- 期刊
Epidural Coadministration of Ketamine, Morphine and Bupivacaine Attenuates Post-herpetic Neuralgia - A Case Report
硬膜外合併給予克太明、嗎啡及麻佳因可減低帶狀疱疹後神經性疼痛－病例報告
摘要
The N-methyl-D-aspartate (NMDA) receptor system plays an important role in nociceptive signal modulation in the central nerve system. There is considerable evidence that NMDA receptor antagonists can abolish hypersensitivity of nociceptors in animal models. In this case report, we described a patient who suffered post-herpetic neuralgia with severe pain, allodynia, and hyperesthesia over right side T_2 to T_8 dermatomes. Treatment with conventional doses of non-steroid anti-inflammatory drug (NSAID), antidepressant, anticonvulsant and benzodiazepine failed to provide satisfactory pain relief. With the patient's consent, we administered subanalgesic doses of ketamine (10 mg), morphine (1 mg), and 6 ml bupivacaine (0.1%) through the thoracic epidural route. After the treatment, hyperalgesia and allodynia improved dramatically, and the receptive field also reduced. After four weeks' treatment, satisfactory pain relief was achieved with conventional analgesics treatment. The combination of relatively low doses of morphine, ketamine and bupivacaine epidurally provides effective pain relief in this case. The result strongly suggests a synergy from this combination that warrants a formal study of the dose-response relationship involved in this treatment and the mechanism by which this effect is achieved. This regimen provides a promising treatment for the neuropathic pain with limited side effects.
並列摘要
NMDA受體系統在中樞神經痛覺訊息調控上扮演重要之角色。許多證據顯示NMDA受體拮抗劑可防止痛覺受體之致敏化。本病例報告是一位23歲的年輕男性在帶狀疱疹感染後，在右側胸脊神經第二至第八皮節處產生嚴重之疼痛、感覺異常以及感覺過敏之現象。雖經長期之非類固醇抗發炎藥物、抗抑鬱劑、抗癲癇藥物及安眠鎮靜劑均無法達到滿意之止痛效果。經過病人之同意，我們放置一胸椎硬膜外導管，然後經由此導管給予克太明（10毫克）及嗎啡（1毫克）合併低濃度麻佳因（0.1％）6毫升，達到良好之止痛效果。經過四週之治療，病人可由原來使用之止痛劑（cabamazepine，tofranil，and benzodiazepine）達到滿意之止痛效。此一合併低劑量之克太明，嗎啡及麻佳因（0.1％）硬膜外注射可提供一滿意之止痛效果。此一結果強烈地顯示此一合併多重藥物產生一加成之止痛效果。此種止痛法值得進一步研究其作用機制，並將其推廣於臨床止痛之用。
延伸閱讀
- Hsiu, H. W., Shyang, Y. T., Hung, H. I., Yi, T. T., & Lin, G. S. (2018). 圍術期之止痛方試不應只有嗎啡類藥物－使用多模式止痛可改善疼痛控制、減少併發症、進而促進術後快速恢復. 疼痛醫學雜誌, 28(2), 23-34. https://www.airitilibrary.com/Article/Detail?DocID=10217959-201809-201904090011-201904090011-23-34
- 張天鈞（2001）。文獻選粹：利用脊髓腔內注射類固醇來治療帶狀疱疹後神經痛。當代醫學，(333)，534-534。https://doi.org/10.29941/MT.200107.0004
- Jean, W. H., Wu, C. C., Mok, M. S., & Sun, W. Z. (2005). Gabapentin治療帶狀皰疹後神經痛的起始劑量－一個藥物劑量反應研究. Acta Anaesthesiologica Taiwanica, 43(2), 73-77. https://www.airitilibrary.com/Article/Detail?DocID=02541319-200506-43-2-73-77-a
- Tan, P. H., Chia, Y. Y., Perng, J. S., Chou, A. K., Chung, H. C., & Lee, C. C. (1997). 使用嗎啡於間歇式硬脊膜外與病患自控式硬脊膜外術後止痛之比較. Acta Anaesthesiologica Sinica, 35(3), 149-154. https://www.airitilibrary.com/Article/Detail?DocID=P20170519003-199709-201904160020-201904160020-149-154
- Yeh, Y. L., Fan, S. Z., Chang, Y., & Wang, K. C. (2020). 以隨機對照試驗研究低濃度硬膜外羅派卡因結合吩坦尼用於生產止痛時所引起之交感神經阻斷作用. 輔仁醫學期刊, 18(2), 43-57. https://doi.org/10.3966/181020932020061802001