Postoperative patient-controlled analgesia: Meta-analyses of initial randomized control trials

doi:10.1016/0952-8180(93)90013-5

Journal of Clinical Anesthesia

Volume 5, Issue 3, May–June 1993, Pages 182-193

https://doi.org/10.1016/0952-8180(93)90013-5 Get rights and content

Abstract

Study Objective: To compare outcomes during conventional analgesia (as-needed intramuscular dosing) and patient-controlled analgesia (PCA) in postoperative patients by analyzing data from published comparative trials.

Design: Meta-analyses of 15 randomized control trials.

Patients: Seven hundred eighty-seven adult patients (aged 16 to 65) undergoing various operative procedures.

Interventions: Either PCA or conventional analgesia for postoperative pain control.

Measurements and Main Results: Data were extracted on analgesic efficacy, analgesic use, patient satisfaction, length of hospital stay, and side effects. Meta-analyses of the data showed the following: (1) greater analgesic efficacy when PCA was used, with a mean additional benefit of 5.6 on a scale of 0 to 100 (SED, 2.2; p = 0.006); (2) a nonsignificant trend toward reduced analgesic use in PCA patients, based on a count of trials finding in one direction or the other (p = 0.092); (3) a 42% difference in the proportion of patients expressing satisfaction over dissatisfaction (SED, 20%; p = 0.02), with PCA being preferred; (4) a nonsignificant trend toward shortening of length of hospital stay with PCA use (mean, 0.15 days, SED, 0.13; p = 0.24); (5) no significant differences in the occurrence of any side effect.

Conclusions: Patient preference strongly favors PCA over conventional analgesia. Patients using PCA also obtain better pain relief than those using conventional analgesia, without an increase in side effects. Favorable effects of PCA upon analgesic usage and length of hospital stay did not in the initial trials attain statistical significance. Nonetheless, the favorable trends in the mean effect sizes for both outcomes argue that further studies of both outcomes should be performed to determine whether the favorable impact of PCA upon either may become statistically significant if larger numbers of patients are enrolled.

References (28)

S. Yusuf et al.
Beta blockade during and after myocardial infarction: an overview of the randomized trials
Prog Cardiovasc Dis
(1985)
T.C. Chalmers et al.
A method for assessing the quality of a randomized control trial
Controlled Clin Trials
(1981)
D. McGrath et al.
Comparison of one technique of patient-controlled postoperative analgesia with intramuscular meperidine
Pain
(1989)
R.L. Kleiman et al.
A comparison of morphine administered by patient-controlled analgesia and regularly scheduled intramuscular injection in severe, postoperative pain
J Pain Symptom Manage
(1988)
R. Ellis et al.
Pain relief after abdominal surgery-a comparison of i.m. morphine, sublingual buprenorphine and self-administered i.v. pethidine
Br J Anaesth
(1982)
B.R. Hecker et al.
Patient-controlled analgesia: a randomized, prospective comparison between two commercially available PCA pumps and conventional analgesic therapy for postoperative pain
Pain
(1988)
R. DerSimonian et al.
Meta-analysis in clinical trials
Controlled Clin Trials
(1986)
D. Jackson
A study of pain management: patient controlled analgesia versus intramuscular analgesia
J Intraven Nurs
(1989)

D.B. Carr et al.

Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline

K.A. L'Abbe et al.

Meta-analysis in clinical research

Ann Intern Med

(1987)

H.S. Sacks et al.

Meta-analyses of randomized controlled trials

N Engl J Med

(1987)

S.B. Thacker

Meta-analysis. A quantitative approach to research integration

JAMA

(1988)

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^☆: Supported in part by the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Rockville, MD.

^∗: Clinical and Research Fellow in Anesthesia, Massachusetts General Hospital

^†: Associate Professor of Anaesthesia and Medicine, Harvard Medical School

^§: Senior Lecturer in Statistics, Technology Assessment Group, Harvard School of Public Health

^∥: Associate Professor of Public Health, Harvard School of Public Health

^#: Roger I. Lee Professor of Mathematical Statistics, Emeritus, Harvard School of Public Health

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Original contributionPostoperative patient-controlled analgesia: Meta-analyses of initial randomized control trials☆

Abstract

Prog Cardiovasc Dis

Controlled Clin Trials

Pain

J Pain Symptom Manage

Br J Anaesth