姑息关怀中的皮肤护理课件

1、姑息关怀中的皮肤护理Skin care in palliative care Dr. Z. ZyliczHospice in the WealdPembury, Tunbridge Wells, UK皮肤护理 Skin care 放射治疗过程中的皮肤护理 skin care during radiotherapy 皮肤瘙痒 / 瘙痒症 itchy skin / pruritus 蕈状瘤，出血 fungating cancer, bleeding 患处疼痛 painful wounds某些因素可加剧放疗后皮肤反应，包括： There are some things that can make t

2、he skin reactions to radiotherapy more severe. These include: 在接受放疗前曾行化疗，或放化疗同时进行 having chemotherapy before or at the same time as radiotherapy 体重超重 being overweight 合并其它疾病 （如糖尿病） having other health problems such as diabetes光敏感肤质 having sun-damaged skin 吸烟 Smoking化疗期间的皮肤护理Skin care during radiothe

3、rapy有证据表明以下措施可以帮助减低皮肤反应的严重程度 there is evidence that the following activities can help to reduce the severity of skin reactions: 选用温和的皂性溶液或清洁剂清洗皮肤 Wash: with a mild soap or cleansing agent 使用温和的的润肤霜增加皮肤湿度 Moisturise: with a light moisturising cream为了缓解症状病人能做些什么？ What can patient do to relieve symptom

4、s? 如果皮肤出现发红，发痒，变干，起水疱，医生（或护士）建议使用乳剂涂搽并加以敷料覆盖患处，以缓解症状，使病人感觉更舒适。 if skin becomes red and dry, itchy, or develops blisters, the doctor or nurse can recommend creams and dressings to help reduce your symptoms and make the patient more comfortable.对照组Control patientsn= 25试验组Skin moistured with 3% urea lo

5、tion, n=6350%病人出现I度皮肤损害50 % of patients with grade I damage 22 Gy26 Gy50%病人出现II度皮肤损害50% of patients with grade II damage34 Gy51 Gy出现III度皮肤损伤的病人的百分比% of patients suffering grade III damage56%22%选用3%尿素洗液作为增湿剂用于皮肤保护Skin protection by moisturing with 3% urea lotionMomm F et al. 2003瘙 痒 症Pruritus = itch癌

6、症相关的瘙痒症状Pruritic syndromes associated with cancer 胆汁淤积（胰源性，胆管癌，转移性肝癌） cholestasis (pancreatic, bile-duct cancer, liver mets)皮肤转移癌（乳腺癌） cutaneous mets (breast cancer)副癌综合征 Paraneoplastic合并皮肤病（类天疱疮） with dermatosis (parapemphigus) 不合并皮肤病 without dermatosis 瘙痒是全身性癌病罕见而重要的症状Pruritus, an uncommon but imp

7、ortant symptom of systemic carcinomaCormia FE. Arch Dermatol 1965;92:36-39. 肺癌 Lung乳腺癌 Breast 胃癌 Stomach 前列腺癌 Prostate 子宫肿瘤 Uterus 结肠癌 Colon 鼻咽癌 Nasopharynx 一名72岁的老年女性乳腺癌患者，7年前曾接受过乳癌手术治疗。现因肿瘤皮内扩散，而饱受极度疼痛和瘙痒的折磨。 Woman, 72 years of age, intracutaneous spread of breast cancer. Originally treated with s

8、urgery 7 years earlier. She experienced extreme pain and pruritus. 疼痛Pain 瘙痒Itch_ H O Handwerker疼痛 Pain 瘙痒 Itch内源性阿片类endogeneousOpioids+_ H O Handwerker疼痛 Pain 瘙痒Itch内源性阿片类endogeneousOpioids+_ H O Handwerker椎管内注射阿片类药物： Spinaopioids节段性或全身性； segmental or generalised;机理 ： mechanisms: 局部兴奋（5-HT）或激活2受体 l

9、ocal excitation (5-HT) or stimulation of 2receptors PGE ?治疗 ： treatment: 5-HT3 拮抗剂 5-HT3 antagonists 异丙酚 Propofol 2受体拮抗剂 2 antagonism ?双氯芬酸 diclofenac全身性应用阿片类药物 Systemic opioids:全身性 ； generalised; 机理 ： mechanisms: 非阿片类药物依赖的组胺释放，特异质反应，或阿片类药物介导的 opioid-independent histamine release, idiosyncratic reac

10、tion or opioid-mediated 治疗： treatment: H 1受体拮抗剂 H1 receptor antagonist 阿片类受体通道调节剂 opioid switch ?5-HT3 拮抗剂 5-HT3 antagonists,SSRI阿片类药物诱发的瘙痒 Opioid induced pruritus帕罗西汀治疗瘙痒症Paroxetine for pruritus初始剂量 5 -10 mg, 可增加到20mg qd, 与早饭同服 start with 5 or 10 mg, increase to 20 mg o.d. with breakfast如服药后出现恶心，可加

11、服恩丹西酮4mg，连用数天 for early nausea add ondansetron 4 mg for few days瘙痒症病人服用帕罗西汀后更容易出现恶心、镇静等副作用 in pruritic patients side effects of paroxetine appear more often (nausea, sedation)即使疾病进展或停止病因性治疗，作用仍可持续几个星期 The effect may last for a few weeks if disease will progress or causal treatment will be discontinu

12、ed. Zylicz et al. 2003帕罗西汀治疗瘙痒症的临床证据（1） Clinical evidence on paroxetine (i) 对抗瘙痒症状起效迅速 Works rapidly against pruritus药效可持续到停药4-8周以后 effect weans after 4-8 weeks服药后患者多出现精神性恶心和呕吐 more nausea and vomiting seen then in psychiatry部分副反应类似于阿片类药物撤药综合征的表现 part of the side effects similar to opioid abstinence

