Page 63 - 2022-36-中国全科医学

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analgesia. Objective To investigate the efficacy and safety of PCIA with hydromorphone，sufentanil or morphine in treatment of
refractory cancer pain with dysphagia. Methods A total of 102 patients with refractory cancer pain and dysphagia were selected
from Department of Oncology and Hospice Care Center of the Second Hospital of Wuhan Iron and Steel（Group）Corporation
from May 2020 to January 2022，and equally divided into hydromorphone PCIA group，sufentanil PCIA group and morphine
PCIA group single-blindly and randomly．The Numerical Rating Scale（NRS）score，the frequency of episodes of breakthrough
pain，the Morphine Equivalent Daily Dose（MEDD），Pittsburgh Sleep Quality Index（PSQI）score，Cancer Quality of Life
Questionnaire Core 30（QLQ-C30）score and the incidence of adverse reactions were compared among the three groups before
and after treatment. Results The participants included 51 males and 51 females，with an average age of（60.2±6.3）years.
There were no statistical differences in sex ratio，average age，degree of pain，NRS score，MEDD，distribution of primary
cancer type，pain type and TNM classification of cancers among the three groups（P>0.05）. The NRS score and the frequency
of episodes of breakthrough pain in three groups deceased significantly after treatment（P<0.05）. The type and time of treatment
had interactive effects on both the NRS score and the frequency of episodes of breakthrough pain（P<0.05）. The type of treatment
produced main effect on the NRS score and the frequency of episodes of breakthrough pain，so did the time of treatment（P<0.05）.
The NRS score and the frequency of episodes of breakthrough pain of hydromorphone PCIA group were significantly lower than
those of each of other two groups after 24 hours or 72 hours of treatment（P<0.05）. Morphine PCIA group had higher NRS score
than other two groups（P<0.05），and had higher frequency of episodes of breakthrough pain than hydromorphone PCIA group
（P<0.05）after one-week treatment. Morphine PCIA group had higher NRS score and frequency of episodes of breakthrough
pain than each of other two groups after two-week or one-month treatment（P<0.05）. After one-month treatment，all groups
demonstrated increased MEDD and decreased PSQI（P<0.05）. In particular，morphine PCIA group had higher MEDD than
other two groups（P<0.05）. Sufentanil PCIA group had higher MEDD than hydromorphone PCIA group（P<0.05）. Morphine
PCIA group had higher PSQI score than other two groups（P<0.05）. All groups demonstrated increased score of each item of the
QLQ-C30（P<0.05）. In particular，morphine PCIA group ranked bottom in terms of the score of each item of the QLQ-C30
（P<0.05）. The emotional function score of sufentanil PCIA group was significantly lower than that of hydromorphone PCIA
group（P<0.05）. The incidence of adverse reactions had no significant differences among the three groups after one-month
treatment（P>0.05）. Conclusion For patients with refractory cancer pain and dysphagia，hydromorphone and sufentanyl were
superior to morphine for PCIA in terms of reducing pain and the frequency of episodes of breakthrough pain，improving quality of
sleep and life. But hydromorphone was superior to sufentanyl in quick onset，and effective improvement of emotion with reduced
dose of opioid and without increased incidence of adverse reactions.
【Key words】 Cancer pain；Analgesics，opioid；Hydromorphone；Sufentanil；Morphine；Comparative effectiveness
research；Refractory cancer pain；Dysphagia；Patient-controlled intravenous analgesia；Randomized controlled trial

癌痛是一种令人痛苦的症状，随着癌症的进展，疼 的生活质量 ［6］ 。患者静脉自控镇痛（patient-controlled
痛的频率和强度往往会增加。晚期癌症患者疼痛的患病 intravenous analgesia，PCIA）能保持达到止痛所需的最
率高达 90%，其中 30%~50% 为中、重度疼痛 ［1］ 。世 低血药浓度，通过“背景输注 + 患者自控”模式，可实
界卫生组织（WHO）的癌症三阶梯止痛法是目前首选 现持续有效镇痛，同时将阿片类药物的过量、不足和毒
的止痛方案。在临床实践中，该方案在最初控制轻、中 性风险降至最低，避免阿片类药物的延迟给药 ［2，7］ 。
度癌痛方面有效且迅速 ［2］ ，在 80% 以上的癌痛患者中 PCIA 近年来被广泛用于晚期癌痛的治疗 ［8］ ，已有研究
有效，但仍有 10%~20% 的中、重度癌痛患者并不能通 证明氢吗啡酮、舒芬太尼在癌痛患者中的镇痛效能均优
过其有效缓解疼痛或因不可耐受的副作用而中断治疗导 于吗啡 ［9-10］ ；但在比较氢吗啡酮、舒芬太尼的镇痛效
致疼痛加剧 ［3-4］ ，即为难治性癌痛。癌痛药物治疗基 能上得出的结论却不一致，有研究认为氢吗啡酮明显优
本原则首选口服给药，但难治性癌痛患者常伴有口服困 于舒芬太尼 ［11-13］ ，也有研究认为无明显差异 ［2，14］ ，
难（如：吞咽困难、恶心呕吐、消化道出血或因大量口 且目前尚无研究探讨氢吗啡酮与舒芬太尼在难治性癌痛
服阿片类药物导致严重胃肠道反应），增加了治疗难 合并口服困难患者 PCIA 中的疗效比较。因此，本研究
度，且由于爆发痛频繁发作，频繁口服或注射短效镇痛 对 102 例难治性癌痛合并口服困难患者进行随机对照试
药物时间延迟易引发患者的焦躁情绪 ［5］ ；持续的疼痛 验，综合比较氢吗啡酮、舒芬太尼及吗啡 3 种强阿片类
给患者带来身体及精神上的双重痛苦，高达 20% 的癌 药物在 PCIA 中的疗效及安全性，以期为难治性癌痛合
症患者会出现抑郁，未缓解的剧烈疼痛严重影响患者 并口服困难患者提供更优的镇痛治疗方案。