植入性鞘内给药系统输注吗啡治疗晚期胰腺癌顽固性疼痛患者的护理

目的探讨晚期胰腺癌顽固性疼痛患者姑息治疗中使用植入性鞘内给药系统输注吗啡的护理经验。方法对12例晚期胰腺癌患者行植入性鞘内给药系统输注吗啡镇痛;同时行规范化疼痛管理,加强并发症的护理、心理护理及健康教育。结果 NRS评分从(7.00±0.74)分下降至(2.75±0.75)分;爆发痛从(4.67±0.78)次/d下降至(1.25±0.97)次/d;恶心呕吐、便秘、过度镇静、尿潴留发生率明显下降。结论对晚期胰腺癌顽固性疼痛患者给予植入性鞘内给药系统输注吗啡镇痛效果较好,不良反应少,有助于减轻患者的痛苦。     

鞘内药物输注系统用于癌痛治疗时患者和药物的选择

背景 应用鞘内药物输注系统(intrathecal drug delivery systems,IDDS)是目前癌痛介入治疗的有效方法之一.选择合适的患者和镇痛药物,以及有效的管理是获得良好效果的基础.虽然国际上有相关共识和指南,但关于癌痛患者和药物的选择尚无定论. 目的 通过文献检索和阅读,综述最新关于晚期癌痛患者IDDS镇痛治疗时患者和药物的选择的观点,旨在为临床实践提供新的方法和思路. 内容 随着鞘内镇痛药物和管理的进展,目前认为预期寿命小于3个月的患者也可应用IDDS;植入前测试在癌痛患者并非必须；药物的选择主要取决于病因是神经病理性、伤害性或者混合性疼痛；加强鞘内镇痛初期和换药时的监测. 趋向 肿瘤的日趋高发及其治疗后生存率的提升使得癌痛发生日趋增多,WHO癌痛三阶梯指南不能完全有效镇痛,而应用IDDS将是顽固性癌痛治疗的不可替代的方法之一.     

鞘内药物输注系统永久植入术治疗顽固性疼痛病人18例

鞘内药物输注系统(IDDS)永久植入术治疗顽固性疼痛病人18例,其中晚期癌痛病人13例,非癌痛病人5例.首先行筛选试验,随后行IDDS永久植入术.癌痛病人采用视觉模拟评分(VAS评分)及QLQ-C30生活质量评分(QLQ-C30)法,非癌痛病人采用VAS评分法,评价疼痛程度,记录副作用及并发症的发生情况,癌痛病人随访至死亡,非癌痛病人均获得随访至今.术后所有病人经短期鞘内给药量调整后,VAS评分降低,癌痛病人QLQ-C30评分升高.部分病人出现恶心呕吐、便秘、尿潴留、皮肤瘙痒、镇静过度等,约1周均明显缓解,无持续残留症状.术中拔除穿刺针时误割断鞘内导管1例;导管与泵的金属接口过度磨擦至导管破裂,出现渗液1例;术后出现低颅压2例,脑脊液渗漏1例,右小腿后外侧持续性神经病理性疼痛1例,无伤口感染、裂开、愈合不良,无导管渗漏、破裂、异位、折叠、被结扎或肉芽肿形成,无泵翻转、位置异常等,设备本身无故障出现.

Abstract：

From November 2003 to May 2010, intrathecal drug delivery system (IDDS) was implanted in 18 patients with chronic intractable pain. Analgesia was provided with morphine. Thirteen patients suffered from late stage cancer and 5 from diseases other than cancer. VAS score was used to measure intensity of pain in all 18patients. QLQ-C30 score was used to evaluate quality of life in cancer patients. The patients were followed up for 3-62 months in 5 non-cancer patients. All 13 cancer patients died at 57 days-10 months after operation. VAS scores were significantly decreased and QLQ-C30 scores increased by intrathecal administration of morphine. Side effects developed in all patients to some extent including nausea, vomiting, constipation, urinary retention, pruritus and over-sedation and vanished in a week. Intrathecal catheter was cut while being pulled out of the needle in 1 patient. Two patients developed low intracranial pressure after operation. Cerebrospinal fluid leakage occurred in 1 patient. One patient developed neuropathic pain in the posterolateral side of right leg.     

