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1、新光醫院EBM推動小組實證醫學競賽 CAT 摘要組別：第(A)組实证医学竞赛CAT摘要新光醫院EBM推動小組訂定 PICOP:acutepancreatitiswithabdominalpainI:PerscriptionofdrugsC:Morphine,demerol,otheranalgesicsO:Efficacyofpaincontrol实证医学竞赛CAT摘要新光醫院EBM推動小組資料庫來源1.Pubmed2.MedlineOvid3.Uptodate4.Googlescholar实证医学竞赛CAT摘要新光醫院EBM推動小組搜尋之關鍵字1.Pancreatitisandpainman
2、agement2.Pancreatitisandmorphine3.Pancreatitisand“demerolormeperidineorpethidine”实证医学竞赛CAT摘要新光醫院EBM推動小組搜尋之歷程請列出你們搜尋的歷程。实证医学竞赛CAT摘要新光醫院EBM推動小組文獻研讀1.Efficacyandtoleranceofmetamizoleversusmorphineforacutepancreatitispain.PeirAM,MartnezJ,MartnezE,deMadariaE,LlorensP,HorgaJF,Prez-MateoM.Pancreatology.200
3、8;8(1):25-9.Epub2008Jan31.PMID:18235213PubMed-indexedforMEDLINE2.AmJGastroenterol.2001Apr;96(4):1266-72.Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis.ThompsonDR.DepartmentofInternalMedicine,BaylorUniversityMedicalCente
4、r,Dallas,Texas75246,USA.实证医学竞赛CAT摘要新光醫院EBM推動小組Efficacy and tolerance of metamizole versus morphine for acute pancreatitis pain.AbstractBackground/Aims: Morphinehasbeencontraindicatedforpaintreatmentinacutepancreatitisbecauseofitspresumedopioid-inducedsphincterofOddidysfunction.However,scientificevid
5、encesupportingadeleteriousinfluenceontheclinicalcourseisabsent.Thispilotstudywasundertakentoevaluatetheefficacyandadverseeventsofmetamizoleversusmorphineinacutepancreatitis.Methods: 16patientswithacutepancreatitiswererandomizedtoreceive10mg/4hs.c.(n=8)morphineor2g/8hi.v.(n=8)metamizole.Painscoreswer
6、erecordedevery4hduring48hafteradmissionbyaVisualAnalogueScale.Pethidinewasadditionallyadministeredasarescuetherapy.Results: 75%ofpatientsachievedpainreliefinthemetamizolegroupversus37.5%inthemorphinegroupwithin24hofhospitalization(6/8vs.3/8;p:n.s.).Themeantimetoachievepainreliefwasshorterinthemetami
7、zolegroup(1086.6vs.17818.3h;p:n.s.).Attheendofthestudy,75%ofpatientsachievedpainreliefinthemetamizolegroupversus50%inthemorphinegroup.Threepatientsineachgroupneededpethidine:2outof3achievedpaincontrolinthemetamizolegroupvs.0outof3inthemorphinegroup.Conclusions: Intravenousmetamizoleshowsanon-signifi
8、cantassociationwithaquickerpainreliefthanmorphines.c.inacutepancreatitis.Alargerrandomizedcontrolledtrialshouldbedesirabletoconfirmthisresult.实证医学竞赛CAT摘要新光醫院EBM推動小組实证医学竞赛CAT摘要新光醫院EBM推動小組Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating
9、 pancreatitis.AmJGastroenterol.2001Apr;96(4):1266-72.Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis.ThompsonDR.DepartmentofInternalMedicine,BaylorUniversityMedicalCenter,Dallas,Texas75246,USA.AbstractOBJECTIVE:Tradition
10、alteachingdictatesthatmorphineinducesspasminthesphincterofOddi(SO)andshouldnotbeusedinacutepancreatitisandthatmeperidineistheanalgesicofchoicebecauseitdoesnotelevateSOpressures.AliteraturesearchandreviewwasperformedtoevaluatethisteachingexaminingtheeffectofnarcoticanalgesicseffectsonSO.METHODS:AMedl
11、inesearchwasperformedusingkeywordsandphrases.Themanufacturersofmeperidinewerecontactedandtheirreportsandstudieswereobtainedandreviewed.RESULTS:Initialstudiesmeasuredbiliarypressureafternarcoticadministrationinanimals,andpostoperativeandintraoperativecholecystectomypatients.Allnarcoticsincreasedbilia
12、rypressure,butmorphinewasassociatedwiththelargestelevation.LaterstudiesusingendoscopicretrogradecholangiopancreatographywithdirectSOmanometrydemonstratedthattheSOisexquisitelysensitivetoallnarcoticsincludingmeperidineandthatasmallincreaseinbiliarysphincterpressureisseenwithhigherdosesofmorphine.Alln
13、arcoticsincreaseSOphasicwavefrequencyandinterferewithSOperistalsis.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.Nostudiesdirectlycomparetheeffectsofmeperidineormorphine
14、onSOmanometryandnocomparativestudiesexistinpatientswithacutepancreatitis.Nooutcome-basedstudiescomparingthesedrugshavebeenperformedinpatientswithacutepancreatitis.Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures.Nostudiesorevidenceexisttoindic
