Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY.
Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY.
Ann Emerg Med. 2019 Feb;73(2):133-140. doi: 10.1016/j.annemergmed.2018.06.019. Epub 2018 Aug 14.
As clinicians look to nonnarcotic analgesics in the emergency department (ED), it is essential to understand the effectiveness and adverse effects of nonopioid medications in comparison with existing opioid treatments. Studies of intravenous acetaminophen for acute pain in the ED demonstrate mixed results and suffer from small sample sizes and methodological limitations. This study compares intravenous hydromorphone with intravenous acetaminophen in adult ED patients presenting with acute pain.
This was a prospective, randomized, clinical trial comparing 1 g intravenous acetaminophen with 1 mg intravenous hydromorphone for treatment of adults with severe, acute pain in the ED. The primary outcome was between-group difference in change in numeric rating scale from baseline to 60 minutes postadministration of study medication. Secondary outcomes included the difference in proportion of patients in each group who declined additional analgesia at 60 minutes, received additional medication before 60 minutes, and developed nausea, vomiting, or pruritus.
Of 220 subjects randomized, 103 patients in each arm had sufficient data for analysis. At 60 minutes, the mean decrease in numeric rating scale pain score was 5.3 in the hydromorphone arm and 3.3 in the acetaminophen arm, a difference of 2.0 (95% confidence interval [CI] 1.2 to 2.7) favoring hydromorphone. A greater proportion of patients in the hydromorphone arm also declined additional analgesia at 60 minutes (65% versus 44%; difference 21%; (95% CI 8% to 35%). There was no difference in the proportion of patients receiving rescue analgesia before 60 minutes. Significantly more subjects in the hydromorphone group developed nausea (19% versus 3%; difference 16%; 95% CI 4% to 28%) and vomiting (14% versus 3%; difference 11%; 95% CI 0% to 23%).
Although both 1 mg intravenous hydromorphone and 1 g intravenous acetaminophen provided clinically meaningful reductions in pain scores, treatment with hydromorphone provided both clinically and statistically greater analgesia than acetaminophen, at the cost of a higher incidence of nausea and vomiting.
由于临床医生在急诊科（ED）寻求非麻醉性镇痛药，因此了解非阿片类药物与现有阿片类药物治疗相比的有效性和不良反应至关重要。ED 中静脉用对乙酰氨基酚治疗急性疼痛的研究结果喜忧参半，且存在样本量小和方法学局限性的问题。本研究比较了静脉注射氢吗啡酮与静脉注射对乙酰氨基酚在成人 ED 中出现急性疼痛的患者中的效果。
这是一项前瞻性、随机、临床试验，比较了 1 g 静脉注射对乙酰氨基酚与 1 mg 静脉注射氢吗啡酮治疗 ED 中严重急性疼痛的成人患者。主要结局是两组患者在接受研究药物后 60 分钟时数字评分量表基线变化的组间差异。次要结局包括每组患者在 60 分钟时拒绝额外镇痛剂的比例、在 60 分钟前接受额外药物的比例以及发生恶心、呕吐或瘙痒的比例。
220 名随机患者中，每组 103 名患者的数据足够进行分析。在 60 分钟时，氢吗啡酮组的平均数字评分量表疼痛评分下降 5.3，对乙酰氨基酚组下降 3.3，差异为 2.0（95%置信区间 [CI] 1.2 至 2.7），有利于氢吗啡酮。在氢吗啡酮组中，有更多的患者在 60 分钟时拒绝额外镇痛剂（65%比 44%；差异 21%；95%CI 8%至 35%）。在 60 分钟前接受解救镇痛剂的患者比例无差异。氢吗啡酮组恶心的发生率显著高于对乙酰氨基酚组（19%比 3%；差异 16%；95%CI 4%至 28%）和呕吐（14%比 3%；差异 11%；95%CI 0%至 23%）。
虽然 1 mg 静脉注射氢吗啡酮和 1 g 静脉注射对乙酰氨基酚都能使疼痛评分有临床意义的降低，但与对乙酰氨基酚相比，氢吗啡酮治疗不仅在临床上有更好的镇痛效果，而且在统计学上也更好，但其代价是恶心和呕吐的发生率更高。