鞘内药物输注系统永久植入术治疗顽固性疼痛病人18例

鞘内药物输注系统(IDDS)永久植入术治疗顽固性疼痛病人18例,其中晚期癌痛病人13例,非癌痛病人5例.首先行筛选试验,随后行IDDS永久植入术.癌痛病人采用视觉模拟评分(VAS评分)及QLQ-C30生活质量评分(QLQ-C30)法,非癌痛病人采用VAS评分法,评价疼痛程度,记录副作用及并发症的发生情况,癌痛病人随访至死亡,非癌痛病人均获得随访至今.术后所有病人经短期鞘内给药量调整后,VAS评分降低,癌痛病人QLQ-C30评分升高.部分病人出现恶心呕吐、便秘、尿潴留、皮肤瘙痒、镇静过度等,约1周均明显缓解,无持续残留症状.术中拔除穿刺针时误割断鞘内导管1例;导管与泵的金属接口过度磨擦至导管破裂,出现渗液1例;术后出现低颅压2例,脑脊液渗漏1例,右小腿后外侧持续性神经病理性疼痛1例,无伤口感染、裂开、愈合不良,无导管渗漏、破裂、异位、折叠、被结扎或肉芽肿形成,无泵翻转、位置异常等,设备本身无故障出现.     

鞘内药物输注系统永久植入术治疗顽固性疼痛病人18例

鞘内药物输注系统(IDDS)永久植入术治疗顽固性疼痛病人18例,其中晚期癌痛病人13例,非癌痛病人5例.首先行筛选试验,随后行IDDS永久植入术.癌痛病人采用视觉模拟评分(VAS评分)及QLQ-C30生活质量评分(QLQ-C30)法,非癌痛病人采用VAS评分法,评价疼痛程度,记录副作用及并发症的发生情况,癌痛病人随访至死亡,非癌痛病人均获得随访至今.术后所有病人经短期鞘内给药量调整后,VAS评分降低,癌痛病人QLQ-C30评分升高.部分病人出现恶心呕吐、便秘、尿潴留、皮肤瘙痒、镇静过度等,约1周均明显缓解,无持续残留症状.术中拔除穿刺针时误割断鞘内导管1例;导管与泵的金属接口过度磨擦至导管破裂,出现渗液1例;术后出现低颅压2例,脑脊液渗漏1例,右小腿后外侧持续性神经病理性疼痛1例,无伤口感染、裂开、愈合不良,无导管渗漏、破裂、异位、折叠、被结扎或肉芽肿形成,无泵翻转、位置异常等,设备本身无故障出现.     

鞘膜腔内药物注射疗法的并发症

小儿鞘膜积液及腹股沟斜疝是小儿外科常见疾病,一般不能自愈。鞘状突高位结扎术效果可靠,手术简单易行。但因家长惧怕手术,近年又有药物注射治愈的报道,使部分患儿     

鞘内注射干扰素和地塞米松治疗狂犬病的护理

７例狂犬病患者经鞘内注射干扰素和地塞米松治疗后，存活１例，另６全铁生存时间较未行鞘内注射者明显延长，未发现狂犬病院内感。在护理时应把住３关（１）严密隔离，严格消毒；（２）术中密切配合；（３）加强病情监护及做好自身保护。     

鞘内置管脑脊液置换与反复腰穿放脑脊液分别鞘内注药治疗结核性脑膜炎的疗效比较

目的探讨鞘内置管脑脊液置换与反复腰穿放脑脊液分别鞘内注药治疗结核性脑膜炎的疗效。方法在常规综合治疗的基础上,对照组采用反复腰穿放脑脊液并鞘内注药,观察组采用鞘内置管脑脊液置换加鞘内注药。结果观察组总有效率（93.1%）明显高于对照组（73.0%）（P〈0.01）;观察组脑脊液压力恢复正常和住院时间均明显短于对照组（P〈0.01）;对照组不良反应（5例）明显多于观察组（0例）（P〈0.05）。结论相比反复腰穿放脑脊液,鞘内置管脑脊液置换疗效高,疗程短,不良反应少,值得临床推广应用。     

鞘内注射尿激酶治疗脊髓蛛网膜粘连

目的:观察尿激酶对脊髓蛛网膜粘连的疗效。方法:鞘内注射尿激酶后观察病人的肌力减退、感觉障碍和脑脊液成分的变化。结果:肌力减退9例中改善6例,无变化3例;麻木感减轻8例;大小便障碍5例中好转4例;脑脊液蛋白增高8例(P<0.05),随访半年平均恢复正常,其他成分无明显变化。结论:鞘内注射尿激酶可较明显改善脊髓蛛网膜粘连所致的神经功能障碍。     

产后慢性泌尿生殖疼痛的危险因素分析

目的 探讨产后慢性泌尿生殖疼痛(chronic urogenital pain,CUP)相关性盆底肌损伤的主要危险因素.方法 选取2018年5月至2020年4月产后42 d至6个月于我院盆底康复中心行产后随访并诊断为CUP的患者120例为研究对象(CUP组),以同期来我院行产后随访无盆底功能障碍性疾病的妇女100例为对...     