15、atemorphineiscontraindicatedforuseinacutepancreatitis.实证医学竞赛CAT摘要新光醫院EBM推動小組結論1.Meperidinehastraditionallybeenfavoredovermorphineforanalgesiainpancreatitis,probablybecausehumanstudiesshowedthatmorphinecausedanincreaseinsphincterofOddipressure2.Despitethesedatathereisnoclinicalevidencetosuggestthatmo
16、rphinecanaggravateorcausepancreatitis.3.Repeateddosesofmeperidinecanleadtoaccumulationofthemetabolitenormeperidinethatcausesneuromuscularirritationand,rarely,seizures.Morphinemaybeofmorebenefitthanmeperidinebyofferinglongerpainreliefwithlessriskofseizures4.Intravenousmetamizoleshowsanon-significanta
17、ssociationwithaquickerpainreliefthanmorphines.c.inacutepancreatitis.Alargerrandomizedcontrolledtrialshouldbedesirabletoconfirmthisresult.实证医学竞赛CAT摘要新光醫院EBM推動小組如何應用於臨床？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实证医学竞赛CAT摘要新光醫院EBM推動小組困境或陷阱目前仍無強力RCT證明何者為佳需要更多Trial
18、实证医学竞赛CAT摘要新光醫院EBM推動小組參考資料：證據的強度实证医学竞赛CAT摘要新光醫院EBM推動小組參考資料：證據等級和臨床建議Grade of RecommendationLevel of EvidenceTherapyA1aSystemic review of RCTs1bSingle RCT1cAll-or-noneB2aSystemic review of cohort studies2bCohort study or poor RCT2cOutcomes research3aSystemic review of case-control studies3bCase-contr
19、ol studyC4Case seriesD5Expert opinion, physiology, bench research实证医学竞赛CAT摘要新光醫院EBM推動小組 參考資料实证医学竞赛CAT摘要新光醫院EBM推動小組實證醫學競賽 CAT 摘要組別：第(A)組实证医学竞赛CAT摘要新光醫院EBM推動小組訂定 PICOP:acutepancreatitiswithabdominalpainI:gabexatemesilateC:placeboO:complication,mortality,morbidity,abdominalpain实证医学竞赛CAT摘要新光醫院EBM推動小組資料庫
20、來源PubmedCochraneUptodate实证医学竞赛CAT摘要新光醫院EBM推動小組搜尋之關鍵字請列出你們用了哪些關鍵字。实证医学竞赛CAT摘要新光醫院EBM推動小組搜尋之歷程請列出你們搜尋的歷程。实证医学竞赛CAT摘要新光醫院EBM推動小組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：1.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)2.研究設計(studydesign)3.結
21、果(若有計算NNT、RR、OR等，請一併列出)4.證據等級(levelofevidence)实证医学竞赛CAT摘要新光醫院EBM推動小組第一篇Prospective and randomized study of gabexate mesilate for the treatment of severe acute pancreatitis with organ dysfunction.(Hepatogastroenterology.2000Jul-Aug;47(34):1147-50)METHOD:52patientswithacutepancreatitisandorgandysfunct
22、ionwereenrolled.Thetreatmentgroupincluded26patientsreceivingintravenousgabexatemesilateinfusionatadoseof100mg/hrfor7days.APACHE-II score, clinical and biochemical parametersweremonitoredintensively.CONCLUSION:Coagulopathy ileus, and abdominal painwassignificantlyimprovedwithgabexatemesilate.Gabexate
23、mesilatereduced the necessity for surgical intervention and peritoneal lavage.The7-day-mortalityand90-day-mortality rateswerealsosignificantlyreducedwithgabexatemesilatetherapy.EVIDENCELEVEL:RCT,levelIb(gradeA)实证医学竞赛CAT摘要新光醫院EBM推動小組第二篇Clinical trial with a protease inhibitor gabexate mesilate in acu
24、te pancreatitis.(IntJPancreatol.1991Summer;9:75-9)Retrospective analysisof23patientswithsevereAPand88withmildtomoderateAPwhoweretreatedinourinstituteandfouraffiliatedmedicalcentersduringthe10-yperiodfrom1980to1990.Intravenousinfusionofaproteaseinhibitor,GabexateMesilate(FOY),wasstartedwithin24hfromo
25、nsetofAP(earlyadministration)in17patientswithsevereAPand51withmildtomoderateAP.TheremainingpatientswereputonFOYlaterthan24hfromonsetofAP(lateadministration).Comparisonofthemortalityandmorbiditybetweenthetwogroups,earlyvslateadministrationofFOY,ledtothefollowingconclusions:(1)Early administrationofFO
26、Ysignificantlyimprovedmortality(29.4vs83.3%)insevereAP,althoughtheimprovementinmortalitywasnotdirectlyproportionaltotheshorteningofthetimelagbetweentheonsetofAPandthestartofFOY,and(2)earlieradministrationofFOYbroughtaboutsignificantlyearlierrecoveryofabdominal pain, hyperamylasemia, and leucocytosisinmildtomoderateAP.EVIDENCELEVEL:LEVELIIb(gradeB)实证医学竞赛CAT摘要新光醫院EBM推動小組結論與臨床應用UseofFOYforacutepancreatitisreducesmortalityandmorbidity,especiallyifusedearly.实证医学竞赛CAT摘要新光醫院EBM推動小組困境或陷阱Thesestudiesfocusonseverepancreatitisandlessonmildormoderate.实证医学竞赛CAT摘要新光醫院EBM推動小組謝謝聆聽实证医学竞赛CAT摘要
