Author: CSD The First Affiliated Hospital of Guangzhou Medical University
This article is authorized by the author to be published by Yimaitong, please do not reprint without authorization.
1. Summary of medical records
The patient, a 55-year-old male, was admitted to the hospital with a history of liver disease for 30 years, liver cancer for 7 years, yellow urine and yellow eyes for 1 week.
30 years ago, the patient had fatigue and yellow urine without obvious causes, abnormal liver function in laboratory tests, positive HBsAg, and was treated with traditional Chinese medicine for liver protection, and then re-examined every year, and TBTL continued to fluctuate at 90~110μmol/L. Abdominal CT examination 7 years ago showed that the left lobe of the liver had a mass lesion with AFP of 393ng/mL, and hepatic arteriography was performed, and the diagnosis was primary liver cancer. 1 year ago, the patient had unprovoked sudden lumbar pain, lumbar spine MRI considered T10 Xu Mo nodules, metastases were not excluded, PET-CT showed right iliac bone, T10 metastases, liver cancer bone metastasis was considered, radiotherapy was performed in a tertiary hospital, during which a small amount of peritoneal effusion, diarrhea, leukocytopenia, acute attack of cholecystitis and other complications appeared, and improved after active treatment. 11 months ago, the bone scan showed multiple metastases of the left ilium, and the patient underwent bone radiotherapy again, the patient developed abdominal distension and was hospitalized in our hospital, considering the combination of ascites effusion and hypoproteinemia, and the ascites effusion subsided after treatment. After fever, diarrhea, etc., he was diagnosed with listeria infection, radiotherapy was stopped, and he was discharged after symptomatic supportive treatment such as anti-infection, immune regulation, sorafenib reduction, and leukocyte elevation. 4 months ago, he developed abdominal distension after radiofrequency ablation treatment of bone metastases in other hospitals, and his abdominal distension was relieved after self-administration of diuretics, and abdominal pain appeared. 3 months ago, he underwent two interventional treatments for bone metastases in a tertiary hospital, and after the operation, he developed abdominal distention, edema of both lower limbs, and abnormal liver function, and was discharged from our hospital for inpatient treatment. 1 week ago, it was found that the urine was yellow and the eyes were yellow and gradually worsened, accompanied by pain in the right lower limb, and he began to take oxycodone hydrochloride 20mg regularly for pain relief once a day, and the 24-hour pain score was 2 points, and he was admitted to the hospital for further examination and treatment.
Anamnesis: Anamnesis. Denial of a history of long-term heavy drinking, denial of a history of drug allergies.
Physical examination:
Body temperature 36.4°C, blood pressure 112/72mmHg, heart rate 82 beats/min, breaths 20 breaths/min, clear consciousness, weak spirit, positive palmar disease, unpalpated and enlarged superficial lymph nodes throughout the body, dull complexion, severe yellow staining of the skin and sclera, clear breath sounds in both lungs, no dry or wet rales heard, uniform heartbeat, no murmur, soft abdomen, suspicious full-abdominal tenderness, no rebound tenderness, negative Murphy's sign, no palpation of the liver and spleen under the costals, suspiciously positive moving dullness, mild edema of both lower limbs, negative neurological examination.
INVESTIGATIONS:
入院后化验：WBC 2.03x109/L，RBC 2x1012/L，Hb 67g/L，PLT 87x109/L，NE% 65.1%，CRP 83mg/L；肝、肾功能：ALT 10.1U/L，AST 10.2U/L，TBIL 221.4μmol/L，DBIL 212.3μmol/L，ALB 29.7g/L，BUN 10.22mmol/L，Cr 72μmol/L，GFR 99.84mL/（min·1.73m2），钾3.54mmol/L，钠135mmol/L，氯97.9mmol/L；血氨86μg/dL。 凝血项：PTA 83%。 HBV-DNA测定（进口）：未检测到。 血型O型，Rh（D）：阳性。
Diagnosis: Primary liver cancer stage III.a; metastases of thoracic vertebrae, bilateral iliacs, femur, lumbar 5 vertebrae; Hepatitis cirrhosis, decompensated, type B, peritoneal effusion, intra-abdominal infection, hypoproteinemia; dystrophic anemia, moderate; Pain.
Diagnosis basis: The patient was a middle-aged male with a history of hepatitis B for 30 years, and was clearly diagnosed with liver cancer by imaging and hepatic arteriography 7 years ago. Bone metastasis of liver cancer was found 1 year ago, and radiotherapy, radiofrequency ablation and interventional surgery were performed successively for bone metastases, and the condition improved transiently after surgery, but repeated liver damage, yellow urine, yellow eyes, jaundice was further aggravated by laboratory tests, and pain appeared, the patient suffered from hypoproteinemia, and there was ascites effusion and whole abdominal tenderness.
2. Treatment
Light diet, hepatoprotection, yellowing, diuretic, anti-infection and other treatments.
