Gestin Y, Vainio A, Pégurier A M
Montpellier Cancer Institute Val d'Aurelle, France.
Acta Anaesthesiol Scand. 1997 Jan;41(1 Pt 1):12-7. doi: 10.1111/j.1399-6576.1997.tb04607.x.
Fear of infections and other complications has made many clinicians avoid intrathecal application of morphine in chronic cancer pain. However, recent comparative studies show that, in long-term treatment, intrathecal morphine administration may give a more satisfactory pain relief with lower doses of morphine and fewer side-effects than epidural administration. In Montpellier Cancer Institute, first cancer pain patients received long-term intrathecal morphine as early as in 1979, and since then more than 400 patients have been treated.
In 1991-1994, 50 patients having refractory cancer pain were treated with a continuous intrathecal infusion of morphine using an external pump with patient-controlled boluses. In this retrospective study, the outcome of these 5602 days of morphine therapy will be analysed. The treatment consisted of a lateral puncture technique, strictly aseptic conditions during catheter insertion and changes of pump reservoirs, and effective prevention of side-effects.
The average duration of intrathecal infusion was 142 (7-584) days. The mean starting dose, 2.5 (0.4-8.3) mg/day, increased to a mean final dose of 9.2 (1-94) mg/day, the average dose being 5.4 (1-23) mg/day. During the treatment period, no clinically detectable infections and no respiratory depression occurred. Leakage of cerebrospinal fluid followed by post-spinal headache occurred in only 6 patients who received a temporary external catheter: the lateral lumbar puncture technique seemed to protect from this complication in long-term treatment. The patients stayed at home, coming to agreed control visits only at 4-6 week intervals, using a telephone-telefax service for emergencies.
Long-term intrathecal morphine infusion seems to provide satisfactory analgesia, few side-effects and a high degree of patient autonomy.
对感染及其他并发症的担忧使得许多临床医生避免在慢性癌痛患者中鞘内注射吗啡。然而，近期的比较研究表明，在长期治疗中，鞘内注射吗啡相较于硬膜外注射，能以更低剂量的吗啡实现更满意的疼痛缓解，且副作用更少。早在1979年，蒙彼利埃癌症研究所就有首批癌痛患者接受了长期鞘内吗啡治疗，自那时起已有400多名患者接受了该治疗。
1991年至1994年，50例难治性癌痛患者使用带患者自控追加剂量的外置泵持续鞘内输注吗啡进行治疗。在这项回顾性研究中，将分析这5602天吗啡治疗的结果。治疗包括侧方穿刺技术、导管插入及更换泵储液器时严格的无菌条件，以及有效预防副作用。
鞘内输注的平均持续时间为142（7 - 584）天。平均起始剂量为2.5（0.4 - 8.3）毫克/天，最终平均剂量增至9.2（1 - 94）毫克/天，平均剂量为5.4（1 - 23）毫克/天。治疗期间，未发生临床可检测到的感染及呼吸抑制。仅6例接受临时外置导管的患者出现脑脊液漏并继发脊髓穿刺后头痛：侧方腰椎穿刺技术似乎可在长期治疗中预防此并发症。患者居家，仅每4 - 6周定期前来商定的复诊，通过电话 - 传真服务处理紧急情况。
长期鞘内吗啡输注似乎能提供满意的镇痛效果、较少的副作用及高度的患者自主性。
