Tugas Filsafat 3.pdf

7/24/2019 Tugas Filsafat 3.pdf

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Preoperative Parenteral Analgesic in Appendicitis

Does Administration of Parenteral Analgesic Affect Clinical

Monitoring, Diagnostic Accuracy, and Outcome of Patients with

Acute Appendicitis?

Jeffy G. Guerra, MD

Edgardo Penserga, MD, FPCS

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

__________________________________

Reprint requests: Jeffy G. Guerra, MD, Department of Surgery, Ospital ng

Maynila Medical Center, Quirino Avenue, Malate, Manila, Philippines.

Email: [email protected]


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Preoperative Parenteral Analgesic in Appendicitis 2

Abstract:

Objective: To determine whether administration of parenteral analgesic affects

clinical monitoring, diagnostic accuracy and outcome of patients with suspected

acute appendicitis. Methods: Prospective, double-blind, placebo-controlled

administration of tramadol and normal saline (NS). Patients 11 to 65 years old

with abdominal pain for less than seven days, with possibility of acute

appendicitis and needing clinical monitoring for definitive diagnosis, were

included. Changes in abdominal physical examination findings and pain

response were evaluated 30 minutes after administration of tramadol and

placebo which were given right after initial assessment. Accuracy in diagnosis,

appendiceal perforation rate, and morbidity and mortality rates were the outcome

measures. Results:One hundred sixty-three patients were enrolled. Eighty-four

patients received tramadol (Grp 1) and 79 received NS (Grp 2). Seven patients, 5

in Grp 1 and 2 in Grp 2, did not undergo an operation because of nonsurgical

diagnoses which were verified to be accurate during follow-up. One hundred

fifty-six patients, 79 in Grp 1 and 77 in Grp 2, were admitted with a diagnosis of

acute appendicitis and underwent surgery. There was no significant difference

between the groups when comparing the accuracy of preoperative diagnosis and

outcome of appendectomy in terms of perforation, morbidity, and mortality rates.

In those receiving parenteral analgesics, there was significant pain relief.

Conclusion: When compared with saline placebo, the administration of a

parenteral analgesic (tramadol) to patients being monitored for possible acute


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appendicitis effectively relieved pain and did not alter the ability of the surgeons

to accurately evaluate such patients.

Keywords:Appendicitis, Analgesics, Monitoring


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Introduction

It is a common practice by physicians, here and abroad, not to give

analgesics in patients presenting with a right lower quadrant (RLQ) abdominal

pain and being suspected to have acute appendicitis for fear that it may hamper

the clinical monitoring and thereby cause missed diagnosis and delayed

treatment (1-5). The drawback of this practice is that such patients are

continuously suffering from abdominal pain while awaiting definitive diagnosis

and treatment.

Lately, there are now reports in the literature contesting this practice of

withholding analgesics. Several authors are now advocating administration of

analgesics in patients with possible acute appendicitis while awaiting definitive

diagnosis and treatment (6-10). They claimed that such practice did not affect

the diagnostic accuracy of clinical monitoring and outcome of treatment at the

same time affording analgesia.

Search of local medical literature through HERDIN (11) did not yield any

paper on such an issue. Thus, the primary objective of this paper was to

determine whether administration of parenteral analgesics in Filipino patients

suspected of acute appendicitis would affect clinical monitoring, diagnostic

accuracy, and outcome. The secondary objective was to determine the amount

of pain relief afforded by such an intervention.


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Methods

The study design was a randomized controlled doubled-blinded clinical

trial conducted from May, 2004 to September, 2004, in the Department of

Surgery of Hospital X.

Filipino patients aged 11 to 65 with RLQ abdominal pain of less than 7-day

duration with a primary clinical diagnosis of acute appendicitis and who had no

history of allergy to the parenteral analgesic to be used were included in the

study.

The baseline physical findings on the abdomen (direct tenderness with or

without guarding) and pain score using the numerical 0-10 score were gotten

prior to randomization into two arms, Group 1 with parenteral analgesic

(tramadol, 50 to 100 mg for pediatrics and adults respectively) and Group 2, with

placebo or 5 cc of normal saline solution. A table of random numbers was used

for the randomization. Informed consent for the study was obtained. Those who

refused were not given parenteral analgesics.

Thirty minutes after administration of the parenteral analgesic and

placebo, another evaluation of the abdominal findings and assessment of the

pain score were done. At this point, a decision was made whether the patient

would be booked for appendectomy within 6 to 12 hours or to continue further

monitoring of the abdominal findings for those in which appendicitis was not

strongly considered. For those booked for appendectomy, monitoring was

continued up to the time of operation.


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Those who were booked for appendectomy were operated not later than

12 hours after. The histopathology results of the appendix removed served as

the gold standard for the accuracy of the clinical diagnosis. Those who were not

operated on were observed until they could be discharged with a non-surgical

diagnosis. These patients would be followed up for at least one week to monitor

the accuracy of the non-appendicitis diagnosis.

The study was double-blind in that the patients and the senior residents

who made the initial and subsequent assessment and decided on the

management disposition did not know what was given in the parenteral solution.

The junior residents were the ones administering the parenteral solution.

The outcome measures of the study consisted of the accuracy of the

clinical diagnosis and outcome of treatment in terms of perforation, morbidity,

and mortality rates as well as changes in the pain score before and after the

administration of the parenteral solution. The students t-test was used for

statistical analysis.

