Drug Safety
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Review Comparative Study
Ketorolac for postoperative pain management in children.
Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) with potent analgesic effects and a relatively low incidence of adverse effects. Numerous clinical trials of postoperative pain treatment in children have shown that ketorolac is as effective as the major opioid analgesics, such as morphine, and more effective than codeine. The pharmacokinetics of ketorolac differ in children compared with adult patients after surgery. ⋯ Bleeding time is usually slightly increased, but in most patients it remains within normal values. There is conflicting evidence of the potential for increased surgical-site bleeding after tonsillectomy but, for other types of paediatric surgery, numerous clinical studies have confirmed that ketorolac is not associated with increased bleeding. Thus, ketorolac is well suited for the treatment of postoperative pain in children, either alone or in combination with opioids or local anaesthetics, because of its analgesic potency and relatively low incidence of adverse effects.
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Poisonings are a common problem. In 1995, over 2 million exposures were reported to American poison information centres alone. The majority of poisoning exposures can be treated without major therapeutic intervention. ⋯ Some antidotes, such as digoxin-specific antigen binding fragments (digoxin immune Fab), are very expensive, and both the risk: benefit ratio and the associated cost should be considered before the antidote is administered. The principle aims are to "treat the patient, not the poison' and to do no harm to the patient. Antidotes should be used only when they are indicated and may help a patient.
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Drugs may be the most frequent single cause of delirium, and very often they are a critical element in a multifactorial aetiology. While delirium may be precipitated by virtually any drug, certain classes of drugs are more commonly implicated. Effective management of drug-induced delirium involves recognition, cessation or dosage reduction of the causative drug(s), and initiation of reorientation strategies and supportive medical care. ⋯ Certain benzodiazepines (diazepam, lorazepam, midazolam) and/or haloperidol may be the most appropriate choices in these circumstances. Primary prevention requires the prescription of alternative lower risk medications and the minimisation of polypharmacy. Secondary prevention may be achieved through improved recognition of the condition.
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Tramadol is a cyclohexanol derivative with mu-agonist activity. It has been used as an analgesic for postoperative or chronic pain since the late 1970s, and became one of the most popular analgesics of its class in Germany. International interest has been renewed during the past few years, when it was discovered that tramadol not only acts on opioid receptors, but also inhibits serotonin (5-hydroxytryptamine; 5-HT) and noradrenaline (norepinephrine) reuptake. ⋯ The potential for abuse or addiction seems to be minimal, and serious complications have not been reported. For patients with severe pain, the efficacy of morphine is superior, and most patients with adequate analgesia from tramadol had to be changed to a more potent opioid after a few weeks due to increased nociceptive input during tumour progression. Tramadol can be recommended as a safe and efficient drug for step II according to the World Health Organization guidelines for cancer pain management.
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The pain associated with labour can be severe. The ideal labour analgesic does not exist and systemic opioids provide little relief. Nausea, vomiting and sedation are common adverse effects of systemic opioids. ⋯ Various studies have reported that epidural analgesia slows labour, increases the incidence of malposition of the fetal head, increases the need for forceps delivery and increases the risk of caesarean delivery. Most of the studies reporting these effects are retrospective and nonrandomised. More careful studies suggest that specific anaesthetic techniques (i.e. local anaesthetic-opioid mixtures) or obstetrical management can limit or eliminate these 'risks' of epidural labour analgesia.