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實證醫學競賽 － CAT 摘要

實證醫學競賽 － CAT 摘要. 組別：第 ( A ) 組. 訂定 PICO. P: acute pancreatitis with abdominal pain I: Perscription of drugs C: Morphine, demerol, other analgesics O: Efficacy of pain control. 資料庫來源. 1. Pubmed 2. Medline Ovid 3. Uptodate 4. Google scholar. 搜尋之關鍵字.

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實證醫學競賽 － CAT 摘要

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  1. 實證醫學競賽 － CAT 摘要 組別：第 ( A ) 組

  2. 訂定 PICO • P: acute pancreatitis with abdominal pain • I: Perscription of drugs • C: Morphine, demerol, other analgesics • O: Efficacy of pain control

  3. 資料庫來源 • 1. Pubmed • 2. Medline Ovid • 3. Uptodate • 4. Google scholar

  4. 搜尋之關鍵字 • 1. Pancreatitis and pain management • 2. Pancreatitis and morphine • 3. Pancreatitis and “demerol or meperidine or pethidine”

  5. 搜尋之歷程 • 請列出你們搜尋的歷程。

  6. 文獻研讀 • 1. Efficacy and tolerance of metamizole versus morphine for acute pancreatitis pain. • Peiró AM, Martínez J, Martínez E, de Madaria E, Llorens P, Horga JF, Pérez-Mateo M. • Pancreatology. 2008;8(1):25-9. Epub 2008 Jan 31.PMID: 18235213 [PubMed - indexed for MEDLINE] • 2. Am J Gastroenterol. 2001 Apr;96(4):1266-72. • Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. • Thompson DR. • Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA.

  7. Efficacy and tolerance of metamizole versus morphine for acute pancreatitis pain. • Abstract • Background/Aims: Morphine has been contraindicated for pain treatment in acute pancreatitis because of its presumed opioid-induced sphincter of Oddi dysfunction. • However, scientific evidence supporting a deleterious influence on the clinical course is absent. This pilot study was undertaken to evaluate the efficacy and adverse events of metamizole versus morphine in acute pancreatitis. • Methods: 16 patients with acute pancreatitis were randomized to receive 10 mg/4 h s.c. (n = 8) morphine or 2 g/8 h i.v. (n = 8) metamizole. Pain scores were recorded every 4 h during 48 h after admission by a Visual Analogue Scale. Pethidine was additionally administered as a rescue therapy. • Results: 75% of patients achieved pain relief in the metamizole group versus 37.5% in the morphine group within 24 h of hospitalization (6/8 vs. 3/8; p: n.s.). The mean time to achieve pain relief was shorter in the metamizole group (10 8 6.6 vs. 17 8 18.3 h; p: n.s.). At the end of the study, 75% of patients achieved pain relief in the metamizole group versus 50% in the morphine group. Three patients in each group needed pethidine: 2 out of 3 achieved pain control in the metamizole group vs. 0 out of 3 in the morphine group. • Conclusions: Intravenous metamizole shows a non-significant association with a quicker pain relief than morphine s.c. in acute pancreatitis. A larger randomized controlled trial should be desirable to confirm this result.

  8. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. • Am J Gastroenterol. 2001 Apr;96(4):1266-72. • Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. • Thompson DR. • Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA. • Abstract • OBJECTIVE: Traditional teaching dictates that morphine induces "spasm" in the sphincter of Oddi (SO) and should not be used in acute pancreatitis and that meperidine is the analgesic of choice because it does not elevate SO pressures. A literature search and review was performed to evaluate this teaching examining the effect of narcotic analgesic's effects on SO. • METHODS: A Medline search was performed using keywords and phrases. The manufacturers of meperidine were contacted and their reports and studies were obtained and reviewed. • RESULTS: Initial studies measured biliary pressure after narcotic administration in animals, and postoperative and intraoperative cholecystectomy patients. All narcotics increased biliary pressure, but morphine was associated with the largest elevation. Later studies using endoscopic retrograde cholangiopancreatography with direct SO manometry demonstrated that the SO is exquisitely sensitive to all narcotics including meperidine and that a small increase in biliary sphincter pressure is seen with higher doses of morphine. All narcotics increase SO phasic wave frequency and interfere with SO peristalsis. • CONCLUSIONS: Narcotic-induced increases in phasic wave frequency interfere with SO filling and are responsible for the increase in bile duct pressure seen on the initial studies. No studies directly compare the effects of meperidine or morphine on SO manometry and no comparative studies exist in patients with acute pancreatitis. No outcome-based studies comparing these drugs have been performed in patients with acute pancreatitis. Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.