Results

A total of 163 patients were included in the study, 84 in Group 1 and 79 in

Group 2. All completed the study. In Group 1, the male to female ratio was 59 to

25 and the age ranged from 11-65 years with a mean of 26.76. In Group 2, the

male to female ratio was 55 to 24 and the age ranged from 14 to 46 with a mean

of 23.77 (Table 1).


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Table 1. Age and sex distribution of patients who participated in the study.

Group 1 Group 2

Age Male Female Male Female

11-15 4 3 4 3

16-20 15 5 17 7

21-25 13 8 18 6

26-30 10 4 5 4

31-35 11 0 6 3

36-40 1 0 3 0

41-45 1 2 1 1

46-50 1 1 1 0

51-55 1 0 0 0

56-60 0 0 0 0

61-65 2 2 0 0

Total 59 25 55 24

Mean age 26.76 23.77

Seven patients were not operated on and discharged with a non-

appendicitis diagnosis after clinical monitoring and administration of the

parenteral solution. The diagnoses consisted of urinary tract infection (2) ,

ureterolithiasis (1) and nonspecific RLQ pain (4). The follow-up confirmed the

100% accuracy of the non-appendiceal diagnosis. (Table 2).


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Table 2. Outcome of patients not operated and discharged with non-

appendicitis diagnosis.

Group 1 Group 2

Non-appendicitis diagnosis

on discharge

5 2

Urinary tract infection 2 0

Non-specific RLQ pain 3 1

Ureterolithiasis 0 1

Diagnostic accuracy rate 100% 100%

One hundred fifty-six patients, 79 in Grp 1 and 77 in Grp 2, were admitted

with a diagnosis of acute appendicitis and underwent surgery.

Table 3 shows the outcome in terms of accuracy of diagnosis. There was

no significant difference in the accuracy of diagnosis.


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Table 3. Outcome of patients operated on with a preoperative diagnosis of

appendicitis in terms of diagnostic accuracy.

Final Diagnosis Group 1

(n=79)

Group 2

(n=77)

Appendicitis 73 74

Non-appendicitis 3 2

Normal 3 1

Perforated typhoid ileitis 1

Perforated cecum 1

Perforated diverticulitis 1

Ileocecal TB 1

Mesenteric adenitis 1

Appendicitis-diagnosis

accuracy rate

92.41% 96.10%

Surgical abdomen-

diagnosis accuracy rate

96.20% 96.10%


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Table 4 shows the outcome in terms of changes in physical abdominal

findings in operated patients, perforation, morbidity and mortality rates. There

was no significant difference in all the parameters.

Table 4. Outcome of patients operated on with a preoperative diagnosis of

appendicitis in terms of changes in physical abdominal findings, perforation,

morbidity, and mortality rates.

Group 1 Group 2

Changes in physical

abdominal findings

0% 0%

Perforation rate 47.95% 44.59%

Morbidity rate 0% 0%

Mortality rate 0% 0%


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Table 5 shows the changes in the pain scores before and after

administration of the parenteral solutions. There was a 4-point drop in pain score

in Group 1 in contrast to a 1-point increase in Group 2.

Table 5. Changes in the pain scores in the two groups.

Group 1 Group 2

Pain score before

administration

Range:

5-9

Mean:

7.9

Range: 4-9

Mean: 7.22

Pain score

After

administration

Range:

0-9

Mean:

3.75

Range: 3-10

Mean: 8.13

Mean difference 4.15 0.91


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Discussion

The results of this clinical trial showed that administration of parenteral

analgesic (tramadol in this study) did not hamper the clinical monitoring,

diagnostic accuracy, and outcome of treatment in terms of perforation, morbidity,

and mortality rate. It afforded pain relief while monitoring for a definitive

diagnosis was taking place.

This study reinforced the five prospective randomized controlled trials

reported in the international literature (6-10). All 5 studies evaluated the effects

of analgesia on pain relief and diagnoses and treatment decisions in patients with

acute abdominal pain. Two studies evaluated the effects of analgesia on physical

examination findings (7,10) and one evaluated the effects of analgesia on the

diagnostic performance of ultrasonography in patients with acute abdominal pain

(9). Three trials used morphine (7-9); one, sublingual buprenorphine (10); and

one, intramuscular papaveretum (6). One study was limited to right lower

abdominal pain (9).

All 5 studies showed that provision of analgesia decreased pain more than

it decreased localization of tenderness. None of the 5 studies indicated that the

practice of giving early analgesia was harmful. Specifically, no study found

compromises in diagnosis or treatment of the acute abdomen after the use of

analgesia.


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With this local study, the authors hope that changes in the traditional belief

among Filipino physicians that analgesic use in patients with acute abdominal

pain may mask signs and symptoms, delay diagnosis, and lead to increased

morbidity and mortality would occur. With such a change, less and less patients

will suffer unnecessarily while physicians conduct their clinical monitoring

scheme for acute surgical abdomen and specifically, appendicitis. The authors,

therefore, recommend the provision of analgesia while conducting a clinical

monitoring scheme in patients with possible acute appendicitis.


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References

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general surgeons attitudes toward the use of pain medication in the acute

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6. Attard AR, Corlett MJ, Kidner NJ et al. Safety of early pain relief for acute

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9. Vermeulen B, Morabia A, Unger PF et al. Acute appendicitis: influence of

early pain relief on the accuracy of clinical and US findings in the decision

to operate - a randomized trial. Radiology1999;210:639-43.


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10. Zoltie N and Cust MP. Analgesia in the acute abdomen. J Roy Coll Surg

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11. Herdin Health Research and Development Information Network

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