Farmacoriflessioni
Θ ragionevole trattare il dolore addominale acuto con i farmaci analgesici?
EARLY ANALGESIA FOR CHILDREN WITH ACUTE ABDOMINAL PAIN: IS IT APPLICABLE WITHOUT AFFECTING DIAGNOSTIC ACCURACY?
DANIELE RADZIK, CRISTINA ZARAMELLA
UO di Pediatria, Ospedale di Castelfranco Veneto (Treviso)
Ottobre 2006 - pagg. 519 -524
Abstract
Background Many paediatricians and surgeons are reluctant to use analgesics in children with acute abdominal pain for the fear of masking symptoms and delaying a possible diagnosis of appendicitis. Over the past few years this traditional belief has been challenged, after the publication of several controlled trials performed on adult patients, showing that early analgesia in this context is safe.
Objective We systematically reviewed the literature, searching which is the best available evidence for effectiveness and safety of analgesics in paediatric patients with abdominal pain.
Data Sources Medline, Embase, Cochrane Register of Controlled Trials.
Results Three double blind Randomized Controlled Trials comparing opioids with placebo were retrieved. The overall methodological quality of these studies was good. With active treatment there was a greater decrease in pain score, with no delay in surgical intervention and no significant change in the ability of physicians of making a correct diagnosis. No important complication was eventually documented. A post hoc power calculation has shown that all these trials were not large enough to detect a statistical difference with regard to the main outcomes.
Conclusions The use of analgesia effectively reduces the intensity of pain in children with acute abdominal pain and does not interfere with diagnostic accuracy. The small sample size of the studies included in our review should however be considered a potential limitation to their results.
Parole chiave
Classificazione MeSH
Bibliografia
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8. Lo Vecchio F, Oster N, Sturmann K. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997;15:775-9.
9. Vermeulen B, Morabia A, Unger PF. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate: a randomized trial. Radiology 1999;210:639-43.
10. American College of Emergency Physicians. Clinical policy: critical issues for the initial evaluation and management of patients presenting with chief complaint of non-traumatic acute abdominal pain. Ann Emerg Med 2000;36:406-15.
11. Agency for Healthcare Research and Quality (AHRQ). Making Health Care Safer: a Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No.43 Rockville, MD:AHRQ;2001. Publ No.01-E058: 396-400.
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14. Green R, Bulloch B, Kabani A, Hancock BJ, Tenenbein M. Early analgesia for children with acute abdominal pain. Pediatrics 2005; 116:978-83.
15. Kokki H, Lintula H, Vanamo K, Heiskanen M, Eskelinen M. Oxycodone vs placebo in children with undifferentiated abdominal pain. Arch Pediatr Adolesc Med 2005;159:320-5.
16. Kim MK, Strait RT, Sato TT, Hennes HM. A Randomized Clinical Trial of analgesia in children with acute abdominal pain. Acad Emerg Med 2002;9:281-7.
17. Schulz KF, Chalmers I, Hayes RJ. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408-12.
18. Altman DG, Schultz F. Concealing treatment allocation in randomised trials. BMJ 2001;323:446-7.
19. Bulloch B, Tenenbein M. Validation of two pain scales for use in the pediatric emergency department. Pediatrics 2002;110(3):e33.
20. Lee JS, Hobden E, Stiell IG, Wells GA. Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med 2003;10:1128-30.
21. Wesson DE. Appendicitis in children. In: Rose BD (ed). Up ToDate. Wellesley, Mass, 2004.
2. Kim MK, Galustyan S, Sato TT, Bergholte J, Hennes HM. Analgesia for children with acute abdominal pain: a survey of pediatric emergency physicians and pediatric surgeons. Pediatrics 2003;112:1122-6.
3. National Guidelines Clearinghouse. Evidence based clinical practice guideline for emergency appendectomy. 2002 www.guideline. gov.
4. Cope Z. Early diagnosis of the acute abdomen. Ed Silen, 1987.
5. Zoltie N, Cust MP. Analgesia in the acute abdomen. J Roy Coll Surg Engl 1986;68:209- 10.
6. Attard AR, Corlett MJ, Kidner NJ. Safety of early pain relief for acute abdominal pain. Br Med J 1992;305:554-6.
7. Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996;2:1086-92.
8. Lo Vecchio F, Oster N, Sturmann K. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997;15:775-9.
9. Vermeulen B, Morabia A, Unger PF. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate: a randomized trial. Radiology 1999;210:639-43.
10. American College of Emergency Physicians. Clinical policy: critical issues for the initial evaluation and management of patients presenting with chief complaint of non-traumatic acute abdominal pain. Ann Emerg Med 2000;36:406-15.
11. Agency for Healthcare Research and Quality (AHRQ). Making Health Care Safer: a Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No.43 Rockville, MD:AHRQ;2001. Publ No.01-E058: 396-400.
12. Goldman RD, Crum D, Bromberg R, Rogovik A, Langer JC. Analgesia administration for acute abdominal pain in the Pediatric Emergency Department. Pediatr Emerg Care 2006;1:18-21.
13. Guyatt G, Rennis D. Users guide to the medical literature. A manual for evidence-based medical practice. The Evidence-Based Medicine Working Group. JAMA and Archives Journal, American Medical Association, 2002.
14. Green R, Bulloch B, Kabani A, Hancock BJ, Tenenbein M. Early analgesia for children with acute abdominal pain. Pediatrics 2005; 116:978-83.
15. Kokki H, Lintula H, Vanamo K, Heiskanen M, Eskelinen M. Oxycodone vs placebo in children with undifferentiated abdominal pain. Arch Pediatr Adolesc Med 2005;159:320-5.
16. Kim MK, Strait RT, Sato TT, Hennes HM. A Randomized Clinical Trial of analgesia in children with acute abdominal pain. Acad Emerg Med 2002;9:281-7.
17. Schulz KF, Chalmers I, Hayes RJ. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408-12.
18. Altman DG, Schultz F. Concealing treatment allocation in randomised trials. BMJ 2001;323:446-7.
19. Bulloch B, Tenenbein M. Validation of two pain scales for use in the pediatric emergency department. Pediatrics 2002;110(3):e33.
20. Lee JS, Hobden E, Stiell IG, Wells GA. Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med 2003;10:1128-30.
21. Wesson DE. Appendicitis in children. In: Rose BD (ed). Up ToDate. Wellesley, Mass, 2004.
Corrispondenza: dradzik@tiscali.it