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  1. 1. Evidence Based MedicineEvidence Based Medicine R1R1 黃俊清黃俊清 96.09.1396.09.13
  2. 2. BackgroundBackground  Patient: a young female with a history ofPatient: a young female with a history of gallstone admitted due to pancreatitisgallstone admitted due to pancreatitis  Problem: analgesics selectionProblem: analgesics selection
  3. 3. PICOPICO  P: A patient of acute pancreatitisP: A patient of acute pancreatitis  I: Analgesics with morphineI: Analgesics with morphine  C: or other narcotics such as demerolC: or other narcotics such as demerol  O: Analgesic effectO: Analgesic effect
  4. 4. Narcotic Analgesic Effects on theNarcotic Analgesic Effects on the Sphincter of Oddi:Sphincter of Oddi: A Review of the Data and TherapeuticA Review of the Data and Therapeutic Implications in Treating PancreatitisImplications in Treating Pancreatitis Donald R. Thompson, M.D.Donald R. Thompson, M.D. Gastroenterology Division, Department of InternalGastroenterology Division, Department of Internal Medicine, Baylor University Medical Center, Dallas, TexasMedicine, Baylor University Medical Center, Dallas, Texas The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  5. 5. IntroductionIntroduction  Morphine causes sphincter of Oddi (SO)Morphine causes sphincter of Oddi (SO) spasmsspasms  Meperidine does not elevate SO pressureMeperidine does not elevate SO pressure  Dependence, side effect, and drug-drugDependence, side effect, and drug-drug interactionsinteractions The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  6. 6. Materials and MethodsMaterials and Methods  Medline search with keywordsMedline search with keywords  Published in English from 1966 to 2001Published in English from 1966 to 2001  Contact the manufacturers of meperidineContact the manufacturers of meperidine for reports on studiesfor reports on studies The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  7. 7. Result (1)Result (1)  Study on opossums (Study on opossums ( 負鼠負鼠 ))  Migrating motor complexes of theMigrating motor complexes of the duodenum increases, but not SOduodenum increases, but not SO  No significant change of biliary pressureNo significant change of biliary pressure in animals with a gallbladderin animals with a gallbladder The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  8. 8. Result (2)Result (2)  Increase of SO toneIncrease of SO tone  stone dislodgedstone dislodged  relief of biliary colic? Greenstein(1972)relief of biliary colic? Greenstein(1972)  No significance between pentazocineNo significance between pentazocine (114%) and meperidine (93%)(114%) and meperidine (93%) The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  9. 9. Result (3): Indirect measureResult (3): Indirect measure Investigator Method Medication Biliary pressure (baseline) Biliary pressure (postmedication) Coelho(1985) N=7 Postcholecystectomy in opossum Pentazocine Morphine Meperidine Tramadol 13.1±2.9 13.2±2.3 12.9±2.3 12.4±2.6 (mmHg) 17.0±2.1 17.2±1.5 16.2±1.9 13.3±2.5 Greenstein(1972) N=12 Postop T tube Pentazocine Meperidine 80 78 (mmH2 O) 168 151 Economou(1971) N=31 Postop T tube Morphine Meperidine Pentazocine Phenazocine 0 0 0 0 (cm of bile) 8.5±1.7 3.9±0.8 2.8±0.9 3.8±1.8 Mc Cammon(1983) N=56 Intraop post- cholecystectomy Fentanyl Butorphanol Nalbuphine 14.3±0.8 13.6±0.7 14.4±0.9 (cm of saline) 17.6 15.2 15.3
  10. 10. Result (4)Result (4)  Hepatobiliary scans: HIDAHepatobiliary scans: HIDA  Narcotics: all delay more than 60 minsNarcotics: all delay more than 60 mins  Morphine : meperidine = 200 : 100 minsMorphine : meperidine = 200 : 100 mins  Morphine delayed > 3.5h in 75%Morphine delayed > 3.5h in 75% The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  11. 11. Result (5)Result (5)  Indirect measure: unphysiologicalIndirect measure: unphysiological  Intraopreative: anesthesiaIntraopreative: anesthesia  Postoperative: artificiallyPostoperative: artificially The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  12. 12. Result (6)Result (6)  Direct measurement byDirect measurement by SO manometrySO manometry using ERCPusing ERCP  SO is sensitive to morphineSO is sensitive to morphine  Naloxone have little effect on SONaloxone have little effect on SO The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  13. 13. Result (7)Result (7)  Direct comparing morphine to meperidineDirect comparing morphine to meperidine with SO manometry in 1990 by Thunewith SO manometry in 1990 by Thune  Phasic wave frequency↑in morphinePhasic wave frequency↑in morphine  No significanceNo significance in SO pressurein SO pressure The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  14. 14. Result (8)Result (8)  Duration of contractionDuration of contraction↓↓  Frequency of contractionFrequency of contraction↑↑  No increaseNo increase in basal SO pressurein basal SO pressure The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  15. 15. DiscussionDiscussion  Indirect: all narcotics invoked bile stasisIndirect: all narcotics invoked bile stasis  Direct: frequency↑ and amplitude ↑Direct: frequency↑ and amplitude ↑  Morphine increases SO pressureMorphine increases SO pressure only inonly in one study.one study. Helm(1988)Helm(1988) The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  16. 16. ConclusionConclusion  No definite benefit of meperidineNo definite benefit of meperidine  No absolute contraindication of morphineNo absolute contraindication of morphine  No evidenceNo evidence of meperidine better thanof meperidine better than morphinemorphine The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001
  17. 17. Thanks for your attention!Thanks for your attention!

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