Influence of a latent period in QALY analysis: pilot study of intrathecal drug delivery systems for chronic non-malignant pain

Cost effectiveness of a treatment is an important factor in decision making in the United Kingdom. Preceding most interventional health care treatments there is a waiting period between decision and procedure where health care costs may be lessened. Intrathecal drug delivery systems (IDDS) are a recognised pain management therapy for chronic non-malignant pain. To our knowledge, the period of time between being placed on a waiting list for IDDS and the implant (latent period) has not been taken into consideration for cost effectiveness analysis. A retrospective longitudinal analysis of all pain related costs for a period no less than 4 years was undertaken by assessment of medical records of 12 consecutive patients implanted with IDDS for chronic non-malignant pain. The total cost of patient care for 2 years before latent, the latent period itself and 2 years after the implant of an IDDS was computed, according to the National Health Service tariff. An EQ-5D questionnaire was filled by all participants before and after IDDS implant. Total costs were converted to cost per day for comparison with latent period. The average duration of the latent period was 263 ± 176 days (range 3-489). The cost of conventional treatments during the pre-implant phase excluding the latent period was significantly higher (M = ￡ 5,005.86, SE = ￡ 918.56) compared with the costs of the same phase including the latent period (M = ￡ 4,086.35, SE = ￡ 959.09, t(11) = 2.23, p = 0.05, r = 0.56). The cost per day changed significantly over the different periods (χ(2)(2) = 24.00, p < 0.05). The variability and significantly lower costs of the latent period may influence cost effectiveness evaluations and consequently decision making, if not considered. Further studies analysing the influence of a latent period on the cost effectiveness of other treatments are warranted.     

Clinical experience using intrathecal (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I)

BACKGROUND AND AIM: To date, there is no reliable method for treating the severe pain and for modifying the natural evolution of CRPS-I. Therefore, we explored the effect of long-term IT bupivacaine infusion (with or without buprenorphine) on this syndrome. PATIENTS AND METHODS: (a) Patients: two women and one man, 25, 31 and 42 years old, with CRPS-I of the lower (n=2) or upper (n=1) extremity lasting for 4 and 5 months, and 14 years. (b) INTERVENTIONS: insertion of externalized IT catheters; IT infusion of buprenorphine 0.015 mg/ml and bupivacaine 4.75 mg/ml (n=1), or only bupivacaine 5 mg/ml (n=2) from external electronic pumps. RESULTS: The IT treatment lasted for 172, 282 and 668 days. The mean/maximal daily doses of the IT bupivacaine were 39/66, 55/80 and 69/125 mg, respectively. The pain intensity decreased from VASmean =7+/-1 to VASmean =2+/-2. None of the patients had regression of allodynia, edema, and trophic disturbances in the affected extremities. In 2 patients, the IT treatment did not prevent spread of the disease to the opposite extremity or the occurrence of phantom pain and stump allodynia after amputation. The IT catheters were withdrawn as being no longer needed: in 2 patients 56 and 458 days after amputation of the involved extremity, and in another one before replacement of the IT bupivacaine infusion with epidural dorsal column stimulation (EDCS). After termination of the IT treatment, the patients were observed for 1437, 1575, and 2689 days (until September 1, 1998). At that date, all the patients were alive, and still affected by their CRPS-I, either in the amputation stump (n=2), and/or in the opposite or remote extremities (n=2); further, two were unemployed and one worked for 75% of the time. One of them was taking up to 1500 mg of slow-release morphine to cope with pain. CONCLUSION: The IT pain treatment with bupivacaine (with or without buprenorphine) alleviated the "refractory" pain, but affected neither the associated symptoms and signs of the CRPS-I, nor its natural evolution. Thus, the IT treatment cannot be recommended in preference to other pain treatment regimens for CRPS-I.     

Perioperative management of patients with an intrathecal drug delivery system for chronic pain

The use of intrathecal medications in the treatment of chronic pain is becoming more commonplace. As such, the incidence of encountering patients receiving therapy via an intrathecal drug delivery system in the perioperative period will also increase. In this case series, we discuss anesthetic management and postoperative analgesic issues in three patients with indwelling intrathecal drug delivery systems placed for treatment of chronic pain.     

