Mercadante S
Department of Anesthesia and Intensive Care, Buccheri La Ferla Hospital, Palermo, Italy.
Reg Anesth Pain Med. 1999 Jan-Feb;24(1):74-83. doi: 10.1016/s1098-7339(99)90169-4.
Epidural and intrathecal techniques are well established for minimizing cancer pain. However, several issues remain unresolved.
A review of studies published in the last 10 years regarding neuraxial techniques in cancer pain management was made. The following issues were assessed: appropriate indications; techniques and delivery systems; conversion from systemic to spinal administration; route and modes of administration; choice of opioids, analgesic response and adverse effects of opioids; use of local anesthetics; use of adjuvants; technical complications; and possible problems only recognized at home.
Indications for the use of neuraxial opioids include patients treated with systemic opioids who received effective pain relief but with unacceptable side effects or unsuccessful treatment despite escalating doses with sequential, strong opioid drug trials. The choice of exteriorized or implanted delivery systems is based on different clinical considerations. The use of externalized, tunnelled intrathecal catheters has not been proven to be associated with higher rates of complications, and they may be easier to place and use at home in debilitated patients late in the course of their disease. Intrathecal administration has a lower incidence of catheter occlusion, lower malfunction rate, lower dose and volume requirements, and more effective pain control. Advantages of continuous infusion techniques are more evident when using local anesthetics, because intermittent administration of bupivacaine often results in motor paralysis and hemodynamic instability. Morphine appears to be the opioid of choice, and an epidural dose of 10% of the systemic dose is often used. Bupivacaine-induced adverse effects have been reported infrequently with bupivacaine doses less than 30-60 mg/d. Adjuvant drugs, such as clonidine and neostigmine, may further improve analgesia. Varied ranges of technical complication rates have been reported in the literature, with most being associated with epidural catheters.
A subcutaneous tunnelling and fixation of the catheter, bacterial filters, minimum changes of tubings, weekly exit site care, site protection, and monitoring for any signs of infection are suggested for advanced cancer patients. Areas still needing clarification include the optimum use of spinal adjuvants, the appropriate spinal morphine-bupivacaine ratio, methods to improve spinal opioid responsiveness, and long-term catheter management during home-care programs.
硬膜外和鞘内技术在减轻癌痛方面已得到充分确立。然而，仍有几个问题尚未解决。
对过去10年发表的关于神经轴技术在癌痛管理中的研究进行综述。评估了以下问题：合适的适应症；技术与给药系统；从全身给药转换为脊髓给药；给药途径和方式；阿片类药物的选择、镇痛反应及阿片类药物的不良反应；局部麻醉药的使用；辅助药物的使用；技术并发症；以及仅在家庭中才认识到的可能问题。
使用神经轴阿片类药物的适应症包括接受全身阿片类药物治疗但疼痛缓解有效但伴有不可接受的副作用或尽管依次进行强效阿片类药物试验且剂量递增但治疗仍未成功的患者。外置或植入给药系统的选择基于不同的临床考虑因素。使用外置的、经隧道的鞘内导管尚未被证明与更高的并发症发生率相关，并且对于疾病晚期虚弱的患者，它们可能更易于在家中放置和使用。鞘内给药的导管堵塞发生率较低、故障率较低、剂量和容量要求较低，且疼痛控制更有效。当使用局部麻醉药时，持续输注技术的优势更为明显，因为布比卡因的间歇性给药常常导致运动麻痹和血流动力学不稳定。吗啡似乎是首选的阿片类药物，硬膜外剂量通常为全身剂量的10%。当布比卡因剂量小于30 - 60mg/d时，布比卡因引起的不良反应报道较少。辅助药物，如可乐定和新斯的明，可能会进一步改善镇痛效果。文献报道的技术并发症发生率范围各异，大多数与硬膜外导管有关。
对于晚期癌症患者，建议对导管进行皮下隧道式固定、使用细菌过滤器、尽量减少管路更换、每周进行出口部位护理、保护部位以及监测任何感染迹象。仍需阐明的领域包括脊髓辅助药物的最佳使用、脊髓吗啡 - 布比卡因的合适比例、提高脊髓阿片类药物反应性的方法以及家庭护理计划期间的长期导管管理。
