Factors associated with refractory pain in emergency patients admitted to emergency general surgery

doi:10.5847/wjem.j.1920-8642.2021.01.002

Abstract

Abstract:

BACKGROUND: Oligoanalgesia in emergency departments (EDs) is multifactorial. A previous study reported that emergency providers did not adequately manage patients with severe pain despite objective findings for surgical pathologies. Our study aims to investigate clinical and laboratory factors, in addition to providers’ interventions, that might have been associated with oligoanalgesia in a group of ED patients with moderate and severe pains due to surgical pathologies.

METHODS: We conducted a retrospective study of adult patients who were transferred directly from referring EDs to the emergency general surgery (EGS) service at a quaternary academic center between January 2014 and December 2016. Patients who were intubated, did not have adequate records, or had mild pain were excluded. The primary outcome was refractory pain, which was defined as pain reduction <2 units on the 0-10 pain scale between triage and ED departure.

RESULTS: We analyzed 200 patients, and 58 (29%) had refractory pain. Patients with refractory pain had significantly higher disease severity, serum lactate (3.4±2.0 mg/dL vs. 1.4±0.9 mg/dL, P=0.001), and less frequent pain medication administration (median [interquartile range], 3 [3-5] vs. 4 [3-7], P=0.001), when compared to patients with no refractory pain. Multivariable logistic regression showed that the number of pain medication administration (odds ratio [OR] 0.80, 95% confidence interval [95% CI] 0.68-0.98) and ED serum lactate levels (OR 3.80, 95% CI 2.10-6.80) were significantly associated with the likelihood of refractory pain.

CONCLUSIONS: In ED patients transferring to EGS service, elevated serum lactate levels were associated with a higher likelihood of refractory pain. Future studies investigating pain management in patients with elevated serum lactate are needed.

Key words: Serum lactate, Refractory pain, Emergency general surgery, Emergency department

William Gilliam, Jackson F. Barr, Brandon Bruns, Brandon Cave, Jordan Mitchell, Tina Nguyen, Jamie Palmer, Mark Rose, Safura Tanveer, Chris Yum, Quincy K. Tran. Factors associated with refractory pain in emergency patients admitted to emergency general surgery[J]. World Journal of Emergency Medicine, 2021, 12(1): 12-17.

Figures/Tables 5

Figure 1.

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Parameters	All patients
Total patients, n (%)	200 (100)
Gender, n (%)
Male	88 (44)
Female	112 (56)
Age in years, mean±SD	55±19
Past medical history, n (%)
CHF	13 (7)
Hypertension	95 (48)
DM	36 (18)
Any liver disease	13 (7)
Any kidney disease	12 (6)
ESI, median (IQR)	3 (2-3)
Triage systolic blood pressure (mmHg), mean±SD	133±20
Triage heart rate (bpm), mean±SD	94±19
Triage pain score, mean±SD	8±2
Triage GCS, median (IQR)	15 (14-15)
ED LOS (minutes), median (IQR)	491 ( 327-728)
Pain score at departure, mean±SD	5±3
Total MEU, mean±SD	12±11
Total IVF (liter), mean±SD	1.4±1.0
Refractory pain at ED departure, n (%)	58 (29)
ED diagnosis, n (%)
Appendicitis	4 (2)
Bowel obstruction	40 (20)
Bowel perforation	30 (15)
Bowel ischemia	16 (8)
GI bleeding	12 (6)
Hernia	13 (7)
Intra-abdominal infection	28 (14)
Pancreatitis	18 (9)
Other	39 (20)
Operation, n (%)
None	70 (35)
Laparotomy	61 (31)
Laparoscopy	26 (13)
Endoscopy	10 (5)
Percutaneous intervention by IR	9 (4)
Incision and drainage	9 (4)
Other	15 (8)
Mortality, n (%)	8 (4)
Hospital length of stay (days), median (IQR)	6 (3-10)

