Efficacy and Impact of Intravenous Morphine Before Surgical Consultation in Children With Right Lower Quadrant Pain Suggestive of Appendicitis: A Randomized Controlled Trial

Study objective

The evidence supporting the use of analgesia in children with abdominal pain suggestive of appendicitis is limited. The objectives of the study are to evaluate the efficacy of morphine before surgical consultation in children presenting to the pediatric emergency department (ED) with right lower quadrant pain suggestive of appendicitis and determine whether it has an impact on the time between arrival in the ED and the surgical decision.

Methods

All children between the ages of 8 and 18 years who presented to a pediatric ED with a presumptive diagnosis of appendicitis were eligible to be enrolled in a randomized double-blind placebo-controlled trial if the initial pain was at least 5 of 10 on a verbal numeric scale. Patients received either 0.1 mg/kg of intravenous morphine (maximum 5 mg) or placebo. The primary outcomes were (1) the difference in pain using a visual analog scale at baseline and 30 minutes after the completion of the intervention, analyzed by comparing the mean pain differences for the treatment versus placebo groups; and (2) the time between arrival in the ED and the surgical decision, analyzed by comparing the median delay for the 2 groups.

Results

Ninety patients with a suspected diagnosis of appendicitis were randomized to receive morphine or placebo. Both groups were similar in terms of demographics, medical history, physical findings, emergency physician assessment of the probability of appendicitis, and initial pain score. There was no important difference in the decrease of pain between the morphine (n=45) and placebo (n=42) groups 30 minutes after the intervention: 24±23 mm and 20±18 mm, respectively (Δ 4 mm [95% confidence interval [CI] −5 to 12 mm]). There was also no important difference in the time between arrival in the ED and the surgical decision: median 269 minutes (95% CI 240 to 355 minutes) for morphine and 307 minutes (95% CI 239 to 415 minutes) for placebo (Δ −34 minutes [95% CI −105 to 40 minutes]).

Conclusion

The use of morphine in children with a presumptive diagnosis of appendicitis did not delay the surgical decision. In our group of patients, however, morphine at a dose of 0.1 mg/kg was not more effective than placebo in diminishing their pain at 30 minutes.