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Boyev A, Prakash LR, Chiang YJ, Childers CP, Jain AJ, Newhook TE, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Lee JE, Snyder RA, Katz MHG, Tzeng CWD, Maxwell JE. Postoperative Opioid Use Is Associated with Increased Rates of Grade B/C Pancreatic Fistula After Distal Pancreatectomy. J Gastrointest Surg 2023; 27:2135-2144. [PMID: 37468733 DOI: 10.1007/s11605-023-05751-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/03/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major source of morbidity after distal pancreatectomy. This study examined the association between postoperative opioid use and CR-POPF in the context of opioid-sparing postoperative care. METHODS A case-control study was performed on consecutive patients who underwent distal pancreatectomy between October 2016 and April 2022 at a single institution. Patients who developed CR-POPF were compared to controls. Multivariable regression modeling was used to identify factors associated with CR-POPF. RESULTS A total of 281 patients underwent 187 open, 20 laparoscopic, and 74 robotic-assisted operations. The rate of CR-POPF was 21% (n = 58). CR-POPF rate declined from 32 to 8% over the study period (p < 0.001). Median oral morphine equivalents (OME) administered on POD 0-1 and 0-3 were 94 and 129 mg, respectively, in patients who did not develop a fistula versus 130 and 180 mg in those who did (both p ≤ 0.001). POD 0-3 OME (OR 1.11, p = 0.044) was independently associated with increased odds of CR-POPF, with each additional 50 mg (equivalent to 10 tramadol pills) increasing the relative risk by 11% and absolute risk by 2%. CONCLUSION Early postoperative opioid use after distal pancreatectomy was associated with increased odds of CR-POPF. Decreasing perioperative opioid use through enhanced postoperative management is a low-cost and generalizable approach that may reduce rates of CR-POPF after distal pancreatectomy.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Christopher P Childers
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Anish J Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Almulhim M, Almulihi QA, Almumtin HS, Alghanim MH, AlAbdulbaqi DA, Almulihi FAA. The Efficacy and Safety of Using Opioids in Acute Pancreatitis: an Update on Systematic Review and Meta-Analysis. Med Arch 2023; 77:281-287. [PMID: 37876565 PMCID: PMC10591254 DOI: 10.5455/medarh.2023.77.281-287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/05/2023] [Indexed: 10/26/2023] Open
Abstract
Background Most patients with acute pancreatitis (AP) suffer from abdominal pain that requires immediate pain relief, and there are various medication choices available, with opioids being the most prescribed analgesics. Objective Our objective is to compare the use of opioids with other medications in emergency settings for managing pain in patients with AP. Methods A systemic search was conducted in electronic databases (PubMed/Medline, Cochrane Library, Embase and Google Scholar) from inception to Feb 2023. All statistical analyses were conducted in Review Manager 5.4.1. The study's inclusion criteria was then selected. Only those Randomized Controlled Trials were involved that included patients having AP in an emergency setting. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in the Odds Ratio (OR) and Mean Difference (MD) along with the corresponding 95% confidence interval (CI). Narrative analysis was conducted for those variables which did not have sufficient data be included in the quantitative analysis. Results We include eight Randomized Controlled Trials in our study. The Pooled result showed non-significant differences in adverse effects between the two interventions (OR 1.42 [95% CI 0.62, 3.23]; p value= 0.40; I2= 20%). While overall, significantly additional drugs were used in the control group (OR 0.22 [95% CI 0.06, 0.85]; p value= 0.03; I2= 72%). Pain score and severity levels were also analyzed. We used a narrative approach to analyze the length of stay, mean time to reach significant decrease in pain, and mortality, which were all non-conclusive. We also narratively assessed the Pediatric population. Conclusion Opioids do not provide significant superiority over other medications and should be avoided due to their addictive nature.