Effect of intrathecal tramadol administration on postoperative pain after transurethral resection of prostate

Background. Tramadol administered epidurally has been demonstratedto decrease postoperative analgesic requirements. However, itseffect on postoperative analgesia after intrathecal administrationhas not yet been studied. In this double-blind, placebo-controlledstudy, the effect of intrathecal tramadol administration onpain control after transurethral resection of the prostate (TURP)was studied. Methods. Sixty-four patients undergoing TURP were randomizedto receive bupivacaine 0.5% 3 ml intrathecally premixed witheither tramadol 25 mg or saline 0.5 ml. After operation, morphine5 mg i.m. every 3 h was administered as needed for analgesia.Postoperative morphine requirements, visual analogue scale forpain at rest (VAS) and sedation scores, times to first analgesicand hospital lengths of stay were recorded by a blinded observer. Results. There were no differences between the groups with regardto postoperative morphine requirements (mean (SD): 10.6 (7.9)vs 9.1 (5.5) mg, P=0.38), VAS (1.6 (1.2) vs 1.2 (0.8), P=0.18)and sedation scores (1.2 (0.3) vs 1.2 (0.2), P=0.89). Timesto first analgesic (6.3 (6.3) vs 7.6 (6.2) h, P=0.42) and lengthof hospital stay (4.7 (2.8) vs 4.4 (2.2) days, P=0.66) weresimilar in the two groups. Conclusion. Intrathecal tramadol was not different from salinein its effect on postoperative morphine requirements after TURP. Br J Anaesth 2003; 91: 536–40     

肝切除术后慢性疼痛的影响因素

目的：探讨肝切除术后慢性疼痛（CPSP）的影响因素。
方法：选择2019年6月至2021年5月择期行肝切除术的患者110例,男91例,女19例,年龄≥18岁,BMI 15～30 kg/m²,ASA Ⅱ或Ⅲ级。根据术后3个月是否诊断CPSP将患者分为两组：非CPSP组和CPSP组。单因素分析后将差异有统计学意义的指标纳入多因素Logistic回归,分析肝切除术CPSP的影响因素。采用回归系数以及常数项构建肝切除术CPSP的预测模型,绘制受试者工作特征（ROC）曲线并计算曲线下面积（AUC）,采用Hosmer-Lemeshow进行拟合优度检验。
结果：有42例（38%）患者肝切除术后发生CPSP。多因素Logistic回归分析显示,BMI≥25 kg/m²是发生CPSP的保护因素,手术时间≥3 h、术后1 d白细胞计数≥13×10⁹/L、术后24 h VAS疼痛评分≥4分是发生CPSP的危险因素。建立的预测模型的AUC为0.86,敏感性73.8%,特异性79.4%,Hosmer-Lemeshow拟合优度检验提示模型区分度和校准度均较好。
结论：BMI≥25 kg/m²是肝脏切除术发生CPSP的保护因素,手术时间≥3 h、术后1 d白细胞计数≥13×10⁹/L、术后24 h VAS疼痛评分≥4分是肝脏切除术发生CPSP的危险因素。     

脊柱侧弯矫形术患者术后慢性疼痛的危险因素

目的 探讨脊柱侧弯矫形术患者术后慢性疼痛(CPSP)的危险因素,并建立预测模型。方法 回顾性分析2017年1月至2020年9月择期行后入路脊柱侧弯矫形术206例患者资料,男88例,女118例,ASAⅠ—Ⅲ级,根据术后3个月是否发生CPSP将患者分为两组：CPSP组(n=76)和无CPSP组(n=130)。收集术前、术中和术后资料,并通过电话随访获取患者CPSP以及术后3个月并发症(如内固定松动、连接棒断裂、螺钉拔出等)的发生情况。采用多因素Logistic回归分析CPSP的危险因素并建立预测模型。结果 有76例(36.9%)患者发生CPSP。多因素Logistic回归分析显示：术前VAS疼痛评分>3分(OR=5.794,95%CI 2.224～15.097,P<0.001)、融合椎体数增加(每增加1个单位,OR=1.525,95%CI 1.256～1.853,P<0.001)、术后72 h VAS疼痛评分>3分(OR=3.022,95%CI 1.360～6.715,P=0.007)以及术后3个月内有并发症(OR=5.424,95%CI 1.058～27.800,...