TITLE: Patient-Controlled Analgesia for Acute Injury Transfers: A Review of the Clinical Effectiveness, Safety, and Guidelines DATE: 11 August 2014 CONTEXT AND POLICY ISSUES Patient-controlled analgesia (PCA) refers to the use of a medical device that delivers defined doses of pain medication to a patient on demand. 1 Specific doses are programmed by a health care professional, and the device is also programmed to limit the administration of each dose or a cumulative amount of drug within certain time intervals. 1 PCA typically involves intravenous opioid delivery, but may include other drugs (such as non-steroidal anti-inflammatory drugs or local anaesthesia) or other routes of administration (for example, subcutaneous, transdermal, pulmonary or nasal administration). 1 It is commonly used for post-operative pain, 1 but PCA for acute pain management in the hospital emergency department has also been studied. 2,3 It has been documented that acute pain is not adequately controlled in patients in pre-hospital emergency care settings. 4,5 This observation of suboptimal pain management may extend to situations in which patients who require transfer from a rural or remote hospital to a higher level of care are in emergency vehicles for up to several hours. In some jurisdictions, ambulances are staffed by paramedics with basic life support training; doctors and nurses are not available to administer analgesics. Therefore, there is a potential role for PCA to provide sufficient acute pain management in this setting. The purpose of this report is to review the evidence of the clinical effectiveness and guidelines regarding PCA for patients with acute injury during transfer to a higher level of care. RESEARCH QUESTIONS 1. What is the clinical effectiveness of patient-controlled analgesia for patients with acute injury during transfer to a higher level of care? 2. What is the clinical evidence on the safety and harms of patient-controlled analgesia for patients with acute injury during transfer to a higher level of care? Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH copyright material and may contain material in which a third party owns copyright. This report may be used for the purposes of research or private study only. It may not be copied, posted on a web site, redistributed by email or stored on an electronic system without the prior written permission of CADTH or applicable copyright owner. Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners own terms and conditions.
3. What are the evidence-based guidelines regarding pain management for patients with acute injury during transfer to a higher level of care? KEY FINDINGS No relevant clinical evidence or guidelines regarding patient-controlled analgesia for patients with acute injury during transfer to a higher level of care were identified. METHODS Literature Search Strategy A limited literature search was conducted on key resources including PubMed, The Cochrane Library (2014, Issue 7), University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2009 and July 10, 2014. Selection Criteria and Methods One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1. Population Intervention Table 1: Selection Criteria Adults with acute injury or trauma (e.g., unstable fractures) requiring transfer to a higher level of care (particularly in rural/remote settings where transport by ground is the only option requiring more than two hours of travel time). Patient-controlled analgesia (any drug combination). Comparator No comparator Models requiring a nurse or doctor escort to assess pain and administer narcotic during transfer Outcomes Q1 and Q2: Pain control, physiological stability, avoidance of respiratory depression, safe transfer to target facility. Q3: Guidelines. Study Designs Health technology assessments, systematic reviews, meta-analyses, randomized controlled trials, non-randomized studies, evidence-based guidelines. Exclusion Criteria Articles were excluded if they did not meet the selection criteria outlined in Table 1, they were duplicate publications, or were published prior to 2009. Patient-Controlled Analgesia for Acute Injury Transfers 2
SUMMARY OF EVIDENCE Quantity of Research Available A total of 387 citations were identified in the literature search. Following screening of titles and abstracts, 373 citations were excluded and 14 potentially relevant reports from the electronic search were retrieved for full-text review. No potentially relevant publications were retrieved from the grey literature search. Of the potentially relevant articles, all 14 publications were excluded for various reasons; seven studies evaluated an irrelevant intervention, four studies and one clinical practice guideline focused on an emergency department or trauma centre setting, and two publications were review articles. Appendix 1 describes the PRISMA flowchart of the study selection. Summary of Findings No relevant literature regarding PCA for patients with acute injury during transfer to a higher level of care was identified; therefore, a summary of findings cannot be provided. CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING No relevant clinical evidence or guidelines regarding PCA for patients with acute injury during transfer to a higher level of care were identified; therefore, no review of the evidence can be provided. The potential role of PCA to provide sufficient acute pain management during patient transport to a higher level of care remains unclear. PREPARED BY: Canadian Agency for Drugs and Technologies in Health Tel: 1-866-898-8439 www.cadth.ca Patient-Controlled Analgesia for Acute Injury Transfers 3
REFERENCES 1. Hudcova J, McNicol E, Quah C, Lau J, Carr DB. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2006;(4):CD003348. 2. Rahman NH, DeSilva T. The effectiveness of patient control analgesia in the treatment of acute traumatic pain in the emergency department: a randomized controlled trial. Eur J Emerg Med. 2012 Aug;19(4):241-5. 3. Rahman NH, DeSilva T. A randomized controlled trial of patient-controlled analgesia compared with boluses of analgesia for the control of acute traumatic pain in the emergency department. J Emerg Med. 2012 Dec;43(6):951-7. 4. Frakes MA, Lord WR, Kociszewski C, Wedel SK. Factors associated with unoffered trauma analgesia in critical care transport. Am J Emerg Med. 2009 Jan;27(1):49-54. 5. Bounes V, Barniol C, Minville V, Houze-Cerfon CH, Ducasse JL. Predictors of pain relief and adverse events in patients receiving opioids in a prehospital setting. Am J Emerg Med. 2011 Jun;29(5):512-7. Patient-Controlled Analgesia for Acute Injury Transfers 4
APPENDIX 1: Selection of Included Studies 387 citations identified from electronic literature search and screened 373 citations excluded 14 potentially relevant articles retrieved for scrutiny (full text, if available) 0 potentially relevant reports retrieved from other sources (grey literature, hand search) 14 potentially relevant reports 14 reports excluded: -irrelevant population (5) -irrelevant intervention (7) -other (review articles, editorials) (2) 0 reports included in review Patient-Controlled Analgesia for Acute Injury Transfers 5