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Affiliation(s)
- Mohamed Almulhim
- Department of Emergency Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Qasem Ahmed Almulihi
- Department of Emergency Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
- Department, King Fahad University Hospital, Al Khobar, Saudi Arabia
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Koo HC, Moon JH, Choi HJ, Hwang KH, Maeng HJ, Kim HK, Park JK, Hong SJ, Cheon YK, Cho YD, Lee JS, Lee MS. Effect of transdermal fentanyl patches on the motility of the sphincter of oddi. Gut Liver 2010; 4:368-72. [PMID: 20981215 DOI: 10.5009/gnl.2010.4.3.368] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 03/31/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIMS Pain is one of the most troublesome symptoms of pancreatitis. Transdermal fentanyl patches (TFPs) are long-acting analgesics with a reduced risk of dependency. This prospective study evaluated the effect of TFPs on sphincter of Oddi (SO) motility for the management of pain in pancreatitis. METHODS SO manometry (SOM) was performed using triple-lumen catheters anterogradely inserted through the percutaneous transhepatic route during cholangioscopy in 16 patients. The basal pressure, amplitude, and frequency of the SO were assessed before and after applying a TFP at 24 hour at doses of 25 and 12.5µg/hr, respectively. RESULTS Two of 16 patients receiving a 25µg/hr. TFP were excluded because of adverse side effects (headache and/or nausea). The mean basal pressure, amplitude, and frequency of SOM did not change significantly in the 25µg/hr TFP group (n=4 patients). Parameters of SO function also did not significantly change in the 12.5µg/hr TFP group (n=11 patients). CONCLUSIONS TFPs below a dose of 25µg/hr may not affect the motility of the SO. Administration of TFPs at lower dosages seems to be a safe analgesic treatment for the pain control of patients with pancreatitis without affecting the function of the SO.
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Affiliation(s)
- Hyun Cheol Koo
- Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon and Seoul, Korea
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Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman M, Geenen J, Ryan M, Parker H, Frakes JT, Fogel EL, Silverman WB, Dua KS, Aliperti G, Yakshe P, Uzer M, Jones W, Goff J, Lazzell-Pannell L, Rashdan A, Temkit M, Lehman GA. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006; 101:139-47. [PMID: 16405547 DOI: 10.1111/j.1572-0241.2006.00380.x] [Citation(s) in RCA: 408] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. METHODS A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. RESULTS Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. CONCLUSION This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.
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Affiliation(s)
- Chi-Liang Cheng
- Indiana University Medical Center, Indianapolis, Indiana 46202, USA
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Seifert CF, Kennedy S. Meperidine Is Alive and Well in the New Millennium: Evaluation of Meperidine Usage Patterns and Frequency of Adverse Drug Reactions. Pharmacotherapy 2004; 24:776-83. [PMID: 15222668 DOI: 10.1592/phco.24.8.776.36066] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To report a classic case of normeperidine toxicity, and to present institution-specific data on meperidine usage patterns and the frequency of adverse drug reactions (ADRs). METHODS A chart review was conducted of patients at high risk for ADRs. High-risk patients were identified through the pharmacy computer system as those with renal insufficiency (creatinine clearance < or = 50 ml/min), those receiving meperidine with patient-controlled analgesia (PCA), or those receiving more than 200 mg/day of intravenous meperidine for multiple days. RESULTS Twenty-five percent of patients who received meperidine had some degree of renal insufficiency. The average daily dose of meperidine was 230 mg; cumulative doses ranged from 10-7200 mg. Adverse drug reactions documented in 20 (14%) of 141 patients were confusion, anxiety, nervousness, hallucinations, twitching, and seizure. Sixteen of the 20 patients received meperidine by PCA pump or a combination of PCA and intravenous administration. Patients with ADRs to meperidine were older (58.5 vs 46.4 yrs, p = 0.004), received more concomitant benzodiazepines (65.0% vs 4.1%, p < 0.0001), and had a longer hospital stay (median 9.5 vs 4.6 days, p < 0.001) than those who did not experience an ADR. A significant difference was found in cumulative PCA doses between patients with and without documented ADRs (median meperidine dose 863 and 455 mg, respectively, p = 0.0157). Doses were directly correlated with both renal function (p < 0.05) and length of stay (p < 0.008). Dosing, duration, and frequency of ADRs for patients using PCA differed significantly between prescribing services (p < 0.01). CONCLUSION Patients using PCA meperidine are at particularly high risk of experiencing ADRs based on cumulative doses and duration of treatment. Adverse drug reactions were documented in approximately 14% of patients. Our results warrant restriction of PCA meperidine and evaluation of meperidine usage policies to improve pain management services and decrease the frequency of ADRs.
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Affiliation(s)
- Charles F Seifert
- School of Pharmacy, Texas Tech University Health Sciences Center, Lubbock 79430, USA.