Parameters	All (n=200)	No refractory pain (group A) (n=142)	Refractory pain (group B) (n=58)	P-value (A vs. B)
SOFA score, mean±SD	2±1	2±1	3±2	0.001
Shock index, mean±SD	0.86±0.30	0.80±0.30	0.95±0.40	0.030
WBC (×10⁹/L), mean±SD	13±7	13±7	15±8	0.034
Lactate (mg/dL), mean±SD	1.9±1.8	1.4±0.9	3.4±2.0	0.001
Triage GCS, median (IQR)	15 (14-15)	15 (14-15)	15 (14-15)	0.510
Triage pain score, mean±SD	8±2	8±2	8±1	0.400
Triage SBP (mmHg), mean±SD	133±20	135±27	127±32	0.070
Triage heart rate (beats per minute), mean±SD	94±19	93±18	97±23	0.220
Pain score at ED departure, mean±SD	5±3	4±3	8±2	0.001
Change of pain score, mean±SD	-3±3	-5±2	0±1	0.001
ED length of stay (minutes), median (IQR)	491 (327-728)	524 (359-774)	355 (233-570)	0.001
Mortality, n (%)	8 (4)	3 (2)	5 (9)	0.047
Hospital length of stay (days), median (IQR)	6 (3-10)	6 (3-9)	9 (4-15)	0.002

Parameters	All (n=200)	No refractory pain (group A) (n=142)	Refractory pain (group B) (n=58)	P-value (A vs. B)
Number of pain medication administration, median (IQR)	4 (3-6)	4 (3-7)	3 (3-5)	0.001
Pain medication type, n (%)^*
No pain medication	26 (13)	13 (9)	13 (22)	0.020
Any opioids	164 (82)	123 (87)	41 (70)	0.010
Opioids+non-opioids	20 (10)	14 (10)	6 (10)	0.890
Non-opioids	30 (15)	20 (14)	10 (17)	0.730
Total MEU, mean±SD	22±11	13±9	9±16	0.020
MEU per kg (body weight), mean±SD	0.15±0.16	0.18±0.20	0.11±0.10	0.004
Total intravenous crystalloids (liter), mean±SD	1.4±1.0	1.2±0.9	1.8±1.2	0.017
IVF per kg, mean±SD	17±1	16±14	21±17	0.060
Any anti-emetics, n (%)	134 (67)	97 (68)	37 (64)	0.650
Total number of antibiotics, median (IQR)	0 (0-1)	0 (0-1)	1 (0-2)	0.038
Receiving any antibiotics, n (%)	92 (46)	60 (42)	32 (55)	0.130

Independent variables	Univariate logistic regression			Multivariable logistic regression
Independent variables	OR	95% CI	P-value	OR	95% CI	P-value
Serum lactate	4.60	2.80-7.60	0.001	3.80	2.10-6.80	0.001
Number of pain medication administration	0.84	0.75-0.95	0.001	0.80	0.68-0.98	0.020
Gender - male	2.30	1.20-4.40	0.008	1.80	0.65-5.20	0.250
Past medical history - any kidney disease	2.30	1.20-4.30	0.080	1.90	0.40-9.10	0.430
Emergency Severity Index	0.55	0.30-0.97	0.040	0.60	0.20-1.90	0.420
SOFA	1.40	1.20-1.70	0.001	1.10	0.80-1.50	0.570
Triage SBP	0.98	0.98-1.00	0.047	1.01	0.98-1.03	0.350
WBC	1.04	1.00-1.08	0.033	0.90	0.90-1.04	0.350
MEU per kg (body weight)^*	0.05	0.00-0.60	0.007	0.10	0.01-1.50	0.380
Opioids+non-opioids^*	1.30	0.50-3.70	0.590	1.60	0.40-6.30	0.490
IVF per kg (body weight)^*	1.02	1.01-1.04	0.044	0.98	0.90-1.02	0.460
Number of antibiotics	1.50	1.03-2.10	0.032	1.60	0.90-2.80	0.090
Diagnosis - bowel obstruction	0.40	0.10-0.90	0.022	0.80	0.20-2.80	0.690
Diagnosis - bowel perforation	2.10	0.90-5.00	0.087	0.60	0.10-2.90	0.530

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