ㄟ... 小弟不才, 謹把急診的觀點貼出 (疼痛是急診的重要議題... 美國統計60%的急診求診病人, 因為疼痛就診!) 節錄自急診教科書p.259, Tintinalli: Emergency Medicine, 6th edition, <<American College of Emergency Physicians>> Meperidine was once the mainstay of pain management in EDs. Meperidine should no longer be routinely used for acute pain management, for several reasons: (1) it is the lowest potency opioid and, as a result, often is underdosed; potency是opioids最低的, 常常劑量過輕 (2) normeperidine, the metabolite of meperidine, has been shown to cause central nervous system toxicity in patients with compromised renal function or those taking monoamine oxidase inhibitors; Demerol的代謝物, normeperidine, 在腎功能不好或者同時服用MAO inhibitors 的病人, 會顯現出他的中樞神經毒性 (3) normeperidine can produce prolonged states of sedation (up to 48 h in rare cases); 會造成延長時間的鎮定效果 (4) meperidine is reported to produce more euphoria and may have an increased risk for addiction when compared with other opioids. 會造成比較多的euphoria, 而產生比較高的成癮機會 另外, 另一個更大本的教科書Rosen, 會有更多的敘述不過就不再列舉了 美國甚至已經有許多急診已經不再使用demerol 急診止痛的drug of choice其實還是morphine, 不是keto或者panadol 只是台灣醫風/民風還尚未習慣 ============== 另外一提, 急診的觀點而言, 為了順利治療動作的鎮定麻醉 (procedural sedation and anesthesia, PSA) 首選短效型benzodiazepine 相較於外科系喜愛使用propoful... 急診的standpoint主要之一也是 萬一造成呼吸抑制可以用flumazenil來馬上reverse Propoful (p.278) Amnesia, however, is not reliably produced in doses used for sedation. (propoful的amnesia效果較無法預測) The drug possesses antiemetic properties. Propofol produces significant cardiovascular depression, with dose-related declines in systolic blood pressure of up to 25 to 40 percent when given in induction doses. This effect is more pronounced in those with impaired hemodynamic status and in the elderly.(propoful降壓效果明顯) The use of propofol for ED PSA is controversial, and its use outside the operating room by nonanesthesia personnel may be restricted by hospital policy. (在OR裡面用比較安全) Limited studies using propofol for ED PSA in children and adults have found a rapid onset of sedation, rapid recovery, and high patient and physician satisfaction scores. (infusion一停掉就會很快醒來, 病人/醫師滿意度高) In doses usually used for PSA, however, analgesic and amnestic agents may be required, which may result in hypoventilation and potentiate the already significant hemodynamic effects of propofol. (較不穩定的病人, 使用propoful較可能會讓呼吸跟循環同受到抑制) The research agenda and issues surrounding propofol use by the emergency physician have been delineated. (急診的場景不常使用啦!!) --

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