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Fogel EL, Sherman S, Bucksot L, Shelly L, Lehman GA. Effects of droperidol on the pancreatic and biliary sphincters. Gastrointest Endosc 2003; 58:488-92. [PMID: 14520278 DOI: 10.1067/s0016-5107(03)01541-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Performance of sphincter of Oddi manometry at ERCP is technically demanding and requires that the patient be well sedated. Droperidol is frequently administered when adequate sedation cannot be achieved with a benzodiazepine and meperidine. This study examined the effects of droperidol on the biliary and pancreatic sphincters. METHODS A total of 31 patients were prospectively evaluated by sphincter of Oddi manometry in the conventional retrograde fashion. Manometry was initially performed with intravenous administration of diazepam alone, diazepam plus meperidine or midazolam plus meperidine. Manometry was then repeated 5 minutes after droperidol was administered. RESULTS The basal pressure of the biliary sphincter and of the pancreatic sphincter were not significantly altered by droperidol. Concordance (normal vs. abnormal) between the basal sphincter pressure before and after droperidol was seen in 30 patients (97%). Droperidol also did not lead to a difference in phasic wave amplitude, duration, or frequency. Thirteen manometry tracings (42%) were judged as being qualitatively better after droperidol, whereas two (6.5%; </= p 0.001) were qualitatively better before droperidol administration. CONCLUSIONS Droperidol does not significantly affect sphincter of Oddi manometric parameters. It appears that it can be added to the armamentarium of agents needed for performance of sphincter of Oddi manometry. However, further study is needed to determine whether recent safety concerns with droperidol use are valid.
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Affiliation(s)
- Evan L Fogel
- Indiana University Medical Center, Indianapolis, Indiana, USA
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Ury WA, Rahn M, Tolentino V, Pignotti MG, Yoon J, McKegney P, Sulmasy DP. Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents? J Gen Intern Med 2002; 17:625-31. [PMID: 12213144 PMCID: PMC1495092 DOI: 10.1046/j.1525-1497.2002.10837.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although opioids are central to acute pain management, numerous studies have shown that many physicians prescribe them incorrectly, resulting in inadequate pain management and side effects. We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practices. DESIGN Prospective chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention, consisting of 10 one-hour case-based modules, including 2 pain management seminars. MEASUREMENTS Consecutive pharmacy and billing records of patients who were cared for by medical residents (n = 733) and a comparison group of neurology and rehabilitative medicine patients (n = 273) that received an opioid during hospitalization in 8-month periods before (1/1/97 to 4/30/97) and after (1/1/99 to 4/30/99) the implementation of the curriculum on the medical service were reviewed. Three outcomes were measured: 1) percent of opioid orders for meperidine; 2) percent of opioid orders with concomminant bowel regimen; and 3) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs). MAIN RESULTS The percentage of patients receiving meperidine decreased in the study group, but not in the comparison group. The percentages receiving NSAIDs and bowel medications increased in both groups. In multivariate logistic models controlling for age and race, the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 (95% confidence interval [95% CI], 0.32 to 0.96), while the odds of receiving a bowel medication or NSAID increased to 1.48 (95% CI, 1.07 to 2.03) and 1.53 (95% CI, 1.01 to 2.32), respectively. In the comparison group models, the odds of receiving a NSAID in the post-period increased significantly to 2.27 (95% CI, 1.10 to 4.67), but the odds of receiving a bowel medication (0.45; 95% CI, 0.74 to 2.00) or meperidine (0.85; 95% CI, 0.51 to 2.30) were not significantly different from baseline. CONCLUSIONS This palliative care curriculum was associated with a sustained (>6 months) improvement in medical residents' opioid prescribing practices. Further research is needed to understand the changes that occurred and how they can be translated into improved patient outcomes.
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Affiliation(s)
- Wayne A Ury
- Saint Vincent's Catholic Medical Centers of New York, Manhattan Campus, New York, NY 10011, USA.
