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Meta-Analysis
. 2015 Jun 2;2015(6):CD003348.
doi: 10.1002/14651858.CD003348.pub3.

Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain

Ewan D McNicol  1 , McKenzie C Ferguson, Jana Hudcova
Affiliations
Meta-Analysis

Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain

Ewan D McNicol et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an updated version of the original Cochrane review published in Issue 4, 2006. Patients may control postoperative pain by self administration of intravenous opioids using devices designed for this purpose (patient controlled analgesia or PCA). A 1992 meta-analysis by Ballantyne et al found a strong patient preference for PCA over non-patient controlled analgesia, but disclosed no differences in analgesic consumption or length of postoperative hospital stay. Although Ballantyne's meta-analysis found that PCA did have a small but statistically significant benefit upon pain intensity, a 2001 review by Walder et al did not find statistically significant differences in pain intensity or pain relief between PCA and groups treated with non-patient controlled analgesia.

Objectives: To evaluate the efficacy and safety of patient controlled intravenous opioid analgesia (termed PCA in this review) versus non-patient controlled opioid analgesia of as-needed opioid analgesia for postoperative pain relief.

Search methods: We ran the search for the previous review in November 2004. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 12), MEDLINE (1966 to 28 January 2015), and EMBASE (1980 to 28 January 2015) for randomized controlled trials (RCTs) in any language, and reference lists of reviews and retrieved articles.

Selection criteria: We selected RCTs that assessed pain intensity as a primary or secondary outcome. These studies compared PCA without a continuous background infusion with non-patient controlled opioid analgesic regimens. We excluded studies that explicitly stated they involved patients with chronic pain.

Data collection and analysis: Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence. We performed meta-analysis of outcomes that included pain intensity assessed by a 0 to 100 visual analog scale (VAS), opioid consumption, patient satisfaction, length of stay, and adverse events.

Main results: Forty-nine studies with 1725 participants receiving PCA and 1687 participants assigned to a control group met the inclusion criteria. The original review included 55 studies with 2023 patients receiving PCA and 1838 patients assigned to a control group. There were fewer included studies in our updated review due to the revised exclusion criteria. For the primary outcome, participants receiving PCA had lower VAS pain intensity scores versus non-patient controlled analgesia over most time intervals, e.g., scores over 0 to 24 hours were nine points lower (95% confidence interval (CI) -13 to -5, moderate quality evidence) and over 0 to 48 hours were 10 points lower (95% CI -12 to -7, low quality evidence). Among the secondary outcomes, participants were more satisfied with PCA (81% versus 61%, P value = 0.002) and consumed higher amounts of opioids than controls (0 to 24 hours, 7 mg more of intravenous morphine equivalents, 95% CI 1 mg to 13 mg). Those receiving PCA had a higher incidence of pruritus (15% versus 8%, P value = 0.01) but had a similar incidence of other adverse events. There was no difference in the length of hospital stay.

Authors' conclusions: Since the last version of this review, we have found new studies providing additional information. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides moderate to low quality evidence that PCA is an efficacious alternative to non-patient controlled systemic analgesia for postoperative pain control.

