Does Administration of Parenteral Analgesic Affect Clinical

Monitoring, Diagnostic Accuracy, and Outcome of Patients with

Acute Appendicitis?

Jeffy G. Guerra, MD
Edgardo Penserga, MD, FPCS
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

__________________________________
Reprint requests: Jeffy G. Guerra, MD, Department of Surgery, Ospital ng
Maynila Medical Center, Quirino Avenue, Malate, Manila, Philippines.
Email: ommcsurgery@yahoo.com

Preoperative Parenteral Analgesic in Appendicitis

Preoperative Parenteral Analgesic in Appendicitis

Abstract:
Objective: To determine whether administration of parenteral analgesic affects
clinical monitoring, diagnostic accuracy and outcome of patients with suspected
acute appendicitis. Methods: Prospective, double-blind, placebo-controlled
administration of tramadol and normal saline (NS).

Patients 11 to 65 years old

with abdominal pain for less than seven days, with possibility of acute
appendicitis and needing clinical monitoring for definitive diagnosis, were
included. Changes in abdominal physical examination findings and pain
response were evaluated 30 minutes after administration of tramadol and
placebo which were given right after initial assessment. Accuracy in diagnosis,
appendiceal perforation rate, and morbidity and mortality rates were the outcome
measures. Results: One hundred sixty-three patients were enrolled. Eighty-four
patients received tramadol (Grp 1) and 79 received NS (Grp 2). Seven patients, 5
in Grp 1 and 2 in Grp 2, did not undergo an operation because of nonsurgical
diagnoses which were verified to be accurate during follow-up. One hundred
fifty-six patients, 79 in Grp 1 and 77 in Grp 2, were admitted with a diagnosis of
acute appendicitis and underwent surgery. There was no significant difference
between the groups when comparing the accuracy of preoperative diagnosis and
outcome of appendectomy in terms of perforation, morbidity, and mortality rates.
In those receiving parenteral analgesics, there was significant pain relief.
Conclusion: When compared with saline placebo, the administration of a
parenteral analgesic (tramadol) to patients being monitored for possible acute

Preoperative Parenteral Analgesic in Appendicitis

appendicitis effectively relieved pain and did not alter the ability of the surgeons
to accurately evaluate such patients.

Keywords: Appendicitis, Analgesics, Monitoring

Preoperative Parenteral Analgesic in Appendicitis

Introduction
It is a common practice by physicians, here and abroad, not to give
analgesics in patients presenting with a right lower quadrant (RLQ) abdominal
pain and being suspected to have acute appendicitis for fear that it may hamper
the clinical monitoring and thereby cause missed diagnosis and delayed
treatment (1-5). The drawback of this practice is that such patients are
continuously suffering from abdominal pain while awaiting definitive diagnosis
and treatment.
Lately, there are now reports in the literature contesting this practice of
withholding analgesics. Several authors are now advocating administration of
analgesics in patients with possible acute appendicitis while awaiting definitive
diagnosis and treatment (6-10). They claimed that such practice did not affect
the diagnostic accuracy of clinical monitoring and outcome of treatment at the
same time affording analgesia.
Search of local medical literature through HERDIN (11) did not yield any
paper on such an issue. Thus, the primary objective of this paper was to
determine whether administration of parenteral analgesics in Filipino patients
suspected of acute appendicitis would affect clinical monitoring, diagnostic
accuracy, and outcome. The secondary objective was to determine the amount
of pain relief afforded by such an intervention.

Preoperative Parenteral Analgesic in Appendicitis

Methods
The study design was a randomized controlled doubled-blinded clinical
trial conducted from May, 2004 to September, 2004, in the Department of
Surgery of Hospital X.
Filipino patients aged 11 to 65 with RLQ abdominal pain of less than 7-day
duration with a primary clinical diagnosis of acute appendicitis and who had no
history of allergy to the parenteral analgesic to be used were included in the
study.
The baseline physical findings on the abdomen (direct tenderness with or
without guarding) and pain score using the numerical 0-10 score were gotten
prior to randomization into two arms, Group 1 with parenteral analgesic
(tramadol, 50 to 100 mg for pediatrics and adults respectively) and Group 2, with
placebo or 5 cc of normal saline solution. A table of random numbers was used
for the randomization. Informed consent for the study was obtained. Those who
refused were not given parenteral analgesics.
Thirty minutes after administration of the parenteral analgesic and
placebo, another evaluation of the abdominal findings and assessment of the
pain score were done. At this point, a decision was made whether the patient
would be booked for appendectomy within 6 to 12 hours or to continue further
monitoring of the abdominal findings for those in which appendicitis was not
strongly considered.

For those booked for appendectomy, monitoring was

continued up to the time of operation.

Preoperative Parenteral Analgesic in Appendicitis

Those who were booked for appendectomy were operated not later than
12 hours after. The histopathology results of the appendix removed served as
the gold standard for the accuracy of the clinical diagnosis. Those who were not
operated on were observed until they could be discharged with a non-surgical
diagnosis. These patients would be followed up for at least one week to monitor
the accuracy of the non-appendicitis diagnosis.
The study was double-blind in that the patients and the senior residents
who made the initial and subsequent assessment and decided on the
management disposition did not know what was given in the parenteral solution.
The junior residents were the ones administering the parenteral solution.
The outcome measures of the study consisted of the accuracy of the
clinical diagnosis and outcome of treatment in terms of perforation, morbidity,
and mortality rates as well as changes in the pain score before and after the
administration of the parenteral solution.

