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The Cochrane Database of Systematic... 2002While morphine is the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable... (Review)
Review
BACKGROUND
While morphine is the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable morphine-related toxicity. For these patients alternatives such as hydromorphone are recommended. However, there appear to be gaps in our understanding of the efficacy and potency of hydromorphone.
OBJECTIVES
This review explores and assesses the evidence for the efficacy of hydromorphone in the management of pain.
SEARCH STRATEGY
Randomised trials which included hydromorphone were sought using electronic databases and by handsearching relevant journals. Date of the most recent search: February 2000.
SELECTION CRITERIA
RCTs which involved the administration of hydromorphone, for both acute and chronic pain conditions, in adults and children, were included.
DATA COLLECTION AND ANALYSIS
A data extraction form was designed for the purpose of the review. The validity of each trial for inclusion was assessed using criteria described in the Cochrane Handbook. A grade was allocated to each study on the basis of allocation concealment. A checklist was used to assess blinding.
MAIN RESULTS
Forty three studies (2725 subjects) were included in the review. Approximately half of these studies received a low quality score. In addition, the heterogeneity of the studies precluded combination of data and results. A meta-analysis was therefore not possible. Of the 43 included studies, 11 (645 subjects) involved chronic pain conditions (all cancer) and 32 (2080 subjects) acute pain. Three studies were placebo-controlled. Of the remainder, hydromorphone was compared with other opioids (morphine, fentanyl, sufentanyl, meperidine, oxycodone, diamorphine), bupivicaine and with itself, using different formulations. The routes of administration included intravenous, oral, spinal, intramuscular and subcutaneous. Overall, hydromorphone appears to be a potent analgesic. The limited number of studies available suggest that there is little difference between morphine and hydromorphone in terms of analgesic efficacy, adverse effect profile and patient preference. However, as most studies involved small numbers of patients, it is difficult to determine real differences between both drugs. In the context of both acute and chronic pain, the issue of equi-analgesic ratios between morphine and hydromorphone was not resolved.
REVIEWER'S CONCLUSIONS
The studies included in this review were varied in terms of quality and methodology. However, the majority demonstrated that hydromorphone is a potent analgesic, that the clinical effects of hydromorphone appear to be dose-related, and that the adverse effect profile of hydromorphone is similar to that of other mu opioid receptor agonists.
Topics: Acute Disease; Analgesics, Opioid; Chronic Disease; Humans; Hydromorphone; Pain; Randomized Controlled Trials as Topic
PubMed: 11869661
DOI: 10.1002/14651858.CD003447 -
Anesthesia and Analgesia Feb 2002Shivering is a frequent complication in the postoperative period. The relative efficacy of interventions that are used for the treatment of postoperative shivering is... (Meta-Analysis)
Meta-Analysis
UNLABELLED
Shivering is a frequent complication in the postoperative period. The relative efficacy of interventions that are used for the treatment of postoperative shivering is not well understood. We performed a systematic search (MEDLINE, EMBASE, Cochrane Library, hand searching, all languages, to August, 2000) for full reports of randomized comparisons of any pharmacological antishivering intervention (active) with placebo (control) in the postoperative period. Dichotomous data on absence of further shivering after treatment and adverse effects were extracted from original reports. Relative risk (RR) and number-needed-to-treat (NNT) were calculated with 95% confidence interval (CI) using a fixed effect model. Data from 20 trials (944 adults received an active intervention, 413 were controls) were analyzed. Antishivering efficacy depended on the active regimen and the length of follow-up. Efficacy with meperidine 25 mg, clonidine 150 microg, ketanserin 10 mg, and doxapram 100 mg was reported in at least three trials; all were significantly more effective than control. After 1 min, the NNT of meperidine 25 mg for no further shivering compared with placebo was 2.7 (RR, 6.8; 95% CI, 2.5-18.5). After 5 min, the NNT of meperidine 25 mg was 1.3 (RR, 9.6; 95% CI, 5.7-16), the NNT of clonidine 150 microg was 1.3 (RR, 6.8; 95% CI, 3.3-14.2), the NNT of doxapram 100 mg was 1.7 (RR 4.0; 95% CI, 2.4-6.5), and the NNT of ketanserin 10 mg was 2.3 (RR 3.1; 95% CI, 1.9-5.1). After 10 min, the NNT of meperidine 25 mg was 1.5 (RR 4.0; 95% CI, 2.5-6.2). After 15 min, the NNT of ketanserin 10 mg was 3.3 (RR 1.5; 95% CI, 1.2-1.9). Long-term outcome data were lacking. There were not enough data for alfentanil, fentanyl, morphine, nalbuphine, lidocaine, magnesium, metamizol, methylphenidate, nefopam, pentazocine, and tramadol to draw meaningful conclusions. Reporting of adverse drug reactions was sparse. Fewer than two shivering patients need to be treated with meperidine 25 mg, clonidine 150 microg, or doxapram 100 mg for one to stop shivering within 5 min who would have continued to shiver had they all received a placebo.