PubMed Disclaimer

Conflict of interest statement

EM has no relevant conflicts of interest to declare

MF has no relevant conflicts of interest to declare

JH has no relevant conflicts of interest to declare

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study. Note: Empty cells denote study where risk of bias was judged for each subgroup (Chan 1995) or for original study only (Egbert 1990)
4
4
Forest plot of comparison: 1 VAS pain scores (0 to 100): PCA versus control, outcome: 1.1 Pain scores 0 to 24 h.
5
5
Forest plot of comparison: 2 Opioid consumption: PCA versus control, outcome: 2.1 Consumption of morphine equivalents 0 to 24 h.
6
6
Forest plot of comparison: 3 Patient satisfaction: PCA versus control, outcome: 3.2 Number of participants in arm satisfied with therapy.
1.1
1.1. Analysis
Comparison 1: VAS pain scores (0 to 100): PCA versus control, Outcome 1: Pain scores 0 to 24 h
1.2
1.2. Analysis
Comparison 1: VAS pain scores (0 to 100): PCA versus control, Outcome 2: Pain scores 25 to 48 h
1.3
1.3. Analysis
Comparison 1: VAS pain scores (0 to 100): PCA versus control, Outcome 3: Pain scores 49 to 72 h
1.4
1.4. Analysis
Comparison 1: VAS pain scores (0 to 100): PCA versus control, Outcome 4: Pain scores 0 to 48 h
1.5
1.5. Analysis
Comparison 1: VAS pain scores (0 to 100): PCA versus control, Outcome 5: Pain scores 0 to 72 h
1.6
1.6. Analysis
Comparison 1: VAS pain scores (0 to 100): PCA versus control, Outcome 6: Pain scores 0 to 24 h minus inadequately randomized trials
1.7
1.7. Analysis
Comparison 1: VAS pain scores (0 to 100): PCA versus control, Outcome 7: Pain scores 25 to 48 h minus inadequately randomized trials
1.8
1.8. Analysis
Comparison 1: VAS pain scores (0 to 100): PCA versus control, Outcome 8: Pain scores 0 to 48 h minus inadequately randomized trials
2.1
2.1. Analysis
Comparison 2: Opioid consumption: PCA versus control, Outcome 1: Consumption of morphine equivalents 0 to 24 h
2.2
2.2. Analysis
Comparison 2: Opioid consumption: PCA versus control, Outcome 2: Consumption of morphine equivalents 25 to 48 h
2.3
2.3. Analysis
Comparison 2: Opioid consumption: PCA versus control, Outcome 3: Consumption of morphine equivalents 0 to 48 h
2.4
2.4. Analysis
Comparison 2: Opioid consumption: PCA versus control, Outcome 4: Consumption of morphine equivalents 0 to 72 h
2.5
2.5. Analysis
Comparison 2: Opioid consumption: PCA versus control, Outcome 5: Consumption of morphine equivalents 0 to 24 h minus inadequately randomized trials
3.1
3.1. Analysis
Comparison 3: Patient satisfaction: PCA versus control, Outcome 1: Satisfaction on a continuous scale
3.2
3.2. Analysis
Comparison 3: Patient satisfaction: PCA versus control, Outcome 2: Number of participants in arm satisfied with therapy
4.1
4.1. Analysis
Comparison 4: Length of stay: time to readiness for discharge, Outcome 1: Number of days: PCA versus control
4.2
4.2. Analysis
Comparison 4: Length of stay: time to readiness for discharge, Outcome 2: Number of days: PCA versus control minus inadequately randomized trials
5.1
5.1. Analysis
Comparison 5: Serious adverse events, Outcome 1: Number of participants with serious adverse event
6.1
6.1. Analysis
Comparison 6: Withdrawals due to adverse events, Outcome 1: Number of participants withdrawing
7.1
7.1. Analysis
Comparison 7: Withdrawals due to lack of efficacy, Outcome 1: Number of participants withdrawing
8.1
8.1. Analysis
Comparison 8: Sedation, Outcome 1: Sedation on a continuous scale
8.2
8.2. Analysis
Comparison 8: Sedation, Outcome 2: Number of participants in arm reporting sedation
9.1
9.1. Analysis
Comparison 9: Nausea and vomiting, Outcome 1: Nausea and vomiting on a 0 to 10 scale (10 = most severe)
9.2
9.2. Analysis
Comparison 9: Nausea and vomiting, Outcome 2: Number of participants reporting nausea or vomiting, or both
10.1
10.1. Analysis
Comparison 10: Pruritus, Outcome 1: Number of participants reporting pruritus
11.1
11.1. Analysis
Comparison 11: Respiratory depression, Outcome 1: Number of participants affected
12.1
12.1. Analysis
Comparison 12: Urinary retention, Outcome 1: Number of participants reporting urinary retention
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Harrison 1988 {published data only}
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Hu 2006 {published data only}
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Jackson 1989 {published data only}
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Keita 2003 {published data only}
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Kenady 1992 {published data only}
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Kyzer 1995 {published data only}
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McGrath 1989 {published data only}
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Morad 2009 {published data only}
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Morad 2012 {published data only}
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Munro 1998 {published data only}
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Murphy 1994 {published data only}
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Myles 1994 {published data only}
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O'Halloran 1997 {published data only}
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Paoletti 1993 (gyn) {published data only}
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Passchier 1993 {published data only}
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Pettersson 2000 {published data only}
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Precious 1997 {published data only}
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Rayburn 1988 {published data only}
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Rogers 1990 {published data only}
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Rosen 1998 {published data only}
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Smythe 1994 {published data only}
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Snell 1997 {published data only}
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Stoneham 1996 {published data only}
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Sudheer 2007 {published data only}
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Thomas 1995 {published data only}
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Wheatley 1992 {published data only}
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References to studies excluded from this review

