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首页> 外文期刊>Prescrire international >Analgesia for terminally ill adult patients. Preserve quality of life.
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Analgesia for terminally ill adult patients. Preserve quality of life.

机译：成人绝症患者的镇痛。保持生活质量。

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摘要

Adequate pain management is crucial in maintaining the best possible quality of life for terminally ill patients. This article examines pain management in the palliative care setting, based on a review of the literature using the standard Prescrire methodology. Accurate pain evaluation, preferably by the patient, is essential for guiding treatment decisions. Some causes of pain are amenable to specific treatments. The expected benefits and harms of the various treatment options and procedures must be weighed on a case by case basis. Quality of life should always be the first priority. The World Health Organization has developed a "three-step analgesic ladder", based on the use of increasingly potent analgesics: step I analgesics include paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs); codeine is the standard step II analgesic; and morphine is the standard step III analgesic. Fentanyl is an alternative to morphine. The daily morphine dose must be determined for each patient. Morphine titration starts with oral doses given every 4 hours, but additional doses can be taken every hour if necessary. Total consumption is then used to calculate the dose required the following day. A sustained-release product can be used to reduce the number of doses required when a consistently effective daily dose has been established. When patients are unable to take morphine orally, it can be given by subcutaneous injection, and by subcutaneous or intravenous infusion. Pumps allow the patient to self-administer morphine on demand. Fentanyl transdermal patches are another option for stable pain. Immediate-release oral forms and injections are useful for preventing or treating breakthrough pain. If morphine requirements increase during treatment, the most likely explanations are exacerbations of pain or an excessively long interval between doses. Pharmacological tolerance and psychological dependence are rare during palliative care. In case of renal failure, the morphine dose should be reduced, sustained-release morphine should be replaced by immediate-release morphine, or morphine should be replaced by fentanyl, as fentanyl metabolism is only slightly affected by renal function. The main adverse effects of morphine are constipation, nausea and vomiting. Drowsiness is frequent at initiation of treatment. Respiratory depression is rare when morphine is introduced gradually. Tricyclic antidepressants and carbamazepine have acceptable harm-benefit balances in patients with neuropathic pain. Cannabinoids are another option but have not been adequately assessed. Localised refractory pain may respond to local anaesthesia, chemical neurolysis or surgical ablation. In practice, it is best to allow patients to control their own analgesic consumption, within limits set by their physician to prevent dosing errors.
机译：充分的疼痛管理对于维持绝症患者的最佳生活质量至关重要。本文根据对使用标准Prescrire方法进行的文献回顾，研究了姑息治疗环境中的疼痛管理。准确的疼痛评估（最好由患者评估）对于指导治疗决策至关重要。某些引起疼痛的原因可以接受特殊治疗。必须根据具体情况权衡各种治疗方案和程序的预期收益和危害。生活质量应该始终是第一要务。世界卫生组织在使用日益有效的止痛药的基础上，开发了“三步止痛梯”：第一步止痛药包括扑热息痛和非甾体抗炎药（NSAIDs）;可待因是标准的第二步镇痛药;吗啡是标准的第三步镇痛药。芬太尼是吗啡的替代品。必须确定每位患者的每日吗啡剂量。吗啡滴定开始于每4个小时口服一次剂量，但如有必要，可以每小时增加一次剂量。然后将总消耗量用于计算第二天所需的剂量。当确定了持续有效的每日剂量后，可以使用缓释产品减少所需的剂量数量。当患者无法口服吗啡时，可以通过皮下注射，皮下或静脉内输注来服用。泵使患者可以根据需要自行服用吗啡。芬太尼透皮贴剂是稳定疼痛的另一种选择。速释口服形式和注射剂可用于预防或治疗突破性疼痛。如果在治疗期间吗啡需求量增加，则最可能的解释是疼痛加重或给药间隔过长。姑息治疗期间很少有药理耐受性和心理依赖性。如果发生肾功能衰竭，应减少吗啡剂量，应将速释吗啡替换为速释吗啡，或将吗啡替换为芬太尼，因为芬太尼的代谢仅受肾脏功能的轻微影响。吗啡的主要不良反应是便秘，恶心和呕吐。开始治疗时经常出现嗜睡现象。逐渐引入吗啡会导致呼吸抑制。三环类抗抑郁药和卡马西平在神经性疼痛患者中具有可接受的伤害效益平衡。大麻素是另一种选择，但尚未得到充分评估。局部难治性疼痛可能对局部麻醉，化学神经溶解或手术消融有反应。在实践中，最好让患者在医生设定的限制范围内控制自己的镇痛药用量，以防止剂量错误。

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