Pain Management in ED for Incision and Drainage of Abscess
Information source: University of California, Los Angeles
ClinicalTrials.gov processed this data on August 23, 2015 Link to the current ClinicalTrials.gov record.
Condition(s) targeted: Abscess
Intervention: Fentanyl (Drug); Normal Saline (Drug)
Phase: Phase 4
Status: Withdrawn
Sponsored by: University of California, Los Angeles Official(s) and/or principal investigator(s): Larry J Baraff, MD, Principal Investigator, Affiliation: University of California, Los Angeles Joshua W Elder, B.S., Study Director, Affiliation: University of California, Los Angeles Adaira Landry, B.A., Study Director, Affiliation: University of California, Los Angeles
Summary
Patients presenting with painful procedures in the Emergency Department (ED) have been shown
to frequently have inadequate pain management. The incision and drainage (I&D) of an abscess
is a common procedure that is viewed by many emergency physicians as only requiring a
localized anesthetic for pain management. However, it has been documented in previous
research that there can be disconnect between what emergency medicine physicians interpret
as painful and what patients experience as pain. A trial will be conducted to focus on use
of intramuscular (IM) Fentanyl as an intervention to help alleviate pain associated with the
incision and drainage of an abscess. This is a procedure that rarely receives systemic
opioids.
This double blinded protocol will randomize a total of 50 patients patients with abscesses
to receive either a combination of Fentanyl IM followed by subcutaneous (SC) local
bupivicaine analgesia or Normal Saline IM followed by SC local bupivicaine analgesia. Only
opiate naive patients will be enrolled. The primary outcomes studied are patients overall
satisfaction with procedure, and patients level of pain associated with the procedure.
Clinical Details
Official title: Randomized Controlled Trial of the Use of Intramuscular Fentanyl for the Incision and Drainage of Abscess in the Emergency Department
Study design: Allocation: Randomized, Endpoint Classification: Safety Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Outcomes Assessor), Primary Purpose: Treatment
Primary outcome: Highest level of pain during the incision and drainage of the abscessSafety of Intramuscular Injection of Fentanyl
Detailed description:
Patients presenting with painful procedures in the Emergency Department (ED) have been shown
to frequently have inadequate pain management. The incision and drainage of an abscess is a
common procedure that is usually treated by emergency physicians with only localized
anesthetic for pain management. For those abscesses that require incision and drainage, a
physician will usually inject a local anesthetic to help decrease sensation to the affected
area prior to incision and drainage. Occasionally, physicians will administer a systemic
pain medication, in addition to the localized anesthetic, as a method to better help
alleviate pain associated with more complex procedures.
Wilson and Pendleton (1989) wrote a landmark study that highlighted the problem of
physicians undertreating patients pain in the ED, a problem known as oligoanalgesia. They
found that only 50% of patients with moderate to severe pain were receiving narcotics. Since
then the literature has highlighted a number of additional deficits in the use of pain
medication in the ED to include the amount of time it takes patients to receive medication,
the lack of education medical personnel receive in pain management, the bias that physicians
have toward using pain medication, and the lack of pain medication given for painful
procedures. Five areas of inadequate management of painful conditions in the ED include 1)
failure to acknowledge pain, 2) failure to assess initial pain, 3) failure to have pain
management guidelines, 4) failure to document pain and assess treatment adequacy, and 5)
failure to meet patients expectations. The use of adequate pain medication for painful
procedures covers has been a recent attempt to fill in the gap of one area contributing to
oligoanalgesia.
Incision and drainage procedures are a common condition that emergency physicians manage yet
there is no evidence to suggest whether they are appropriately managing the pain associated
with their treatment. We propose a trial to determine whether intramuscular (IM) Fentanyl,
given prior to the incision and drainage of the abscess, decreases the level of pain
during/after the procedure and increases the patients overall satisfaction with the
procedure.
This double blind protocol will randomize 50 patients with abscesses to receive either a
combination of an intramuscular injection of Fentanyl followed by subcutaneous (SC) local
bupivacaine analgesia (Fentanyl Group), or a combination of an intramuscular injection of
normal saline (Control Group) IM followed by SC local bupivacaine analgesia. Patients will
receive a questioner administered by a research assistant after the procedure to assess
outcomes of study.
Neither treating physicians, nurses nor patients and research assistants will be aware to
which group the patient has been randomized. Fentanyl was chosen due to the rapidity of
onset (7-8 minutes) and clearance (1-2 hours). The choice of abscess was made given the ease
at which to make a diagnosis, standard treatment with incision and drainage and known
association with pain during and after the procedure.
After appropriate identification, screening, and consenting, the patient will then be
randomized to receive intramuscular Fentanyl (1 ug/kg) OR Normal Saline (1. 5 ml) 7-8 minutes
before the procedure is began. Patients in either group will still receive usual care with
local subcutaneous bupivacaine anesthetics. Patients are at liberty to request more local
subcutaneous bupivacaine and or more pain systemic pain medication and the treating provider
may deliver more at their discretion. Contamination may occur if patients receiving IM
Normal Saline request systemic narcotics for pain levels not controlled with local
bupivacaine alone. These patients may receive systemic narcotics again at the discretion of
treating providers. However all patients will remain in the initial group to which they were
assigned and data will be evaluated on an intention to treat analysis basis.
Eligibility
Minimum age: 18 Years.
Maximum age: 65 Years.
Gender(s): Both.
Criteria:
Inclusion Criteria:
- Age >18 and < 65 years
- Presenting with a simple abscesses requiring incision and drainage
- Treating physician has to state that the patient's usual treatment would not include
systemic opioids before incision and drainage.
Exclusion Criteria:
- Patients are unable to consent to procedure the procedure
- Patients are less than age 18 or older than age 65
- Patients are unable to avoid driving for 2 hours after administration of the
intramuscular medication (Fentanyl or placebo)
- Patients have hypersensitivity or allergy to Fentanyl
- Patients are pregnant
- Patients have taken a narcotic pain medication in the last 14 days
- Patients have a history of drug or alcohol addiction
- Patients have taken an monoamine oxidase (MAO) inhibitor in the last 14 days (such as
furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine (Nardil), rasagiline
(Azilect), selegiline (Eldepryl, Emsam, Zelapar), or tranylcypromine (Parnate)
- Patients have a breathing disorder such as chronic obstructive pulmonary disease
- Patients have a history of head injury or brain tumor
- Patients have a heart rhythm disorder
- Patients have seizures or epilepsy
- Patients have mental illness such as depression, hallucinations
- Patients have low blood pressure
- Patients have liver or kidney disease.
Locations and Contacts
Additional Information
Starting date: June 2011
Last updated: June 17, 2013
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