Validation de deux méthodes d'évaluation de la douleur aiguë en médecine d'urgence

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal

Impact of Age, Sex and Route of Administration on Adverse Events after Opioid Treatment in the Emergency Department: A Retrospective Study

BACKGROUND: The efficacy of opioids for acute pain relief in the emergency department (ED) is well recognized, but treatment with opioids is associated with adverse events ranging from minor discomforts to life-threatening events

Relationship between acute pain trajectories after an emergency department visit and chronic pain: a Canadian prospective cohort study

Objectives Inadequate acute pain management can reduce the quality of life, cause unnecessary suffering and can often lead to the development of chronic pain. Using group-based trajectory modelling, we previously identified six distinct pain intensity trajectories for the first 14-day postemergency department (ED) discharge; two linear ones with moderate or severe pain during follow-up (~40% of the patients) and four cubic polynomial order trajectories with mild or no pain at the end of the 14 days (low final pain trajectories). We assessed if previously described acute pain intensity trajectories over 14 days after ED discharge are predictive of chronic pain 3 months later.Design Prospective cohort study.Setting Tertiary care trauma centre academic hospital.Participants This study included 18 years and older ED patients who consulted for acute (≤2 weeks) pain conditions that were discharged with an opioid prescription. Patients completed a 14-day diary in which they listed their daily pain intensity (0–10 numeric rating scale).Outcomes Three months after ED visit, participants were questioned by phone about their current pain intensity (0–10 numeric rating scale). Chronic pain was defined as patients with current pain intensity ≥4 at 3 months.Results A total of 305 participants remained in the study at 3 months, 49% were women and a mean age of 55±15 years. Twelve per cent (11.9; 95% CI 8.2 to 15.4) of patients had chronic pain at the 3-month follow-up. Controlling for age, sex and pain condition, patients with moderate or severe pain trajectories and those with only a severe pain trajectory were respectively 5.1 (95% CI 2.2 to 11.8) and 8.2 (95% CI 3.4 to 20.0) times more likely to develop chronic pain 3 months later compared with patients in the low final pain trajectories.Conclusion Specific acute pain trajectories following an ED visit are closely related to the development of chronic pain 3 months later.Trial registration number NCT02799004; Results

Estimation of pain intensity in emergency medicine: a validation study

International audienceThis study was designed to estimate the validity of an 11-point verbal numerical rating scale (VNRS) and a 100 Unit (U) plasticized visual analogue scale (VASp) using a 100mm paper visual analogue scale (VAS) as a gold standard, to recommend the best method of reporting the intensity of acute pain in an emergency department (ED). A convenience sample of 1176 patients with acute pain were recruited in the ED of a teaching hospital. Patients >18 years and able to use the different scales were included. Scales were presented randomly. Results were converted to a 0-100 U scale and validity was quantified using the Bland-Altman method and the intra-class correlation (ICC). The limits of acceptability were previously set for the limits of agreement at +/-20 U, with a constant bias. The Bland-Altman method revealed a small bias of -4 U for the VNRS and +1 U for VASp. However, the bias of the VNRS varied with the intensity of pain from -10 to +1 U. The limits of agreement between the VNRS&VAS and the VASp&VAS were -25; +17 U and -17; +18 U, respectively. The ICC was excellent between the VNRS&VAS (0.88) and the VASp&VAS (0.92). In conclusion, the VASp has a small bias, acceptable limits of agreement and an excellent intra-class correlation. It is probably a valid tool to estimate acute pain in the ED. However, the VNRS is less valid in that context because of its wide limits of agreement and variable bias (mainly in lower scores)

Evaluation of interventions to reduce opioid prescribing for patients discharged from the emergency department: a systematic review and meta-analysis.

IMPORTANCE: Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse. OBJECTIVE: To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021. STUDY SELECTION: Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I(2) values. MAIN OUTCOMES AND MEASURES: The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies. RESULTS: Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, −22.61%; 95% CI, −30.70% to −14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, −8.64%; 95% CI, −17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, −0.30; 95% CI, −0.51 to −0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, −33.31%; 95% CI, −39.67% to −26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, −11.18%; 95% CI, −22.34% to −0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients’ satisfaction. CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed. TRIAL REGISTRATION: PROSPERO Identifier: CRD4202018725