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Stevens M, Esler R, Asher G. Transdermal fentanyl for the management of acute pancreatitis pain. Appl Nurs Res 2002; 15:102-10. [PMID: 11994827 DOI: 10.1053/apnr.2002.29532] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although the hazards of using Demerol for pain management is well documented, physicians at a 350-bed tertiary-care center in the upper midwest continued to follow the antiquated practice of ordering intramuscular Demerol and Vistaril to manage pain for patients with acute pancreatitis. Their reasoning was based on early evidence that Demerol, unlike morphine, does not cause biliary-tract spasms resulting in epigastric or right upper quadrant pain. In an effort to change practice patterns, a multidisciplinary team was formed to study the efficacy of using Transdermal Therapeutic System (TTS) fentanyl to manage pain in this patient population. Thirty-two subjects were enrolled in a double-blind, placebo-controlled study to evaluate the efficacy of using TTS fentanyl with intramuscular Demerol for breakthrough pain in comparison to using a placebo system and intramuscular Demerol. There was no statistically significant difference in self-reported pain intensity between the control and experimental groups on the first day of hospitalization. This finding would be expected because serum fentanyl concentrations rise gradually during the first 12 to 14 hours after application of the TTS fentanyl and plateau at 24 hours. There was a statistically significant difference between groups at 36 hours (exact p <.0154) and 45 hours (exact p <.0132) after application of the TTS fentanyl. This is probably because of greater serum fentanyl concentrations observed during the 36- to 48-hour period after application of TTS fentanyl. Although not statistically significant, trends in the data revealed that the experimental group had lower self-reported pain intensity scores than the control group throughout the course of hospitalization. Even though the experimental group had significantly more previous hospitalizations for acute pancreatitis and a higher pain intensity score on admission, this group had a significantly shorter length of stay in the hospital c2 (1, N = 31) = 4.3706 p <.05. There was no statistically significant difference between the two groups for self-reported satisfaction with pain management.
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Affiliation(s)
- Marcia Stevens
- School of Nursing, Minnesota State University, Mankato 56001, USA.
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Butler KC, Selden B, Pollack CV. Relief by naloxone of morphine-induced spasm of the sphincter of Oddi in a post-cholecystectomy patient. J Emerg Med 2001; 21:129-31. [PMID: 11489400 DOI: 10.1016/s0736-4679(01)00355-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Spasm of the sphincter of Oddi is a well-recognized effect of the narcotic class of drugs. Although it is usually clinically silent, such spasm occasionally causes debilitating pain that may be mistaken for more serious disorders. We present the case of a patient who had undergone cholecystectomy previously, but in whom morphine given in the Emergency Department precipitated pain consistent with biliary colic; the pain resolved promptly after administration of naloxone. This entity may considered in the differential diagnosis of acute onset of colicky abdominal pain in the patient given narcotics.
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Affiliation(s)
- K C Butler
- Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona 85008, USA
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Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol 2001; 96:1266-72. [PMID: 11316181 DOI: 10.1111/j.1572-0241.2001.03536.x] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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.
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Affiliation(s)
- D R Thompson
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA
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Gordon DB, Jones HD, Goshman LM, Foley DK, Bland SE. A quality improvement approach to reducing use of meperidine. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 2000; 26:686-99. [PMID: 11143208 DOI: 10.1016/s1070-3241(00)26058-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 1991 the University of Wisconsin Hospital and Clinics formed a pain management QI team whose goal was to improve pain management through education, outcome monitoring, and the development of programs intended to improve clinical practice. Longitudinal monitoring mechanisms were established to audit medical records and survey patients to examine both staff practice patterns and patient outcomes. The QI team targeted use of meperidine, one of the most widely used opioid analgesics for the treatment of moderate to severe pain, which is now discouraged as a first-line agent for most painful conditions. IMPLEMENTING THE QI PROCESS A QI process was implemented using a traditional plan-do-check-act (PDCA) model, resulting in a successful and sustained reduction of inappropriate meperidine use. A cause-and-effect diagram helped highlight the multiple factors contributing to the drug's overuse and was used to prioritize targets for action. A flow chart helped to uncover some of the interrelationships between the myths about meperidine and the resultant customary prescribing and administration practices. While most of the strategies were implemented in 1996 (formulary guideline release, change in stock supply and physician orders, staff education and feedback), a significant impact in practice was not seen until late 1997. Ongoing tracking and feedback loops were established to ensure continued low use of meperidine. CONCLUSION Use of a QI approach in pain management has been shown to affect the visibility of pain as a clinical priority, enhance interdisciplinary collaboration, facilitate the implementation of clinical guidelines at the bedside, and improve the quality of care for patients.
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Affiliation(s)
- D B Gordon
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin, 600 Highland Avenue, F6-121-1535, Madison, WI 53792, USA.
