实证医学竞赛-CAT摘要课件.ppt

1、新光醫院 EBM 推動小組實證醫學競賽 CAT 摘要組別：第(A)組新光醫院 EBM 推動小組訂定 PICOP:acute pancreatitis with abdominal painI:Perscription of drugs C:Morphine,demerol,other analgesicsO:Efficacy of pain control新光醫院 EBM 推動小組資料庫來源1.Pubmed2.Medline Ovid3.Uptodate4.Google scholar新光醫院 EBM 推動小組搜尋之關鍵字1.Pancreatitis and pain management2.

2、Pancreatitis and morphine3.Pancreatitis and“demerol or meperidine or pethidine”新光醫院 EBM 推動小組搜尋之歷程請列出你們搜尋的歷程。新光醫院 EBM 推動小組文獻研讀1.Efficacy and tolerance of metamizole versus morphine for acute pancreatitis pain.Peir AM,Martnez J,Martnez E,de Madaria E,Llorens P,Horga JF,Prez-Mateo M.Pancreatology.2008;

3、8(1):25-9.Epub 2008 Jan 31.PMID:18235213 PubMed-indexed for MEDLINE2.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

4、Medical Center,Dallas,Texas 75246,USA.新光醫院 EBM 推動小組Efficacy and tolerance of metamizole versus morphine for acute pancreatitis pain.AbstractBackground/Aims:Morphine has been contraindicated for pain treatment in acute pancreatitis because of its presumed opioid-induced sphincter of Oddi dysfunction.

5、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

6、/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

7、 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

8、 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 b

9、e desirable to confirm this result.新光醫院 EBM 推動小組新光醫院 EBM 推動小組Narcotic analgesic effects on the sphincter of Oddi:a review of the data and therapeutic implications in treating pancreatitis.Am J Gastroenterol.2001 Apr;96(4):1266-72.Narcotic analgesic effects on the sphincter of Oddi:a review of the da

10、ta and therapeutic implications in treating pancreatitis.Thompson DR.Department of Internal Medicine,Baylor University Medical Center,Dallas,Texas 75246,USA.AbstractOBJECTIVE:Traditional teaching dictates that morphine induces spasm in the sphincter of Oddi(SO)and should not be used in acute pancrea

11、titis 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 analgesics effects on SO.METHODS:A Medline search was performed using keywords and phrases.The manufac

12、turers 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

13、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 do

14、ses 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 compa

15、re 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

16、 relief with less risk of seizures.No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.新光醫院 EBM 推動小組結論1.Meperidine has traditionally been favored over morphine for analgesia in pancreatitis,probably because human studies showed that morphine caused an i

17、ncrease 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.Morph

18、ine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures4.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

19、 result.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 新光醫院 EBM 推動小組參考資料：證據的強度新光醫院 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-no

20、neB2aSystemic review of cohort studies2bCohort study or poor RCT2cOutcomes research3aSystemic review of case-control studies3bCase-control studyC4Case seriesD5Expert opinion,physiology,bench research新光醫院 EBM 推動小組 參考資料新光醫院 EBM 推動小組實證醫學競賽 CAT 摘要組別：第(A)組新光醫院 EBM 推動小組訂定 PICOP:acute pancreatitis with abd

21、ominal painI:gabexate mesilate C:placeboO:complication,mortality,morbidity,abdominal pain新光醫院 EBM 推動小組資料庫來源PubmedCochraneUptodate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。新光醫院 EBM 推動小組搜尋之歷程請列出你們搜尋的歷程。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 wit

22、h severe brain injury.J Neurosurg.2008;109(4):699-707)2.研究設計(study design)3.結果(若有計算NNT、RR、OR等，請一併列出)4.證據等級(level of evidence)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.2000 Jul-Au

23、g;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.C

24、ONCLUSION: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.EVID

25、ENCE LEVEL:RCT,level Ib(grade A)新光醫院 EBM 推動小組第二篇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 affili

26、ated 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 t

27、han 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

28、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)新光醫院 EBM 推動小組結論與臨床應用Use of FOY for acute pancreatitis reduces mortality and morbidity,especially if used early.新光醫院 EBM 推動小組困境或陷阱These studies focus on severe pancreatitis and less on mild or moderate.新光醫院 EBM 推動小組謝謝聆聽