Am Fam Physician. 1999;60(9):2648
Emergency diagnostic and therapeutic procedures can be painful, and the use of anesthetic in patients before these procedures are performed is variable. Inadequate management of pain, called “oligoanalgesia,” is common and usually results from inadequate pain assessment or insufficient use of anesthetic or analgesic.
Singer and associates performed a prospective study in an emergency department to evaluate the ability of physicians to predict patient pain levels caused by commonly performed emergency procedures and to assess the concomitant use of anesthetics before various painful procedures were performed. Patients presenting to the emergency department requiring emergency procedures were enrolled in the study unless they had taken analgesics or anesthetics before the visit. After completion of the procedure, patients rated the amount of pain they experienced. Practitioners were independently asked to assess the pain they believed patients experienced. Most pain assessments were recorded within one hour following the procedure. Patients were also asked if they would want a local anesthetic administered before undergoing a similar procedure in the future.
Reports involving all procedures showed a significant difference between patient and physician pain scores, although there was agreement between physician and patient about which procedures were the most painful. Patients listed the most painful procedures, in descending order, as nasogastric intubation, incision and drainage of abscesses, fracture reduction and urethral catheterization. Physicians listed the most painful procedures, in descending order, as nasogastric intubation, fracture reduction, incision and drainage of abscesses, performance of a digital block and urethral catheterization. Physicians did not accurately judge individual patient pain scores. Of the participating patients, 12.8 percent received local anesthesia before undergoing these procedures. Among patients who received anesthesia, two thirds stated that they would want anesthesia before undergoing a similar procedure in the future.
The authors conclude that patient and physician estimations of pain caused by procedures commonly performed in the emergency department differ. Patients' highest pain scores occurred with nasogastric intubation, incision and drainage of abscesses, fracture reduction and urethral catheterization. More consideration is needed to individualize patients' anesthetic needs before they undergo painful procedures. Subjective pain assessment by patients may also vary according to sex, age, cultural background, intoxication or drug use, comfort level with the practitioner and expectations regarding pain.