  9. 結論 • 1. Meperidinehas traditionally been favored over morphinefor analgesia in pancreatitis, probably because human studies showed that morphine caused an increase in sphincter of Oddi pressure • 2. Despite these data there is no clinical evidence to suggest that morphine can aggravate or cause pancreatitis. • 3. Repeated doses of meperidine can lead to accumulation of the metabolite normeperidine that causes neuromuscular irritation and, rarely, seizures. Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures • 4. Intravenous metamizole shows a non-significant association with a quicker pain relief than morphine s.c. in acute pancreatitis. A larger randomized controlled trial should be desirable to confirm this result.

  10. 如何應用於臨床？ • 1.沒有強力証據顯示Demerol比morphine好 • 2.使用Demerol需小心seizure的風險 • 3. Metamizole也許是臨床上更好的選擇,仍需更多RCT

  11. 困境或陷阱 • 目前仍無強力RCT證明何者為佳 • 需要更多Trial

  12. 參考資料：證據的強度

  13. 參考資料：證據等級和臨床建議

  14. 參考資料

  15. 實證醫學競賽 － CAT 摘要 組別：第 ( A ) 組

  16. 訂定 PICO • P: acute pancreatitis with abdominal pain • I: gabexate mesilate • C: placebo • O: complication, mortality, morbidity, abdominal pain

  17. 資料庫來源 • Pubmed • Cochrane • Uptodate

  18. 搜尋之關鍵字 • 請列出你們用了哪些關鍵字。

  19. 搜尋之歷程 • 請列出你們搜尋的歷程。

  20. 文獻研讀 • 請列出你們認為證據最強的相關文獻一至三篇 • 針對每篇文獻，請摘錄其： • 題目及出處 (e.g. Dosing and safety of cyclosporine in patients with severe brain injury. J Neurosurg. 2008;109(4):699-707) • 研究設計 (study design) • 結果 (若有計算NNT、RR、OR等，請一併列出) • 證據等級 (level of evidence)

  21. 第一篇 • Prospective and randomized study of gabexate mesilate for the treatment of severe acute pancreatitis with organ dysfunction. (Hepatogastroenterology. 2000 Jul-Aug;47(34):1147-50) • METHOD: 52 patients with acute pancreatitis and organ dysfunction were enrolled. The treatment group included 26 patients receiving intravenous gabexate mesilate infusion at a dose of 100 mg/hr for 7 days. APACHE-II score, clinical and biochemical parameters were monitored intensively. • CONCLUSION: Coagulopathy ileus, and abdominal pain was significantly improved with gabexate mesilate. Gabexate mesilate reduced the necessity for surgical intervention and peritoneal lavage. The 7-day-mortality and 90-day-mortality rates were also significantly reduced with gabexate mesilate therapy. • EVIDENCE LEVEL: RCT, level Ib (grade A)

  22. 第二篇 • Clinical trial with a protease inhibitor gabexate mesilate in acute pancreatitis. (Int J Pancreatol. 1991 Summer;9:75-9) • Retrospective analysis of 23 patients with severe AP and 88 with mild to moderate AP who were treated in our institute and four affiliated medical centers during the 10-y period from 1980 to 1990. Intravenous infusion of a protease inhibitor, Gabexate Mesilate (FOY), was started within 24 h from onset of AP (early administration) in 17 patients with severe AP and 51 with mild to moderate AP. The remaining patients were put on FOY later than 24 h from onset of AP (late administration). Comparison of the mortality and morbidity between the two groups, early vs late administration of FOY, led to the following conclusions: (1) Early administration of FOY significantly improved mortality (29.4 vs 83.3%) in severe AP, although the improvement in mortality was not directly proportional to the shortening of the time lag between the onset of AP and the start of FOY, and (2) earlier administration of FOY brought about significantly earlier recovery of abdominal pain, hyperamylasemia, and leucocytosis in mild to moderate AP. • EVIDENCE LEVEL: LEVEL IIb (grade B)

  23. 結論與臨床應用 • Use of FOY for acute pancreatitis reduces mortality and morbidity, especially if used early.

  24. 困境或陷阱 • These studies focus on severe pancreatitis and less on mild or moderate.

  25. 謝謝聆聽

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