The students t-test was used for

statistical analysis.
Results
A total of 163 patients were included in the study, 84 in Group 1 and 79 in
Group 2. All completed the study. In Group 1, the male to female ratio was 59 to
25 and the age ranged from 11-65 years with a mean of 26.76. In Group 2, the
male to female ratio was 55 to 24 and the age ranged from 14 to 46 with a mean
of 23.77 (Table 1).

Preoperative Parenteral Analgesic in Appendicitis

Table 1. Age and sex distribution of patients who participated in the study.
Group 1
Age

Group 2

Male

Female

Male

Female

11-15

16-20

15

17

21-25

13

18

26-30

10

31-35

11

36-40

41-45

46-50

51-55

56-60

61-65

Total

59

25

55

24

Mean age

Seven

26.76

23.77

patients were not operated on and discharged with a non-

appendicitis diagnosis after clinical monitoring and administration of the

parenteral solution.

The diagnoses consisted of urinary tract infection (2) ,

ureterolithiasis (1) and nonspecific RLQ pain (4). The follow-up confirmed the
100% accuracy of the non-appendiceal diagnosis. (Table 2).

Preoperative Parenteral Analgesic in Appendicitis

Table 2. Outcome of patients not operated and discharged with nonappendicitis diagnosis.
Group 1

Group 2

Urinary tract infection

Non-specific RLQ pain

Ureterolithiasis

100%

100%

Non-appendicitis diagnosis
on discharge

Diagnostic accuracy rate

One hundred fifty-six patients, 79 in Grp 1 and 77 in Grp 2, were admitted

with a diagnosis of acute appendicitis and underwent surgery.
Table 3 shows the outcome in terms of accuracy of diagnosis. There was
no significant difference in the accuracy of diagnosis.

Preoperative Parenteral Analgesic in Appendicitis

Table 3. Outcome of patients operated on with a preoperative diagnosis of

appendicitis in terms of diagnostic accuracy.
Final Diagnosis

Group 1

Group 2

(n=79)

(n=77)

Appendicitis

73

74

Non-appendicitis

Normal

Perforated typhoid ileitis

Perforated cecum

Perforated diverticulitis

Ileocecal TB

Mesenteric adenitis

Appendicitis-diagnosis

92.41%

96.10%

96.20%

96.10%

accuracy rate
Surgical abdomendiagnosis accuracy rate

Preoperative Parenteral Analgesic in Appendicitis

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Table 4 shows the outcome in terms of changes in physical abdominal

findings in operated patients, perforation, morbidity and mortality rates. There
was no significant difference in all the parameters.

Table 4. Outcome of patients operated on with a preoperative diagnosis of

appendicitis in terms of changes in physical abdominal findings, perforation,
morbidity, and mortality rates.

Group 1

Group 2

0%

0%

Perforation rate

47.95%

44.59%

Morbidity rate

0%

0%

Mortality rate

0%

0%

Changes in physical
abdominal findings

Preoperative Parenteral Analgesic in Appendicitis

11

Table 5 shows the changes in the pain scores before and after
administration of the parenteral solutions. There was a 4-point drop in pain score
in Group 1 in contrast to a 1-point increase in Group 2.
Table 5. Changes in the pain scores in the two groups.
Group 1

Pain score before

administration

Group 2

Range:

Range:

4-9

5-9

Mean:

7.22

Range:

Range:

3-10

0-9

Mean:

8.13

Mean:
7.9
Pain score
After
administration

Mean:
3.75

Mean difference

4.15

0.91

Discussion
The results of this clinical trial showed that administration of parenteral
analgesic (tramadol in this study) did not hamper the clinical monitoring,
diagnostic accuracy, and outcome of treatment in terms of perforation, morbidity,
and mortality rate. It afforded pain relief while monitoring for a definitive
diagnosis was taking place.
This study reinforced the five prospective randomized controlled trials
reported in the international literature (6-10). All 5 studies evaluated the effects
of analgesia on pain relief and diagnoses and treatment decisions in patients with
acute abdominal pain. Two studies evaluated the effects of analgesia on physical
examination findings (7,10) and one evaluated the effects of analgesia on the
diagnostic performance of ultrasonography in patients with acute abdominal pain
(9). Three trials used morphine (7-9); one, sublingual buprenorphine (10); and
one, intramuscular papaveretum (6). One study was limited to right lower
abdominal pain (9).
All 5 studies showed that provision of analgesia decreased pain more than
it decreased localization of tenderness. None of the 5 studies indicated that the
practice of giving early analgesia was harmful. Specifically, no study found
compromises in diagnosis or treatment of the acute abdomen after the use of
analgesia.

Preoperative Parenteral Analgesic in Appendicitis

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With this local study, the authors hope that changes in the traditional belief
among Filipino physicians that analgesic use in patients with acute abdominal
pain may mask signs and symptoms, delay diagnosis, and lead to increased
morbidity and mortality would occur. With such a change, less and less patients
will suffer unnecessarily while physicians conduct their clinical monitoring
scheme for acute surgical abdomen and specifically, appendicitis. The authors,
therefore, recommend the provision of analgesia while conducting a clinical
monitoring scheme in patients with possible acute appendicitis.

Preoperative Parenteral Analgesic in Appendicitis

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Preoperative Parenteral Analgesic in Appendicitis

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