求救！肝腹水晚期如何止痛！

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婆婆今年69岁，血吸虫性肝硬化腹水晚期，腹水有十年了，7年前门脉高压吐血过，近一年来连续入院多次，治疗效果很不好，腹水还是逐步加重，现在家中休养，这几个月来经常腹痛腹胀难忍，痛的呼天抢地或失声痛哭，让人看了很不忍，用过芬必得止痛，没有效果，请教老师，有什么止痛药能对腹水引起的腹痛腹胀有效呢？
       还有她还有心衰，肾功能不全。谢谢了！

liver411

麻醉止痛药物会对肝病末期患者造成肝昏迷等脑性疾病，且对肝脏不好。

如果是腹水肿胀造成的疼痛应该每周数次到就近医院抽取腹水（如果利尿剂+低盐饮食不能控制话），减轻患者痛苦。之后在医院给与白蛋白治疗等维持。

如系肝硬化门脉高压造成之腹水，应该考虑分流，比如，远端脾肾分流，或评估肝脏实质状况考虑TIPS。虽然TIPS可能会造成肝性脑病或肝脏衰竭，但是相对患者末期，肝脏中度衰竭，提高生命质量之评估和比较后，如划算也值得（也就是，虽然长远看有损害，但是因为患者已接近末期，让其安逸更重要）。另外分流也能减低出血几率。

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谢谢411老师，牺牲中午休息时间为病人答疑解惑，很感动，祝您一生平安！

liver411

或，有条件，让医院/医生在腹腔肚子上留一个永久性引流管子（permanent peritoneal catheter ），控制性不间断引流。这个做法在肝癌晚期腹水患者中有不错的效果，相对不疼痛，容易介入，患者容易接受，副作用相对低。患者只需要按照指导清除引流液，定期到医院更换插入部位，保持清洁等。这样患者生命质量能够提高很多。也能减低/少每周多次的腹腔穿刺引流步骤。

Peritoneal catheter for continuous drainage of ascites in advanced cancer patients
Journal        Supportive Care in Cancer
Publisher        Springer Berlin / Heidelberg
ISSN        0941-4355 (Print) 1433-7339 (Online)
Issue        Volume 16, Number 8 / August, 2008
Category        Short Communiation
DOI        10.1007/s00520-008-0453-x
Pages        975-978
Subject Collection        Medicine
SpringerLink Date        Thursday, May 01, 2008
       
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Short Communiation
Peritoneal catheter for continuous drainage of ascites in advanced cancer patients

Sebastiano Mercadante1 Contact Information, Giuseppe Intravaia1, Patrizia Ferrera1, Patrizia Villari1 and Fabrizio David1
(1)          Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy

Received: 14 January 2008  Accepted: 3 April 2008  Published online: 1 May 2008
Abstract
Introduction  Advanced cancer patients with refractory ascites do not often respond to dietary sodium restriction and diuretics. While paracentesis is effective, the condition invariably recurs, necessitating repeated procedures. A continuous peritoneal drainage by an indwelling catheter has been reported to be hugely beneficial symptomatically, avoiding the hazards and disadvantages of multiple repeated procedures and direct and indirect costs.
Materials and methods  Forty patients with advanced cancer patients admitted to an acute pain relief and palliative care unit, who presented symptomatic ascites, were recruited for continuous drainage of peritoneal fluid. A central venous catheter set for Seldinger technique was used. Technical failure was defined as an unsuccessful drainage of fluid through the catheter. Immediate and late complications, including hypotension, haemorrhage, tube blockage, dislodgment and sepsis were recorded. Record of daily drainage during admission were noted. At time of discharge, patients were asked to rate their global symptom burden as improved, unchanged or worsened. The follow-up was performed with frequent phone contacts or day-hospital admission in case of problems.
Results  The mean patients’ age was 68 years, and 21 were men. Patients were receiving unsuccessfully a mean dose of furosemide of 32 mg/day. The technique was not painful and was easily accepted by patients. Insertion was technically successful in almost all patients. Mean admission time was 5.5 days (range 2–14), and the mean drained volume during admission was 8,499 ml (range 800–20,700), 2,850 ml (300–4,200) being drained on the first 24 h. No immediate complications were recorded. Six patients died during admission. The mean survival was 38.9 days (range 1–120). Of the 34 patients who were discharged home, 22 patients stated that symptom burden had improved, while in 10 patients symptom burden did not change or worsened, probably due to the advanced status of diseases and multiple contributing factors. Five, two, and one patients required skin sutures at 1, 2 and 3 months, respectively. About one third of patients had mechanical problems, some of them requiring a catheter replacement. No infection was recorded.
Conclusion  In conclusion, a permanent peritoneal catheter was a valuable method to remove abdominal fluids and reduce symptom burden attributable to ascites and was also easy to use at home. Complication rate was acceptable and balanced by the benefits of the technique which avoided frequent paracentesis and associated complications.

Keywords  Malignant ascites - Paracentesis - Peritoneal drainage - Palliative care

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麻醉止痛药物会对肝病末期患者造成肝昏迷等脑性疾病，且对肝脏不好，这点也知道，其实也就是想减轻点病人的痛苦，到这个时候多活一天活一个月意义不大了。因为心衰，每次挂蛋白后就会喘得厉害（医院说是呼吸衰竭），还有就是挂了蛋白就不能睡只能坐了。

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原帖由 liver411 于 2010-5-10 12:48 发表
或，有条件，让医院/医生在腹腔肚子上留一个永久性引流管子（permanent peritoneal catheter ），控制性不间断引流。这个做法在肝癌晚期腹水患者中有不错的效果，相对不疼痛，容易介入，患者容易接受，副作用相对低。患者只需要按照指 ...

这个方法不错，可以试试，谢谢了！