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Evidence Based Medicine

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

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  1. Evidence Based Medicine R1 黃俊清 96.09.13

  2. Background • Patient: a young female with a history of gallstone admitted due to pancreatitis • Problem: analgesics selection

  3. PICO • P: A patient of acute pancreatitis • I: Analgesics with morphine • C: or other narcotics such as demerol • O: Analgesic effect

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. Result (3): Indirect measure

  10. 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

  11. Result (5) • Indirect measure: unphysiological • Intraopreative: anesthesia • Postoperative: artificially The American Journal of Gastroenterology, Vol. 96, No. 4:1266-72, 2001

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. Thanks for your attention!

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