IMPLICATIONS
Less than two shivering patients need to be treated with meperidine 25 mg, clonidine 150 microg, or doxapram 100 mg for one to stop shivering within 5 min who would have continued to shiver had they all received a placebo.
Topics: Adrenergic alpha-Agonists; Analgesics, Opioid; Clonidine; Humans; Ketanserin; Lidocaine; Meperidine; Postoperative Complications; Randomized Controlled Trials as Topic; Shivering
PubMed: 11812718
DOI: 10.1097/00000539-200202000-00043 -
Canadian Journal of Anaesthesia =... Jan 2002To review the use of adjuncts to intravenous regional anesthesia (IVRA) for surgical procedures in terms of their intraoperative effects (efficacy of block and... (Review)
Review
PURPOSE
To review the use of adjuncts to intravenous regional anesthesia (IVRA) for surgical procedures in terms of their intraoperative effects (efficacy of block and tourniquet pain) and postoperative analgesia.
SOURCE
A systematic search (Medline, Embase, reference lists) for randomized, controlled and double-blinded studies using adjuncts to IVRA for surgical procedures was conducted. Data were collected on intraoperative effects (onset/offset and quality of block and tourniquet pain), postoperative effects (pain intensity and analgesic consumption) and side effects recorded. Statistical significance as indicated in the original report and likely clinical relevance were taken into account to arrive at a judgment of overall benefit.
PRINCIPAL FINDINGS
Twenty-nine studies met all inclusion criteria. Data on 1,217 study subjects are included. Adjuncts used were opioids (fentanyl, meperidine, morphine, sufentanil), tramadol, non-steroidal anti-inflammatory drugs (NSAIDs; ketorolac, tenoxicam, acetyl-salicylate), clonidine, muscle relaxants (atracurium, pancuronium, mivacurium), alkalinization with sodium bicarbonate, potassium and temperature. There is good evidence to recommend NSAIDs in general and ketorolac in particular, for improving postoperative analgesia. Clonidine 1 microg/kg also appears to improve postoperative analgesia and prolong tourniquet tolerance. Opioids are poor by this route; only meperidine 30 mg or more has substantial postoperative benefit but at the expense of postdeflation nausea, vomiting and dizziness. Muscle relaxants improve intraoperative motor block and aid fracture reduction.
CONCLUSION
Using NSAIDs or clonidine as adjuncts to IVRA improves postoperative analgesia and muscle relaxant improves motor block.
Topics: Adjuvants, Anesthesia; Anesthesia, Conduction; Anesthesia, Intravenous; Humans; Randomized Controlled Trials as Topic
PubMed: 11782326
DOI: 10.1007/BF03020416 -
The Cochrane Database of Systematic... 2001Eclampsia, the occurrence of a seizure in association with pre-eclampsia, is a rare but serious complication of pregnancy. A number of different anticonvulsants are used... (Review)
Review
BACKGROUND
Eclampsia, the occurrence of a seizure in association with pre-eclampsia, is a rare but serious complication of pregnancy. A number of different anticonvulsants are used to control eclamptic fits and to prevent further seizures.