Early Factors Associated with the Development of Chronic Pain in Trauma Patients

Objective. To identify factors, available at the time of trauma admission, associated with the development of chronic pain to allow testing of preventive approaches. Methods. In a retrospective observational cohort study, we included all patients ≥ 18 years old admitted for injury in 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014. Chronic pain was defined as follows: treated in a chronic pain clinic, diagnosed with chronic pain, or received at least 2 prescriptions of chronic pain medications 3 to 12 months postinjury. Results. A total of 95,134 patients were retained for analysis. Mean age was 59.8 years (±21.7), and 52% were men. The causes of trauma were falls (63%) and motor vehicle accidents (22%). We identified 14,518 patients (15.3%; 95% CI: 15.1–15.5) who developed chronic pain. After controlling for confounding factors, the variables associated with chronic pain were spinal cord injury (OR = 3.9; 95% CI: 3.4–4.6), disc-vertebra trauma (OR = 1.6; 95% CI: 1.5–1.7), history of alcoholism (OR = 1.4; 95% CI: 1.2–1.7), history of anxiety (OR = 1.4; 95% CI: 1.2–1.5), history of depression (OR = 1.3; 95% CI: 1.1–1.4), and being female (OR = 1.3; 95% CI: 1.2–1.3). The area under the receiving operating characteristic curve derived from the model was 0.80. Conclusions. We identified risk factors present on hospital admission that can predict trauma patients who will develop chronic pain. These factors should be prospectively validated

Pain during exacerbation of chronic obstructive pulmonary disease: A prospective cohort study

International audienceBACKGROUND AND OBJECTIVE: Pain, a symptom often present in patients with Chronic Obstructive Pulmonary Disease (COPD), alters quality of life. COPD exacerbation augments several mechanisms that may cause pain (dyspnea, hyperinflation and inflammation) and therefore we hypothesized that pain might be increased during exacerbation.METHODS: A prospective cohort study was conducted in patients admitted for acute exacerbations of COPD (AECOPD) in two emergency departments in France and Canada. Patients with cancer-related pain or recent trauma were not included. The Short Form McGill Pain Questionnaire (SF-MPQ) and the Brief Pain Inventory (BPI) scale were used to evaluate pain intensity and location. Patients also completed the Borg Dyspnea Scale and Hospital Anxiety and Depression Scale. The questionnaires were completed again during an outpatient assessment in the stable phase. The primary outcome was difference in pain intensity (SF-MPQ) between the exacerbation and stable phases.RESULTS: Fifty patients were included. During exacerbation, 46 patients (92%) reported pain compared to 29 (58%) in the stable phase (p<0.001). Pain intensity was higher during exacerbation (SF-MPQ 29.7 [13.6-38.2] vs. 1.4 [0.0-11.2]; p<0.001). Pain was predominantly located in the chest during exacerbation and in the limbs during the stable phase. Pain intensity during exacerbation correlated with anxiety score.CONCLUSION: The frequency and intensity of pain were higher during AECOPD, with a specific distribution. Pain should therefore be routinely assessed and treated in patients with AECOPD

Physiotherapy Can Help Recover Functional Status in Community-dwelling Seniors Assessed in Emergency Departments for Minor Injuries

Background: Around 75% of seniors seeking treatment for injuries in Emergency Departments (ED) are discharged home with minor injuries that put them at risk of functional decline in the following months.&nbsp;Objectives: To 1) describe seniors&rsquo; characteristics using or not physiotherapy services following ED visits for minor injuries and 2) examine their functional status according to physiotherapy use.&nbsp;Methods: Secondary data analyses of the Canadian Emergency Team Initiative cohort study. Participants were 65 years and older, discharged home after consulting EDs for minor injuries and assessed three times: ED, 3- and 6-months. Physiotherapy use was recorded as yes/no. Functional status was measured using the Older American Resources Scale (OARS). Multivariate linear regressions were used to examine change in OARS scores over time, accounting for confounders.&nbsp;Results: Among the 2169 participants, 565 (26%) received physiotherapy, and 1604 (74%) did not. Physiotherapy users were more likely females (71% vs. 64%), more educated, and less cognitively impaired. The overall change in OARS at 6 months was -0.31/28 points (95% CI: -0.55; -0.28) with no difference across groups after adjustment. Subgroup analyses among frail seniors showed that physiotherapy users maintained their function while non-users lost clinically significant function (-0.02 vs. -1.26/28 points, p = 0.03). Among the severely injured (Injury Severity Scale &ge; 5), physiotherapy users&rsquo; results were higher by almost 1/28 points (p = 0.03) compared to non-users.&nbsp;Conclusion: These results suggest that among seniors discharged home after consulting the ED for minor injuries, the frail and severely injured may benefit from being systematically referred to physiotherapy services.&nbsp