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    下載 下載 Presentation Transcript

    • Evidence Based Medicine
      • R1 黃俊清
      • 96.09.13
    • Background
      • Patient: a young female with a history of gallstone admitted due to pancreatitis
      • Problem: analgesics selection
    • PICO
      • P: A patient of acute pancreatitis
      • I: Analgesics with morphine
      • C: or other narcotics such as demerol
      • O: Analgesic effect
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    • Narcotic Analgesic Effects on the Sphincter of Oddi: A Review of the Data and Therapeutic Implications in Treating Pancreatitis Donald R. Thompson, M.D. Gastroenterology Division, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Introduction
      • Morphine causes sphincter of Oddi (SO) spasms
      • Meperidine does not elevate SO pressure
      • Dependence, side effect, and drug-drug interactions
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Materials and Methods
      • Medline search with keywords
      • Published in English from 1966 to 2001
      • Contact the manufacturers of meperidine for reports on studies
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Result (1)
      • Study on opossums ( 負鼠 )
      • Migrating motor complexes of the duodenum increases, but not SO
      • No significant change of biliary pressure in animals with a gallbladder
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Result (2)
      • Increase of SO tone  stone dislodged  relief of biliary colic? Greenstein(1972)
      • No significance between pentazocine (114%) and meperidine (93%)
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Result (3): Indirect measure 17.6 15.2 15.3 14.3±0.8 13.6±0.7 14.4±0.9 (cm of saline) Fentanyl Butorphanol Nalbuphine Intraop post-cholecystectomy Mc Cammon(1983) N=56 8.5±1.7 3.9±0.8 2.8±0.9 3.8±1.8 0 0 0 0 (cm of bile) Morphine Meperidine Pentazocine Phenazocine Postop T tube Economou(1971) N=31 168 151 80 78 (mmH 2 O) Pentazocine Meperidine Postop T tube Greenstein(1972) N=12 17.0±2.1 17.2±1.5 16.2±1.9 13.3±2.5 13. 1± 2.9 13.2±2.3 12.9±2.3 12.4±2.6 (mmHg) Pentazocine Morphine Meperidine Tramadol Postcholecystectomy in opossum Coelho(1985) N=7 Biliary pressure (postmedication) Biliary pressure (baseline) Medication Method Investigator
    • Result (4)
      • Hepatobiliary scans: HIDA
      • Narcotics: all delay more than 60 mins
      • Morphine : meperidine = 200 : 100 mins
      • Morphine delayed > 3.5h in 75%
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Result (5)
      • Indirect measure: unphysiological
      • Intraopreative: anesthesia
      • Postoperative: artificially
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Result (6)
      • Direct measurement by SO manometry using ERCP
      • SO is sensitive to morphine
      • Naloxone have little effect on SO
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Result (7)
      • Direct comparing morphine to meperidine with SO manometry in 1990 by Thune
      • Phasic wave frequency↑in morphine
      • No significance in SO pressure
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Result (8)
      • Duration of contraction ↓
      • Frequency of contraction ↑
      • No increase in basal SO pressure
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Discussion
      • Indirect: all narcotics invoked bile stasis
      • Direct: frequency↑ and amplitude ↑
      • Morphine increases SO pressure only in one study. Helm(1988)
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Conclusion
      • No definite benefit of meperidine
      • No absolute contraindication of morphine
      • No evidence of meperidine better than morphine
      The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
    • Thanks for your attention!