OBJECTIVES
The aim of this review was to compare the effects of magnesium sulphate with those of lytic cocktail when used for the care of women with eclampsia.
SEARCH STRATEGY
The register of trials held by the Cochrane Pregnancy and Childbirth Group was searched for relevant trials. The Cochrane Controlled Trials Register in The Cochrane Library Issue 2, 2000 was also searched.
SELECTION CRITERIA
Randomised trials recruiting women with eclampsia, and comparing any use of magnesium sulphate with any use of lytic cocktail.
DATA COLLECTION AND ANALYSIS
Data were extracted from each report without any blinding of the results or of the treatments which women received.
MAIN RESULTS
Two trials with 199 women were included in the review. These were both small and of average quality. Magnesium sulphate was better than lytic cocktail at preventing further fits (relative risk (RR) 0.09, 95% confidence interval (CI) 0.03-0.24; risk difference (RD) 0.43, 95% CI -0.53, -0.34; number needed to treat (NNT) 3, 95% CI 2-3) and was associated with less respiratory depression (RR 0.12, 95% CI 0.02-0.91). Magnesium sulphate was also associated with fewer maternal deaths than lytic cocktail, but the difference was not statistically significant (RR 0.25, 95% CI 0.04-1.43).
REVIEWER'S CONCLUSIONS
Magnesium sulphate is the anticonvulsant of choice for women with eclampsia. Lytic cocktail should be abandoned.
Topics: Anticonvulsants; Chlorpromazine; Drug Combinations; Eclampsia; Female; Humans; Magnesium Sulfate; Meperidine; Pregnancy; Promethazine; Randomized Controlled Trials as Topic
PubMed: 11279786
DOI: 10.1002/14651858.CD002960 -
The Cochrane Database of Systematic... 2000Pethidine is the most widely used intra-muscular opioid for the relief of labour pain. However concerns have been raised about its effectiveness and the possibility of... (Review)
Review
BACKGROUND
Pethidine is the most widely used intra-muscular opioid for the relief of labour pain. However concerns have been raised about its effectiveness and the possibility of depressing respiration in newborns.
OBJECTIVES
The objective of this review was to assess the effects of different opioids (and different doses of the same opioid) administered intra-muscularly in labour.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 1997) and reference lists of articles.
SELECTION CRITERIA
Randomised trials comparing the effects of different currently used opioids (and different doses of the same opioid) administered intramuscularly in labour for women who request systemic analgesia.
DATA COLLECTION AND ANALYSIS
Two reviewers assessed trial quality and extracted data. Analysis was based on the groups as randomly allocated.
MAIN RESULTS
Sixteen trials were included. There were problems with methodological quality of some of the trials, and lack of consistency in the way various outcomes were reported. There was no evidence of a difference between pethidine and tramadol in terms of pain relief, interval to delivery, or instrumental or operative delivery. There appeared to be more adverse effects such as nausea and vomiting and drowsiness with pethidine. Maternal pain relief seemed almost identical between the meptazinol and pethidine groups, whether assessed as maternal satisfaction with pain relief, visual analogue scales, or use of other pain relief, but meptazinol gave rise to slightly more side effects. Maternal satisfaction with pain relief appeared similar for pentazocine and pethidine, with more frequent nausea and vomiting with pethidine.
REVIEWER'S CONCLUSIONS
There is not enough evidence to evaluate the comparative efficacy and safety of the various opioids used for analgesia in labour.
