本文選題：鞘內(nèi)輸注　切入點：難治性癌性疼痛　出處：《青島大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:觀察鞘內(nèi)氫嗎啡酮自控鎮(zhèn)痛治療難治性癌性疼痛的臨床療效及對患者免疫狀態(tài)的影響。方法:選取自2016年1月到2016年12月之間因癌性疼痛來我院就診,經(jīng)常規(guī)口服嗎啡(每日劑量超過200mg),疼痛控制效果仍不理想(VAS5),預(yù)計生存期1月的癌性疼痛患者40例。對患者進行完善的評估與相關(guān)檢查包括:患者意識水平、心肺功能、肝腎功能、凝血功能、脊椎CT或MRI檢查等,以排除手術(shù)禁忌及確定是否存在穿刺困難。準備完善后于手術(shù)室行C型臂引導(dǎo)下的鞘內(nèi)輸注港植入術(shù),采用C型臂定位L3/4間隙,在C型臂引導(dǎo)下進行穿刺置管,穿刺成功后根據(jù)患者病變情況將導(dǎo)管頭端置于與患者疼痛部位相應(yīng)的椎體平面。在C型臂引導(dǎo)下進行鞘內(nèi)置管,避免導(dǎo)管在鞘內(nèi)打折、繞圈。于腋前線平肋弓處切開皮膚,鈍性分離皮下組織用于埋置輸液港,采用專用隧道針自穿刺點到輸注港埋置處(腋中線平肋弓水平)做一皮下通道,將鞘內(nèi)導(dǎo)管與輸液港相連接,采用無損傷蝶形針連接PCA鎮(zhèn)痛泵進行鞘內(nèi)輸注,鞘內(nèi)輸注開始后停止其他口服鎮(zhèn)痛藥物。檢查并記錄癌性疼痛患者接受鞘內(nèi)治療前(T_0)、鞘內(nèi)治療后1天(T_1)、鞘內(nèi)治療后1周(T_2)VAS疼痛評分、淋巴細胞亞群CD3~+、CD4~+、CD8~+、CD4~+/CD8~+、NK細胞活性變化;記錄鞘內(nèi)鎮(zhèn)痛前(T_0)、及鞘內(nèi)鎮(zhèn)痛后1周(T_2)的SF-36生活質(zhì)量(QOL)評分、SDS抑郁評分;觀察并記錄鞘內(nèi)鎮(zhèn)痛、后患者便秘、惡心嘔吐及尿潴留等并發(fā)癥的發(fā)生率。本研究使用SPSS19.0軟件進行數(shù)據(jù)分析,相關(guān)計量資料采用均數(shù)±標準差(x±s)表示,鞘內(nèi)鎮(zhèn)痛前后數(shù)據(jù)資料的比較采用兩獨立樣本均數(shù)的t檢驗,計數(shù)資料的比較采用卡方檢驗,P0.05為差異有統(tǒng)計學(xué)意義。結(jié)果:所有癌痛患者均成功進行了鞘內(nèi)輸注港植入術(shù),并在生存期內(nèi)完成了隨訪,所有數(shù)據(jù)納入統(tǒng)計學(xué)分析。經(jīng)過患者術(shù)前與術(shù)后相關(guān)觀察指標數(shù)據(jù)的對比,發(fā)現(xiàn)患者在給予氫嗎啡酮鞘內(nèi)自控制痛后,VAS疼痛評分明顯降低(P0.01);鞘內(nèi)氫嗎啡酮鎮(zhèn)痛術(shù)后1周(T_2)SF-36生活質(zhì)量(QOL)評分較鞘內(nèi)鎮(zhèn)痛前(T_0)有明顯改善(P0.01);氫嗎啡酮鞘內(nèi)鎮(zhèn)痛術(shù)后1周(T_2)SDS抑郁評分較鞘內(nèi)鎮(zhèn)痛前(T_0)有改善(P0.01);在鞘內(nèi)氫嗎啡酮輸鎮(zhèn)痛后1天(T_1)患者T細胞亞群CD3~+、CD4~+、CD4~+/CD8~+以及NK細胞水平較術(shù)前(T_0)口服嗎啡時降低(P0.05);在氫嗎啡酮鞘內(nèi)輸鎮(zhèn)痛后1周(T_2)患者T細胞亞群CD3~+、CD4~+、CD4~+/CD8~+以及NK細胞水平較術(shù)前(T_0)口服嗎啡時有顯著改善(P0.05);在氫嗎啡酮鞘內(nèi)自控輸注鎮(zhèn)痛術(shù)后1周(T_2)患者便秘、惡心嘔吐并發(fā)癥的發(fā)生率較術(shù)前(T_0)顯著降低(P0.01)。鞘內(nèi)置入術(shù)后患者出現(xiàn)尿潴留3例,出現(xiàn)術(shù)后頭痛2例,均于術(shù)后3天內(nèi)好轉(zhuǎn),所有患者在隨訪期內(nèi)未出現(xiàn)患者感染事件。結(jié)論:氫嗎啡酮鞘內(nèi)自控鎮(zhèn)痛治療難治性癌性疼痛較口服嗎啡相比能明顯改善患者疼痛,改善癌痛患者的抑郁狀態(tài)及生活質(zhì)量,改善患者的免疫狀態(tài),降低患者便秘、惡心嘔吐的發(fā)生率。
[Abstract]:Objective: to observe the clinical effect of intrathecal controlled analgesia with hydromorphine ketone in the treatment of intractable cancerous pain and its influence on the immune state of patients. Methods: from January 2016 to December 2016, patients with cancer pain were treated in our hospital. After routine oral administration of morphine (daily dose of more than 200 mg / g), the pain control effect is still not satisfactory, and 40 patients with cancerous pain are expected to survive in January. The complete evaluation and related examinations of the patients include: the patients' consciousness level, cardiopulmonary function, heart and lung function. Liver and kidney function, coagulation function, spinal CT or MRI examination were used to remove the contraindication of operation and to determine whether there was any difficulty in puncture. After the procedure was completed, the intrathecal infusion port implantation guided by C-arm was performed in the operating room, and the C-arm was used to locate the L3 / 4 space. The catheterization was carried out under the guidance of type C arm. After successful puncture, the head end of the catheter was placed in the vertebral plane corresponding to the pain site of the patient according to the pathological changes of the patient, and the catheter was placed in the sheath under the guidance of the C-arm to avoid the discounting of the catheter in the sheath. Circle. Cut the skin at the anterior axillary rib arch, obtuse the subcutaneous tissue to bury the infusion port, and use a special tunnel needle from the puncture point to the port of infusion to make a subcutaneous passage from the point of puncture to the place where the port of infusion is buried (the level of the flat rib arch in the central axillary line). The intrathecal catheter was connected with the infusion port, and the PCA analgesia pump was connected with a non-invasive butterfly needle for intrathecal infusion. After intrathecal infusion, other oral analgesic drugs were stopped. The changes of NK cell activity in patients with cancer pain before intrathecal treatment were examined and recorded. After intrathecal treatment, T _ (1), T _ (2) VAS pain score and lymphocyte subsets CD3 ~ ~ ~ (4 ~ +) CD8 ~ ~ (8) ~ (-CD8 ~ +) -NK cell activity were recorded 1 day after intrathecal treatment, and 1 week after intrathecal treatment, the pain score of T2VAS and the activity of NK cells were recorded. SF-36 quality of life (QOL) score and depression score were recorded before intrathecal analgesia and 1 week after intrathecal analgesia, and observed and recorded for patients with constipation after intrathecal analgesia. The incidence of nausea and vomiting and urinary retention were analyzed by SPSS19.0 software. The relevant data were expressed as mean 鹵standard deviation (x 鹵s). The data before and after intrathecal analgesia were compared with t test of two independent samples. Results: all patients with cancer pain underwent intrathecal infusion port implantation successfully and were followed up during the survival period. All the data were included in statistical analysis. It was found that the pain score of VAS decreased significantly after intrathecal control of hydromorphone, and the QOLscore of T2SF-36 was significantly improved 1 week after intrathecal analgesia compared with that of T0 before intrathecal analgesia, and the intrathecal analgesia of hydromorphone was significantly improved by intrathecal analgesia of hydromororphone, and the QOLs of T2SF-36 after intrathecal analgesia were significantly improved in patients with intrathecal analgesia compared with those before intrathecal analgesia. After 1 week, the depression score of T2SDS was improved compared with that before intrathecal analgesia, and the level of T cell subsets CD3 ~ + CD4 ~ P ~ + CD8 ~ and NK cells decreased in patients with intrathecal hydromororphone on day 1 after intrathecal analgesia, and the levels of NK cells were lower than those before oral administration of morphine, and in hydromorphone sheath, the level of NK cells was lower than that before oral administration of morphine, and the level of NK cells was lower than that before administration of morphine, and the level of NK cells was significantly lower than that before administration of morphine. One week after analgesia, T cell subsets CD3 ~ + CD4 ~ + CD4 ~ / CD8 ~ and NK cell level were significantly improved in patients with constipation compared with those before oral administration of morphine, and in patients with constipation 1 week after patient-controlled intrathecal infusion of hydromorphine and intrathecal infusion of hydromorphine. The incidence of nausea and vomiting complications was significantly lower than that of preoperation (P 0.01). Urinary retention was found in 3 cases and headache in 2 cases, which was improved within 3 days after operation. Conclusion: intrathecal analgesic analgesia with hydromororphone can significantly improve the pain, depression and quality of life of patients with cancer pain, compared with that of oral morphine, conclusion: intrathecal analgesia with hydromorphone can significantly improve the pain of patients with intractable cancerous pain, and improve the quality of life of patients with cancer pain. Improve the immune status of patients, reduce the incidence of constipation, nausea and vomiting.
【學(xué)位授予單位】：青島大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R730.5

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