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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

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evidence based medicine
Evidence Based Medicine

R1 黃俊清

96.09.13

background
Background
  • Patient: a young female with a history of gallstone admitted due to pancreatitis
  • Problem: analgesics selection
slide3
PICO
  • P: A patient of acute pancreatitis
  • I: Analgesics with morphine
  • C: or other narcotics such as demerol
  • O: Analgesic effect
slide10

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
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
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
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
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 4
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
Result (5)
  • Indirect measure: unphysiological
  • Intraopreative: anesthesia
  • Postoperative: artificially

The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

result 6
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
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
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
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
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