The patient started oral oxycodone hydrochloride extended-release tablets 20 mg outside the hospital, once a day, and began to have stable pain control, and from January 3, 2020, he intermittently complained of pain in the left lower limb, which was moderate pain, with an NRS score of 4 points, with an average interval of 4~5 hours, oral administration of aminophen oxycodone 5mg, and the NRS score could be reduced to 2 points after 1 hour, and long-acting oxycodone hydrochloride extended-release tablets 10mg, oral administration once every 12 hours, and 5mg of aminophen oxycodone every 6 hours, combined control of outbreak pain, Assess the patient's pain dynamically.
On January 4, due to the patient's stable pain control for 24 hours, he was converted to maintenance therapy with a total oral oxycodone amount of 40 mg equivalent to 24 hours, that is, oxycodone hydrochloride extended-release tablets 20 mg, orally once every 12 hours, and long-acting laxative with lactulose.
On January 20, the patient complained of pain in the left lower limb at 00:30 a.m., showing moderate pain, with an NRS score of 4, and was given 5 mg of aminophen oxycodone orally, and the NRS score dropped to 2 points after 1 hour; He complained of pain in the left lower limb again at night, and the NRS score was 5 points, and the 1-hour NRS score dropped to 0 points.
On January 21, the total equivalent dose of oxycodone in the previous 24 hours was 50mg once a day and converted to long-acting oxycodone hydrochloride extended-release tablets 20mg in the morning and 30mg in the evening, and was taken orally once every 12 hours, and the patients were monitored for no dizziness, drowsiness, nausea, vomiting, constipation, normal blood pressure, heart rate, and breathing.
On January 22, he had another outbreak of pain, and was given 5 mg orally with aminophen oxycodone, and the 1-hour NRS score dropped to 0.
On January 23, the painkiller was adjusted to oxycodone hydrochloride sustained-release tablets 30mg, oral pain relief once every 12 hours, the patient's pain control was stable, the NRS score was 2 points, there were no adverse drug reactions such as nausea, vomiting, dizziness, constipation, etc., and blood pressure, heart rate, and breathing were normal.
After that, the NRS score of the patients was 0~2 for 1 consecutive week, and the quality of life improved.
3. Case analysis
In this case, the patient had advanced liver cancer, and pain was the main factor affecting his quality of life. Health care providers should conduct a thorough and detailed assessment of the patient's pain, using extended-release opioids as the base drug, and in titration and in the presence of flare-up pain, an immediate-release opioid combined with acetaminophen can be given, the opioid dose can be titrated, and the equivalent dose of oral extended-release opioids can be switched to an equivalent dose of oral extended-release opioids after 24 hours.
Pain can cause great physical and mental pain to cancer patients, so pain treatment is an indispensable and important part of comprehensive cancer treatment. Pain is "an unpleasant sensory and emotional experience associated with tissue damage or underlying tissue damage" and is considered the fifth most important vital sign after heart rate, blood pressure, pulse, and respiration. Chronic pain is not only a symptom, but also a disease. Long-term painful stimulation can cause pathological remodeling of the central nervous system, leading to the progression of painful diseases and becoming more difficult to control. Early control of pain can prevent or delay the progression of this process.
The principle of comprehensive treatment should be adopted for cancer pain, according to the patient's condition and physical condition, quickly and effectively eliminate the pain, prevent and control the adverse reactions of drugs, reduce the pain and the psychological burden caused by the treatment, and strive to effectively relieve the patient's pain, while maintaining the patient's function and comfort.
Analgesic drug therapy: According to the World Health Organization (WHO) guidelines for "three-step analgesic treatment for cancer pain", the five basic principles for the use of analgesic drug therapy are as follows: (1) oral administration is the preferred route of administration; (2) Medication according to the ladder. A. Mild pain: NRS ≤ 3 points, non-steroidal anti-inflammatory drugs (NSAIDs) can be used, and if there are contraindications to the use of non-steroidal anti-inflammatory drugs, low-dose opioids can also be considered. B. Moderate pain: 3<NRS<7 points, weak opioids can be used, and strong opioids can also be used in small doses. C. Severe pain: NRS ≥ 7 points, strong opioids can be used, and non-steroidal anti-inflammatory drugs can be combined; (3) Medication on time; (4) Individualized drug administration and the development of individualized drug regimens; (5) Pay attention to specific details: closely observe the degree of pain relief and body reactions, pay attention to the interaction of drug combination application, and take necessary measures in time to reduce the adverse reactions of drugs as much as possible and improve the quality of life of patients.
Yimaitong is a professional online doctor platform, and the mission of the platform is to "sense the pulse of the world's medicine and help China's clinical decision-making". Yimaitong has a series of products such as "Clinical Guidelines", "Medication Reference", "Medical Literature King", "Yizhiyuan", "eYantong" and "ePulse", which fully meet the needs of medical workers in clinical decision-making, obtaining new knowledge and improving scientific research efficiency.