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Sherman S, Gottlieb K, Uzer MF, Smith MT, Khusro QE, Earle DT, Brunelle RL, Hawes RH, Lehman GA. Effects of meperidine on the pancreatic and biliary sphincter. Gastrointest Endosc 1996; 44:239-42. [PMID: 8885340 DOI: 10.1016/s0016-5107(96)70158-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Opioids are traditionally avoided during sphincter of Oddi manometry because of indirect evidence suggesting that these agents cause sphincter of Oddi spasm. This study was undertaken to determine the direct effects of meperidine on the biliary and pancreatic sphincter. METHODS Forty-seven patients were prospectively evaluated by sphincter of Oddi manometry in the conventional retrograde fashion. Manometry was initially performed with intravenous diazepam sedation alone. The manometry was repeated 3 to 5 minutes after meperidine was administered. RESULTS The basal sphincter pressure of the biliary sphincter, pancreatic sphincter, and the combined sphincter group were not significantly altered by meperidine. Concordance (normal versus abnormal) between the basal sphincter pressure before and after meperidine was seen in 44 of 47 patients (94%). Meperidine produced a significant increase in the pancreatic, biliary, and combined sphincter phasic frequency and a significant decrease in the phasic duration. The pancreatic and combined sphincter phasic pressures were significantly reduced following meperidine administration. Seventeen manometry tracings (36%) were believed to be qualitatively better after meperidine, while only four (8.5%; p < .001) were qualitatively better with diazepam alone. CONCLUSION Meperidine can be used for additional analgesia during sphincter of Oddi manometry if the basal sphincter pressure is the parameter used to determine therapy.
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Affiliation(s)
- S Sherman
- Department of Medicine, Indiana University School of Medicine, Indianapolis 46202-5000, USA
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Abstract
BACKGROUND In recent years, applications of electromyographic, cineradiographic, scintilographic, and endoscopic manometric techniques have improved our knowledge of normal and abnormal motility of Oddi's sphincter. This sphincter coordinates the time and rate of secretion of about 3 liters of bile and pancreatic juice into the duodenum daily. METHODS Oddi's sphincter may be evaluated by endoscopic manometry, ultrasound, dynamic hepatobiliary scintigraphy, and laboratory tests. Endoscopic manometry is the best method for evaluating the function Oddi's sphincter. RESULTS The basal pressure of Oddi's sphincter is usually 5 to 15 mm Hg greater than the bile and pancreatic duct pressures. Phasic contractions of 50 to 150 mm Hg in amplitude and 3 to 8 contractions per minute in frequency are superimposed on the basal pressure. A small percentage of patients with gastrointestinal symptoms after cholecystectomy has sphincter of Oddi dysfunction, which may have structural abnormality (papillary stenosis) or functional abnormality (Oddi's sphincter dyskinesia). CONCLUSIONS Elevated basal pressure ( > 40 mm Hg) is the most important manometric finding of Oddi's sphincter dysfunction. Endoscopic sphincterotomy is the treatment of choice for patients with Oddi's sphincter dysfunction and elevated basal sphincter pressure.
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Affiliation(s)
- J C Coelho
- Department of Surgery, Federal University of Parana, Curitiba, Brazil
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Azurin DJ, Go LS, Maslack M, Kirkland ML. Bile leak following laparoscopic cholecystectomy. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1995; 5:233-6. [PMID: 7579675 DOI: 10.1089/lps.1995.5.233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The incidence and significance of bile leak after open cholecystectomy have been studied. The purpose of this study was to determine the incidence and significance of postoperative bile leak associated with both emergent and elective laparoscopic cholecystectomies. One thousand four hundred patients undergoing laparoscopic cholecystectomy from July 1990 to January 1995 were retrospectively reviewed. Twenty-seven percent of laparoscopic cholecystectomies were performed urgently for acute cholecystitis. Diisopropyl-iminodiacetic acid (DISIDA) scan was used to determine the presence of a bile leak or obstruction. Also, a subgroup of 63 patients from March to May of 1992 was studied in a nonblinded prospective fashion to determine the rate of asymptomatic bile leak. The incidence of bile leak in the subgroup of 63 patients was 4.7% (n = 3). All of these bile leaks were asymptomatic and of no clinical significance. The incidence of bile leak in the remaining 1337 was 0.14% (n = 2). These bile leaks were discovered by DISIDA scan following a workup of atypical abdominal pain following laparoscopic cholecystectomy. Both of these patients underwent ERCP with papillotomy. There were no ductal injuries in the entire series. Symptomatic bile leaks following laparoscopic cholecystectomy are rare. Asymptomatic bile leaks occur infrequently and are of no clinical significance.
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Affiliation(s)
- D J Azurin
- Pennsylvania Hospital, Philadelphia, USA
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