Atwell 1984 {published data only}
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Bayar 2008 {published data only}
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Bell 2007 {published data only}
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Boulanger 1993 {published data only}
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Choiniere 1998 {published data only}
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Coyle 1990 {published data only}
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D'haese 1998 {published data only}
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Davis 2006 {published data only}
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Duggleby 1992 {published data only}
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Eremenko 2011 {published data only}
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Ferrante 1988 {published data only}
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Forst 1999 {published data only}
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Gaitini 1996 {published data only}
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Gao 2007 {published data only}
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Gursoy 2006 {published data only}
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Gust 1999 {published data only}
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Halilotlu 2010 {published data only}
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Hecker 1988a {published data only}
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Hecker 1988b {published data only}
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Jabri 2010 {published data only}
    1. Jabri H, Rais K, Chahed S, Bouali Y, Ben Hassen K, Kaabachi O. Management of post operative pain in TKR: Oral opioid versus IV PCA morphine. A preliminary study. Regional Anesthesia and Pain Medicine 2010;35:E116.
Jellinek 1990 {published data only}
    1. Jellinek H, Haumer H, Grubhofer G, Klappacher G, Jenny T, Weindlmayr-Goettel M, et al. Tramadol in postoperative pain therapy. Patient-controlled analgesia versus continuous infusion. Anaesthetist 1990;39:513-20. - PubMed
Khalili 2013 {published data only}
    1. Khalili GR, Heidari SM, Sorani Heidari M. Comparison of intravenous morphine with morphine sulfate suppository in control of pain after knee and hip arthroplasty. Journal of Babol University Medical Sciences 2013;15:19-24.
Kilbride 1992 {published data only}
    1. Kilbride MJ, Senagore AJ, Mazier WP, Ferguson C, Ufkes T. Epidural analgesia. Surgery, Gynecology & Obstetrics 1992;174:137-40. - PubMed
Kleiman 1988 {published data only}
    1. Kleiman RL, Lipman AG, Hare BD, MacDonald SD. A comparison of morphine administered in patient-controlled analgesia and regularly scheduled intramuscular injection in severe, postoperative pain. Journal of Pain Symptom Management 1988;3:15-22. - PubMed
Knapp‐Spooner 1995 {published data only}
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Knudsen 1993 {published data only}
    1. Knudsen WP, Boettcher R, Vollmer WM, Griggs DK. A comparison of patient-controlled and intramuscular morphine in patients after abdominal surgery. Hospital Pharmacy 1993;28(2):117-22. - PubMed
Lange 1988 {published data only}
    1. Lange MP, Dahn MS, Jacobs LA. Patient-controlled analgesia versus intermittent analgesia dosing. Heart and Lung 1988;17:495-8. - PubMed
Lee 2010 {published data only}
    1. Lee A, Chan SKC, Chen PP, Gin T, Lau ASC, Chiu CH. The costs and benefits of extending the role of the acute pain service on clinical outcomes after major elective surgery. Anesthesia and Analgesia 2010;111:1042-50. - PubMed
Lee 2013 {published data only}
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Liu 2005 {published data only}
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Martinez‐Ubieto 1992 {published data only}
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Rittenhouse 1999 {published data only}
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Viscusi 2004 {published data only}
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References to studies awaiting assessment

Legeby 2002 {published data only}
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References to other published versions of this review

Hudcova 2006
    1. Hudcova J, McNicol ED, Quah CS, Lau J, Carr DB. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database of Systematic Reviews 2006, Issue 4. [DOI: 10.1002/14651858.CD003348.pub2] - DOI - PubMed

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