

Les retards d’administration du traitement analgésique ainsi que des doses insuffisantes de médicament posent encore des problèmes importants dans les cas d’appendicite présumée chez les enfants dans les SUP au Canada. Les résultats de l’étude donnent à penser qu’il y aurait lieu d’améliorer le temps écoulé avant l’administration des analgésiques par des interventions multidimensionnelles d’application des connaissances et par des protocoles de soins.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Pain management of acute appendicitis in Canadian pediatric emergency departments
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Pain management of acute appendicitis in Canadian pediatric emergency departments
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Pain management of acute appendicitis in Canadian pediatric emergency departments
      Available formats
      ×

Copyright

Corresponding author

Correspondence to: Dr. Graham Thompson, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8; Email: Graham.Thompson@albertahealthservices.ca

References

Hide All
1. Green, R, Bulloch, B, Kabani, A, et al. Early analgesia for children with acute abdominal pain. Pediatrics 2005;116(4):978-983.
2. Vane, DW. Efficacy and concerns regarding early analgesia in children with acute abdominal pain. Pediatrics 2005;116(4):1018.
3. Armstrong, FD. Analgesia for children with acute abdominal pain: a cautious move to improved pain management. Pediatrics 2005;116(4):1018-1019.
4. Manterola, C, Vial, M, Moraga, J, et al. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev 2011;1:CD005660, (1):CD005660.
5. Bailey, B, Bergeron, S, Gravel, J, et al. Efficacy and impact of intravenous morphine before surgical consultation in children with right lower quadrant pain suggestive of appendicitis: a randomized controlled trial. Ann Emerg Med 2007;50(4):371-378.
6. Poonai, N, Paskar, D, Konrad, SL, et al. Opioid analgesia for acute abdominal pain in children: a systematic review and meta-analysis. Acad Emerg Med 2014;21(11):1183-1192.
7. Kang, K, Kim, WJ, Kim, K, et al. Effect of pain control in suspected acute appendicitis on the diagnostic accuracy of surgical residents. CJEM 2015;17(1):54-61.
8. Kokki, H, Lintula, H, Vanamo, K, et al. Oxycodone vs placebo in children with undifferentiated abdominal pain: a randomized, double-blind clinical trial of the effect of analgesia on diagnostic accuracy. Arch Pediatr Adolesc Med 2005;159(4):320-325.
9. Cousins, MJ, Lynch, ME. The Declaration Montreal: access to pain management is a fundamental human right. Pain 2011;152(12):2673-2674.
10. Fein, JA, Zempsky, WT, Cravero, JP. The Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2012;130(5):e1391-e1405.
11. Goyal, MK, Kuppermann, N, Cleary, SD, et al. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr 2015;169(11):996-1002.
12. Goldman, RD, Crum, D, Bromberg, R, et al. Analgesia administration for acute abdominal pain in the pediatric emergency department. Pediatr Emerg Care 2006;22(1):18-21.
13. Delaney, KM, Pankow, A, Avner, JR, et al. Appendicitis and analgesia in the pediatric emergency department: are we adequately controlling pain? Pediatr Emerg Care 2016;32(9):581-584.
14. Thompson, GC, Schuh, S, Gravel, J, et al. Variation in the diagnosis and management of appendicitis at Canadian pediatric hospitals. Acad Emerg Med 2015;22(7):811-822.
15. Cole, MA, Maldonado, N. Evidence-based management of suspected appendicitis in the emergency department. Emerg Med Pract 2011;13(10):1, 29; quiz 29.
16. Goldman, RD, Narula, N, Klein-Kremer, A, et al. Predictors for opioid analgesia administration in children with abdominal pain presenting to the emergency department. Clin J Pain 2008;24(1):11-15.
17. Kim, MK, Galustyan, S, Sato, TT, et al. Analgesia for children with acute abdominal pain: a survey of pediatric emergency physicians and pediatric surgeons. Pediatrics 2003;112(5):1122-1126.
18. Dong, L, Donaldson, A, Metzger, R, et al. Analgesic administration in the emergency department for children requiring hospitalization for long-bone fracture. Pediatr Emerg Care 2012;28(2):109-114.
19. Alexander, J, Manno, M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med 2003;41(5):617-622.
20. Poonai, N, Cowie, A, Davidson, C, et al. Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments. CJEM 2016;18(5):323-330.
21. Mindell, JS, Coombs, N, Stamatakis, E. Measuring physical activity in children and adolescents for dietary surveys: practicalities, problems and pitfalls. Proc Nutr Soc 2014;73(2):218-225.
22. Holdgate, A, Cao, A, Lo, KM. The implementation of intranasal fentanyl for children in a mixed adult and pediatric emergency department reduces time to analgesic administration. Acad Emerg Med 2010;17(2):214-217.
23. Corwin, DJ, Kessler, DO, Auerbach, M, et al. An intervention to improve pain management in the pediatric emergency department. Pediatr Emerg Care 2012;28(6):524-528.
24. Stevens, BJ, Yamada, J, Estabrooks, CA, et al. Pain in hospitalized children: effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes. Pain 2014;155(1):60-68.
25. Bundy, DG, Byerley, JS, Liles, EA, et al. Does this child have appendicitis? JAMA 2007;298(4):438-451.

Keywords

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed