菜鸡 发表于 2024-9-6 11:19:06

癌性爆发疼痛的诊断与治疗

癌性爆发疼痛诊断和治疗 直播时间:2024-9-4直播链接:https://live.yuaigongwu.com/live/page/1395960559?v=1725548740000主讲人:王昆记录:靓超,阿亮审核:鹰版 典型爆发痛案例:“患者晚上有时候会被痛醒,但是一会就过去了。” Ø 什么是“爆发痛”?爆发痛是指持续稳定控制疼痛的基础上出现的瞬间加剧的疼痛。平均发作时间30分钟。                                                       data:image/png;base64,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
Ø “爆发痛”的特点:1.       在持续疼痛基础上瞬间加重,远超出患者的背景痛水平,持续时间平均为30分钟;2.       发作快,一般在3分钟内痛感达到最大;3.       疼痛剧烈,92%以上是重度疼痛;4.       不可预测,无法提前药物干预;5.       对于爆发痛使用即释药片,缓解程度不高,大概只有50%;6.       与慢性痛(位置及痛感)没有必然联系;7.       大多数骨转移类爆发痛存在诱发原因(身体活动、体位改变等),而脏器爆发痛一般没有诱发原因;8.       出现爆发性疼痛后需要及时就医并对症治疗。 Ø“爆发痛”产生原因1.   事件性—与特定活动或事件相关1)          自愿行为引起:如运动、进食等;2)          非自愿行为引起:如肠痉挛等;3)          程序性:与诊疗相关,如伤口换药等。2.   自发性—无特定活动和诱因,不可预测3.   计量末期爆发痛(目前不归类为“爆发痛”),通常出现在下次长效镇痛药物之前,并可归因于长效药物计量不足,或给药间隔时间过长。 Ø “爆发痛”的药物治疗现状1.   药物种类1)       阿片类药物国内以口服即释吗啡为主(起效30-60分钟,较慢,起效时可能已基本过了爆发痛的持续时间,所以相对缓解程度不高);国外有“棒棒糖”(口腔内迅速崩解吸收),按压型皮肤贴剂,鼻喷剂以及雾化药(研究中);2)       非甾体药物;3)       抗惊厥药物。2.   给药途径1)    静脉给药---起效迅速,5分钟左右,适合住院病人;2)    皮下注射---较为常用,10-15分钟左右;3)    肌肉注射---增加局部刺激,长期反复应用存在吸收不佳,不推荐作为常用给药途径;4)    PCA泵推荐,适合住院病人。 Ø “爆发痛”治疗原则1.   全面评估,个体化治疗;2.   目标为降低爆发痛程度和次数,提高生活质量;3.   如有明确诱因,应以去除诱因的治疗为主;4.   对于难治性、难以去除诱因、自发性爆发痛,适量提高基础用药。 Ø 癌性爆发痛的微创介入治疗1.       粒子植入、瘤体物理或化学毁损---减少肿瘤对组织、脏器的损伤;2.       肋间神经毁损术、腹腔神经丛毁损术---截断神经通路;3.       骨水泥---改善组织结构功能;4.       PCA、鞘内镇痛泵---改变给药途径。 Ø答疑1.       对于计量末期疼痛,是否可以在计量末期使用即释片,而缓释片计量不变?答:不建议,可能导致镇痛效果不佳,可以考虑尝试缩短给药时间到8小时/次,或者适当提高缓释片用药剂量,或必要时联合其他辅助药物。2.       男72岁,肺腺癌,高血压,骨转移(部位:胸椎、肋骨、腰椎)、化疗(6周期培美曲塞+卡铂)后手术(肺部根治术+淋巴清扫),手术后放疗(胸部25次+腰椎16次),现在二线化疗(白紫+替雷利珠)高血压药:替米沙坦。疼痛情况:右肩胛骨辐射到右胳膊痛,6分,影响睡眠及进食,不吃止疼药就疼痛,疼起来浑身不舒服,皮肤和肌肉疼,右肩胛骨及右胳膊有灼烧和太阳暴晒后的火辣辣的疼。止痛药服用情况:主要服用奥施康定40mg/次,一天两次(9:00和21:00),服用后一个多小时才能有所缓解,约9小时后开始疼痛,临时服用路盖克2片(每片含对乙酰氨基酚500mg与酒石酸双氢可待因10mg)能短暂缓解疼痛服用奥施康定期间还服用过普瑞巴林75mg*2/次,一天2次,但效果不佳止痛药副作用:便秘和嗜睡问题:1)      每次疼痛服用奥施康定约10天后原剂量就不能很好的控制疼痛,需中途临时服用路盖克,请问是疾病进展导致还是耐药了?2)      如果需要控制疼痛是否需要增加阿片类止痛药计量,一次增加多少?3)      除了奥施康定,是否还可以选择其他长效止疼药物?能否推荐?
答:目前患者疼痛情况可能与其胸椎转移及锁骨上淋巴转移相关,具备神经病理性疼痛特点。患者目前出现计量末期疼痛,可以考虑缩短奥施康定给药时间,8小时服用一次,或者适当增加奥施康定计量到60mg/次,但是更推荐缩短给药时间。患者提到普瑞巴林效果不佳,但是临床上普瑞巴林对于神经病理性疼痛效果较好,普瑞巴林需要滴定,从最小剂量75mg/次,每日两次,逐渐加量,最高计量为600mg/日,同时需要注意的是,普瑞巴林的起效时间较慢,一般3-7日作为评估周期。患者提到是否更换为其他阿片长效用药,目前不建议。
3.       女32岁,鼻咽癌,全身多处骨转移,目前口服靶向药仑伐替尼。左边整个身体8分疼痛,爆发性疼痛的时候吗啡针都止不住。目前一天口服两颗40毫克的羟考酮缓释片(早上7点40mg,晚上7点40mg)。便秘,不排大便。目前疼痛控制不佳,考虑安装镇痛泵。问题:1)      镇痛泵的安装对病人身体情况是否有要求?是否有禁忌症和风险?2)      患者颈椎、胸椎、腰椎都有骨转移和骨质破坏,是否还能装鞘内镇痛泵?3)      看其他患者有联合用药的,请问非甾体抗炎药或者普瑞巴林这种药物,也可以放在镇痛泵中吗?答:膦酸盐类药物,在骨转移侵犯神经后,对止痛效果不佳,但是也需使用,降低骨破坏速度。对于椎体转移的患者,可以安装鞘内镇痛泵,但是需要保证穿刺的骨间隙正常,且骨转移未压迫神经,椎管通畅,脑脊液回流正常。目前鞘内镇痛泵有手持按键,可以在爆发痛时救援使用,但是爆发痛进展期,效果可能不佳,在身体允许的情况下,可以考虑其他介入手段。在用药的情况下可以尝试联合用药,非甾体药物、抗惊厥药物,或者在医生指导下使用糖皮质激素,都可以有效缓解疼痛。另外,对于阿片类药镇痛导致便秘,是最常见及顽固的副作用,无法通过时间缓解,且药物使用计量越大,便秘可能越严重,建议多吃菜多喝水,增加膳食纤维、补充肠道益生菌,有必要可以尝试服用食用油(蓖麻油?)。 4.       患者男,58岁,2023年2月诊断肺腺癌,骨转移、脑转移(2023年3月行伽马刀放疗后头部稳定但伴有周围脑组织轻度水肿),服用靶向药,伊班膦酸钠,2024年5月出现双腿背侧肌肉疼进一步检查:原发病控制稳定,排除原发病、头部、骨转移进展,肌酸激酶、肌电图、动静脉血栓、骨扫描、腰椎核磁、腰椎间盘、肌肉核磁、肌炎抗体、免疫均正常,找不到器质原因,不清楚是不是靶向药原因,阿美替尼换成伏美替尼之后没有改善,下肢肌肉疼痛,并且伴有脚麻、腿软无力的症状,7月份因为出现心烦躁乱,坐立不安,哭泣等症状,诊断焦虑抑郁后服用抗精神类药物(度洛西汀80mg+利培酮1ml+曲唑酮25mg,目前效果挺好);疼痛口服奥施康定20mg+普瑞巴林75mg每12小时1次,现疼痛症状较前明显好转,但双下肢仍然持续伴有腿麻、腿软情况,之前咨询您让排除脊髓脊柱的问题,做了全脊柱增强核磁显示未压迫脊髓神经,电解质钠132mmol/L,总蛋白56.8g/L,白蛋白36g/L精神症状目前好转,睡眠饮食均可。问题:1)      腿软、脚麻的原因目前该做的检查都做了,还能从哪方面排除?2)      奥施康定增加计量后,疼痛缓解,但是仍然非常麻,这种情况下还继续加量止痛药吗?服用10mg奥施康定和20mg奥施康定的时候,感受基本无差异,是否要减量到10mg?3)      想问针对患者腿软、脚麻还有什么治疗办法,是否有介入手段可以考虑?答:对于下肢的麻痛,考虑多是脊髓损伤,同时一些治疗用药也可能导致这个症状,脊髓的病变、脑转移脱落癌细胞到脊髓、供血问题;阿片类药物对脚麻腿软的症状效果很差,不建议再增加计量。目前患者这种情况有进一步发展到截瘫的风险,建议进一步排查处理。
页: [1]
查看完整版本: 癌性爆发疼痛的诊断与治疗