13、 syndrome对各种类型的瘙痒症均有效 effect not selective to one type of pruritus帕罗西汀治疗瘙痒症的临床证据（2） Clinical evidence on paroxetine (ii)帕罗西汀的治疗反应和其所致副反应是相伴出现的 Patients without adverse effects do not show antipruritic effect5羟色氨3受体拮抗剂可以迅速中止恶心和呕吐症状 5-HT3 antagonists able immediatly to block nausea and vomiting米氮平和帕罗西

14、汀联用对治疗有协同作用 combination of mirtazapine and paroxetine has positive effect瘙痒症治疗中的一般处理General measures in pruritus第一步Step 1第二步Step 2第三步Step 3纠正可逆因素例如：治疗皮肤病变Correct the correctable, e.g. treat skin disorders使用润肤剂q.d. t.i.d.Emollient cream o.d. t.id.口服镇静剂每天两次 如：苯唑安定或服用具有镇静作用的H1受体拮抗剂 如：扑尔敏 4mg 每天三次 Cb.d.

15、Sedative, e.g. benzodiazepine or sedative H1antihistamine e.g. chlorphenamine 4mg t.d.s. C尿毒症性瘙痒的治疗Uraemic pruritus第一步Step 1第二步Step 2第三步Step 3行紫外光疗 A 或 （如为 局限性）予0.025-0.075%辣椒碱软膏局部使用 q.d.b.i.d. AUVB phototherapy A or (if localised) capsaicin cream 0.025-0.075% o.d.-b.d. A纳曲酮 50mg q.d. ANaltrexone 50

16、mg o.d. A反应停 100mg q.n. AThalidomide 100mg o.n. A胆汁淤积性瘙痒的治疗Pruritus of cholestasis第一步Step 1第二步Step 2第三步Step 3纳曲酮 12.5-250mg q.d. ANaltrexone 12.5-250mg o.d. A利福平 75-300mg q.d. A或 帕罗西汀5-20mg q.d. ARifampicin 75-300mg o.d. A or paroxetine 5-20mg o.d. A 甲基睾丸酮 25mg 含化 q.d. C或其它同类药物 如：达那唑 200mg q.d. t.i.

17、d. UMethyltestosterone 25mg SL o.d. C oralternative, e.g. danazol 200mg o.d.-t.d.s. U何杰金病所致瘙痒的治疗Hodgkin lymphoma第一步Step 1第二步Step 2第三步Step 3甲基强的松龙 10-20mg t.i.d. CPrednisolone 10-20mg t.d.s. C西米替丁 800mg/24h BCimetidine 800mg/24h B米氮平 15-30mg q.n. UMirtazapine 15-30mg o.n. U真性红细胞增多症所致瘙痒的治疗Polycythaemi

18、a vera第一步Step 1第二步Step 2第三步Step 3阿司匹林 100-300mg q.d. AAspirin 100-300mg o.d. A帕罗西汀 5-20mg q.d. AParoxetine 5-20mg o.d. A镇静剂 如 苯唑安定 CSedative, e.g. benzodiazepine C椎管内注射阿片类药物所致瘙痒的治疗Spinal opioid-induced pruritus第一步Step 1第二步Step 2第三步Step 3鞘内注射布比卡因 ABupivacaine intrathecal A NSAID: 双氯芬酸 100mg 直肠给药或替诺昔康

19、 20mg 静脉用药 ANSAID: diclofenac 100mg PR A or tenoxicam 20mg IV A 恩丹西酮 8mg 静脉立即用药 AOndansetron 8mg IV stat A 痛性伤口的治疗Painful woundsC型纤维上可能存在阿片类受体C-fibres may contain opioid receptorsC. Stein 1995一位82岁的老年患者，因动脉血供不足，导致多处皮损，出现局部缺血性疼痛82 years old, poor arterial supply. Multiple wounds, ischaemic pain经过0.1%

20、吗啡的局部治疗，她的疼痛得到缓解，以上治疗同时也促进了她皮损的愈合。在我们拍下上面第二张照片的两周后，她不幸因败血症去逝。This patient was treated with topical morphine, 0,1%. This eased her pain and eased wound healing. Unfortunately she died of sepsis two weeks after the second photo. 痛性伤口的其他治疗方案Other options for the treatment of wound pain1-2%利多卡因局部治疗 Topi

21、cal lignocaine 1-2%如皮损处并发感染，应全身性使用抗生素抗感染 Systemic antibiotics if wound infected如皮损处并发厌氧菌感染，需采用0.75%灭滴灵局部治疗 Topical metronidazol 0,75% if wound infected with anaerobic bacteria皮损出血的处理Wound bleeding局部按压止血 Compression抗感染治疗（抗生素应用） Treating infection (antibiotics)患者需行凝血功能检查 Check blood coagulation寻找皮损的原因

22、 Is there anything damaging skin?在皮损周围健康的皮肤上涂抹氧化锌 Use zinc oxide on the healthy skin around the wound皮损处可行环卡普隆酸局部治疗 Topical cyclocaprone acid can be used 异味皮损的处理Smelling wound必要时全身性使用抗生素抗感染治疗 Use systemical antibiotics if necessary全身性应用灭滴灵 250mg t.i.d. Systemic metronidazol 250 mg t.d.s.0.75%灭滴灵局部治疗 Topical metronidazol 0,75%用自来水清洗患处（淋浴） Cleaning wounds with tapwater (shower)对房间内异味的处理 Take care of the smell in the room:除臭剂使用 Deodorants咖啡 Coffee保持房间通风良好 Ventilation结论（1） Conclusions (i)对放疗病人进行良好的护理对提高患者的生活质量是至关重要的，可使更多的患者能顺利完成整个治疗期。