氢吗啡酮鞘内自控镇痛治疗难治性癌痛的临床研究及对患者免疫状态的影响

发布时间：2018-03-09 12:32

本文选题：鞘内输注　切入点：难治性癌性疼痛　出处：《青岛大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:观察鞘内氢吗啡酮自控镇痛治疗难治性癌性疼痛的临床疗效及对患者免疫状态的影响。方法:选取自2016年1月到2016年12月之间因癌性疼痛来我院就诊,经常规口服吗啡(每日剂量超过200mg),疼痛控制效果仍不理想(VAS5),预计生存期1月的癌性疼痛患者40例。对患者进行完善的评估与相关检查包括:患者意识水平、心肺功能、肝肾功能、凝血功能、脊椎CT或MRI检查等,以排除手术禁忌及确定是否存在穿刺困难。准备完善后于手术室行C型臂引导下的鞘内输注港植入术,采用C型臂定位L3/4间隙,在C型臂引导下进行穿刺置管,穿刺成功后根据患者病变情况将导管头端置于与患者疼痛部位相应的椎体平面。在C型臂引导下进行鞘内置管,避免导管在鞘内打折、绕圈。于腋前线平肋弓处切开皮肤,钝性分离皮下组织用于埋置输液港,采用专用隧道针自穿刺点到输注港埋置处(腋中线平肋弓水平)做一皮下通道,将鞘内导管与输液港相连接,采用无损伤蝶形针连接PCA镇痛泵进行鞘内输注,鞘内输注开始后停止其他口服镇痛药物。检查并记录癌性疼痛患者接受鞘内治疗前(T_0)、鞘内治疗后1天(T_1)、鞘内治疗后1周(T_2)VAS疼痛评分、淋巴细胞亚群CD3~+、CD4~+、CD8~+、CD4~+/CD8~+、NK细胞活性变化;记录鞘内镇痛前(T_0)、及鞘内镇痛后1周(T_2)的SF-36生活质量(QOL)评分、SDS抑郁评分;观察并记录鞘内镇痛、后患者便秘、恶心呕吐及尿潴留等并发症的发生率。本研究使用SPSS19.0软件进行数据分析,相关计量资料采用均数±标准差(x±s)表示,鞘内镇痛前后数据资料的比较采用两独立样本均数的t检验,计数资料的比较采用卡方检验,P0.05为差异有统计学意义。结果:所有癌痛患者均成功进行了鞘内输注港植入术,并在生存期内完成了随访,所有数据纳入统计学分析。经过患者术前与术后相关观察指标数据的对比,发现患者在给予氢吗啡酮鞘内自控制痛后,VAS疼痛评分明显降低(P0.01);鞘内氢吗啡酮镇痛术后1周(T_2)SF-36生活质量(QOL)评分较鞘内镇痛前(T_0)有明显改善(P0.01);氢吗啡酮鞘内镇痛术后1周(T_2)SDS抑郁评分较鞘内镇痛前(T_0)有改善(P0.01);在鞘内氢吗啡酮输镇痛后1天(T_1)患者T细胞亚群CD3~+、CD4~+、CD4~+/CD8~+以及NK细胞水平较术前(T_0)口服吗啡时降低(P0.05);在氢吗啡酮鞘内输镇痛后1周(T_2)患者T细胞亚群CD3~+、CD4~+、CD4~+/CD8~+以及NK细胞水平较术前(T_0)口服吗啡时有显著改善(P0.05);在氢吗啡酮鞘内自控输注镇痛术后1周(T_2)患者便秘、恶心呕吐并发症的发生率较术前(T_0)显著降低(P0.01)。鞘内置入术后患者出现尿潴留3例,出现术后头痛2例,均于术后3天内好转,所有患者在随访期内未出现患者感染事件。结论:氢吗啡酮鞘内自控镇痛治疗难治性癌性疼痛较口服吗啡相比能明显改善患者疼痛,改善癌痛患者的抑郁状态及生活质量,改善患者的免疫状态,降低患者便秘、恶心呕吐的发生率。
[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 卤standard deviation (x 卤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.
【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R730.5

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