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The Rational Clinical Examination | Clinician's Corner

Do Opiates Affect the Clinical Evaluation of Patients With Acute Abdominal Pain?

Sumant R. Ranji, MD; L. Elizabeth Goldman, MD; David L. Simel, MD, MHS; Kaveh G. Shojania, MD
JAMA. 2006;296(14):1764-1774. doi:10.1001/jama.296.14.1764.
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Context Clinicians have traditionally withheld opiate analgesia from patients with acute abdominal pain until after evaluation by a surgeon, out of concern that analgesia may alter the physical findings and interfere with diagnosis.

Objective To determine the impact of opiate analgesics on the rational clinical examination and operative decision for patients with acute abdominal pain.

Data Sources and Study Selection MEDLINE (through May 2006), EMBASE, and hand searches of article bibliographies to identify placebo-controlled randomized trials of opiate analgesia reporting changes in the history, physical examination findings, or diagnostic errors (those resulting in “management errors,” defined as the performance of unnecessary surgery or failure to perform necessary surgery in a timely fashion).

Data Extraction Two authors independently reviewed each study, abstracted data, and classified study quality. A third reviewer independently resolved discrepancies.

Data Synthesis Studies both in adults (9 trials) and in children (3 trials) showed trends toward increased risks of altered findings on the abdominal examination due to opiate administration, with risk ratios for changes in the examination of 1.51 (95% confidence interval [CI], 0.85 to 2.69) and 2.11 (95% CI, 0.60 to 7.35), respectively. When the analysis was restricted to the 8 adult and pediatric trials that reported significantly greater analgesia for patients who received opiates compared with those who received placebo, the risk of physical examination changes became significant (risk ratio, 2.13; 95% CI, 1.14 to 3.98). These trials exhibited significant heterogeneity (I2 = 68.6%; P = .002), and only 2 trials distinguished clinically significant changes such as loss of peritoneal signs from all other changes; consequently, we analyzed risk of management errors as a marker for important changes in the physical examination. Opiate administration had no significant association with management errors (+0.3% absolute increase; 95% CI, −4.1% to +4.7%). The 3 pediatric trials showed a nonsignificant absolute decrease in management errors (−0.8%; 95% CI, −8.6% to +6.9%). Across adult and pediatric trials with adequate analgesia, opiate administration was associated with a nonsignificant absolute decrease in the risk of management errors (−0.2%; 95% CI, −4.0% to +3.6%).

Conclusions Opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors. The existing literature does not rule out a small increase in errors, but this error rate reflects a conservative definition in which surgeries labeled as either delayed or unnecessary may have met appropriate standards of care. In published research reports, no patient experienced major morbidity or mortality attributable to opiate administration.

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Figures

Figure 1. Diagnosis and Management Pathway in Patients With Acute Abdominal Pain Having Uncertain Diagnosis and Operative Decision After the Initial Examination
Graphic Jump Location

Patients may be given opiates between the initial examination and final examination when a decision is made about surgery. Opiates might alter the clinical findings and therefore affect the decision to proceed to surgery. Surgery may be required to establish the final diagnosis.

Figure 2. Changes in Abdominal Examination Results After Administration of Opiates Compared With Placebo
Graphic Jump Location

The forest plot shows the studies of adult and pediatric patients providing data on physical examination changes, both for all studies and for those studies with adequate analgesia (ie, analgesia significantly greater in the opiate vs placebo groups). The combined risk ratio (RR) for all studies (1.55; 95% confidence interval [CI], 1.02 to 2.36) indicates an increased risk of changes in physical examination findings with opiates. The studies exhibited significant heterogeneity (I2 = 62.1%; P = .003). In studies with multiple examiners, the results of the initial examination were used, with the exception of Thomas et al,27 for which individual examination data were not available. The RR for this study is based on 104 separate examinations performed on 74 patients. Reducing the weight accorded this study by 30% to compensate for this inflation of the sample size produced a negligible change in the summary RR. Deleting the study entirely had little impact on the summary result (RR, 1.60; 95% CI, 1.01 to 2.53). The combined RR for studies with adequate analgesia (2.13; 95% CI, 1.14 to 3.98; I2 = 68.6%; P = .002 for heterogeneity) indicates an increased risk of physical examination changes with opiates. Size of data markers is proportional to the weight of the individual studies in the meta-analysis. Error bars indicate 95% CIs.

Figure 3. Absolute Change in Risk of Incorrect Management Decisions With Opiates
Graphic Jump Location

The forest plot shows the trials that provided data on potential errors in clinical management, defined as possible delays in necessary surgery or the performance of possibly unnecessary surgery. The overall random-effects estimate shows almost no difference in the risk of incorrect management decisions (+0.1% absolute increase with opiates; 95% confidence interval [CI], −3.6% to +3.8%). The trials did not exhibit significant heterogeneity (I2 = 0.0%; P = .67). Size of data markers is proportional to the weight of the individual studies in the meta-analysis.

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