Topics: Analgesia, Obstetrical; Analgesics, Opioid; Female; Humans; Injections, Intramuscular; Labor, Obstetric; Meperidine; Pain; Pregnancy
PubMed: 10796255
DOI: 10.1002/14651858.CD001237 -
British Journal of Anaesthesia Jan 2000For a systematic review of postoperative analgesic efficacy and adverse effects of single doses, injected or oral, of pethidine and ketorolac compared with placebo, we... (Meta-Analysis)
Meta-Analysis
For a systematic review of postoperative analgesic efficacy and adverse effects of single doses, injected or oral, of pethidine and ketorolac compared with placebo, we sought published randomized studies in moderate to severe postoperative pain. Information on summed pain intensity or pain relief outcomes over 4-6 h was extracted and converted to dichotomous information to produce the number of patients with at least 50% pain relief. This was used to calculate the relative benefit and number-needed-to-treat (NNT) for one patient to achieve at least 50% pain relief. Minor and major adverse effect data were extracted and summarized. For pethidine 100 mg i.m., eight randomized, controlled studies met the inclusion criteria, with 203 patients given pethidine and 161 placebo. The NNT to produce at least 50% pain relief was 2.9 (95% confidence interval 2.3-3.9). At this dose, pethidine produced significantly more drowsiness and dizziness than placebo, with numbers-needed-to-harm (NNH) of 2.9 (2.2-4.4) and 7.2 (4.8-14), respectively. For ketorolac, 14 reports met the inclusion criteria (six i.m. and eight oral). Most i.m. information (176 patients) was available for the 30 mg dose, which had an NNT of 3.4 (2.5-4.9). Most oral information was available for the 10 mg dose, which had an NNT of 2.6 (2.3-3.1). Oral ketorolac 10 mg was consistently at least as effective as ketorolac 30 mg i.m. Only with oral ketorolac 10 mg were there significantly more adverse effects than with placebo, with an NNH for any adverse effect of 7.3 (4.7-17).
Topics: Acute Disease; Analgesics, Opioid; Anti-Inflammatory Agents, Non-Steroidal; Humans; Ketorolac; Meperidine; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 10740547
DOI: 10.1093/oxfordjournals.bja.a013381 -
Anesthesia and Analgesia Apr 2000The best intervention to prevent pain on injection with propofol is unknown. We conducted a systematic literature search (Medline, Embase, Cochrane Library,... (Meta-Analysis)
Meta-Analysis
UNLABELLED
The best intervention to prevent pain on injection with propofol is unknown. We conducted a systematic literature search (Medline, Embase, Cochrane Library, bibliographies, hand searching, any language, up to September 1999) for full reports of randomized comparisons of analgesic interventions with placebo to prevent that pain. We analyzed data from 6264 patients (mostly adults) of 56 reports. On average, 70% of the patients reported pain on injection. Fifteen drugs, 12 physical measurements, and combinations were tested. With IV lidocaine 40 mg, given with a tourniquet 30 to 120 s before the injection of propofol, the number of patients needed to be treated (NNT) to prevent pain in one who would have had pain had they received placebo was 1.6. The closest to this came meperidine 40 mg with tourniquet (NNT 1.9) and metoclopramide 10 mg with tourniquet (NNT 2.2). With lidocaine mixed with propofol, the best NNT was 2.4; with IV alfentanil or fentanyl, it was 3 to 4. IV lidocaine before the injection of propofol was less analgesic. Temperature had no significant effect. There was a lack of data for all other interventions to allow meaningful conclusions. The diameter of venous catheters and speed of injection had no impact on pain.
IMPLICATIONS
IV lidocaine (0.5 mg/kg) should be given with a rubber tourniquet on the forearm, 30 to 120 s before the injection of propofol; lidocaine will prevent pain in approximately 60% of the patients treated in this manner.
Topics: Adult; Analgesics, Opioid; Humans; Injections; Lidocaine; Pain; Propofol; Randomized Controlled Trials as Topic; Temperature
PubMed: 10735808
DOI: 10.1097/00000539-200004000-00035