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財團法人天主教聖馬爾定醫院

財團法人天主教聖馬爾定醫院. 安寧療護暨癌症照護研習會. 癌末病患常見之症狀困 擾與處置. 蕭士銓 主任. Mucositis. 蕭士銓. 開場白. 黏膜炎為化療以及放射線治療在腸胃道，特別是口腔或口咽腔的黏膜所引起的傷害。 一般而言發生率約 40% 。 高劑量化療或頭頸部癌症放射線治療的病人是高危險群 。 黏膜炎會帶給病人痛苦疼痛，無法飲食，妨礙說話，造成感染，甚至造成治療中斷影響治療結果。. Causes of Mucositis in Cancer Patients. Radiation therapy :

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財團法人天主教聖馬爾定醫院

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  1. 財團法人天主教聖馬爾定醫院 安寧療護暨癌症照護研習會 癌末病患常見之症狀困 擾與處置 蕭士銓 主任

  2. Mucositis 蕭士銓

  3. 開場白 • 黏膜炎為化療以及放射線治療在腸胃道，特別是口腔或口咽腔的黏膜所引起的傷害。 • 一般而言發生率約40% 。 • 高劑量化療或頭頸部癌症放射線治療的病人是高危險群 。 • 黏膜炎會帶給病人痛苦疼痛，無法飲食，妨礙說話，造成感染，甚至造成治療中斷影響治療結果。

  4. Causes of Mucositis in Cancer Patients • Radiation therapy : • Mucositis usually appears by second week of radiation therapy (at dose of 2000 rad) • Mucositis intensifies may persist 2 to 3 weeks after completion of radiation. • Chemotherapy : • Early symptoms : increased sensitivity to hot/cold foods; intolerance to citrus fruits. • Oral mucositis may indicate ulceration of entire GI tract. • GVHD

  5. Chemotherapeutic Agents with a High Potential to Cause Stomatitis(I) Antimetabolites Antibiotics Cyclocytidine Actinomycin D Cytosine arabinoside Doxorubicin 5-Fluorouracil Bleomycin sulfate Floxuridine Daunomycin 6-Mercaptopurine Mithramycin Methotrexate Mitomycin C 6-Thioguanine Mitoxantrone

  6. Chemotherapeutic Agents with a High Potential to Cause Stomatitis(II) Plant AlkaloidsMiscellaneous Etoposide Hydroxyurea Vinblastine sulfate Procarbazine hydrochloride Vincristine sulfate Taxanes Paclitaxel Taxotere

  7. 過程 • 1.分四個時期 • 2.約在7天後開始 • 3.化療引起的潰爛90%侷限在非角質化黏膜 放射線引起的黏膜炎則不會 • 4.黏膜炎在化療結束後約二到三週會修復而放射線治療引起的粘膜炎可能延遲到六週才修復

  8. 黏膜炎病理機轉之1

  9. 黏膜炎病理機轉之2

  10. 黏膜炎病理機轉之3

  11. 黏膜炎病理機轉之4

  12. Grading system for mucositis :

  13. (I)

  14. (II)

  15. Management of Mucositis

  16. Management of Mucositis General measures : Serve food at room temperature, not hot.  Avoid heavily seasoned or acid foods (or any foods that trigger pain).  Avoid alcohol and tobacco.  Moisten foods with sauces; dry foods may be difficult for patient to swallow.  Chilled or frozen yogurt soothes oral mucosa and provides a high-protein snack.

  17. MAINTAIN CLEANLINESS AND PREVENT INFECTIONMAINTAIN INTEGRITY AND PROMOTE HEALING • Mouth care every 4 hours around the clock • Remove patient’s dentures, if present. • Brush the teeth with a soft-bristle nylon brush and a fluoridated sodium bicarbonate dentifrice within 30 minutes after eating and at bedtime. Brushing before meals can help stimulate the appetite. • Clean and massage the tongue and oral mucosa with a soft-bristle brush and sodium bicarbonate dentifrice after brushing or removing dentures. A sponge-tipped applicator can be used to clean the teeth and the tongue if brushing causes discomfort or bleeding.

  18. MAINTAIN CLEANLINESS AND PREVENT INFECTION MAINTAIN INTEGRITY AND PROMOTE HEALING • Rinse the mouth with one ounce of saline, salt and soda, tap water or 1.5% hydrogen peroxide for 1 to 2 minutes. If saline or peroxide is used, rinse with water to enhance mechanical cleansing and minimize aftertaste. • Remove and brush dentures within 30 minutes after eating and at bedtime, then soak dentures in 1.5% hydrogen peroxide for several minutes.

  19. MAINTAIN CLEANLINESS AND PREVENT INFECTION MAINTAIN INTEGRITY AND PROMOTE HEALING • Floss the teeth once daily after brushing. Omit flossing if it causes pain, if the platelet count is less than 40,000/mm3, or if the leukocyte count is less than 1500/mm3. • Use special precautions to prevent aspiration in the person with a compromised gag reflex. • Eat a high-protein diet with vitamin supplements.

  20. MAINTAIN CLEANLINESS AND PREVENT INFECTION MAINTAIN INTEGRITY AND PROMOTE HEALING • Apply agents to protect the mucosa and promote healing, such as substrates of antacids or sucralfate. • Orabase applied pen pc and hs to ulcerated areas. • Sucralfate 1-gm tabs : Crush and spread through mouth. • Sucralfate suspension : Swish for 2 minutes and swallow, pc and hs. (To prepare: Dissolve eight 1-gm sucralfate tabs in 40 ml of sterile water; add 40 ml of 70% sorbitol and shake; in a separate container,dissolve 3 Ensure falvor packs in 10 ml of water; add to drug mixture; water qs to 120ml.) • Vitamin E: Puncture capsule and apply directly on lesion.

  21. MAINTAIN CLEANLINESS AND PREVENT INFECTION MAINTAIN INTEGRITY AND PROMOTE HEALING • Maintain optimal fluid and nutritional intake while avoiding foods that are irritating. • Consult with the physician and nutritionist regarding the need for enteral or parenteral nutrition.

  22. PROMOTE COMFORT AND MINIMIZE PAIN(I) • Use topical anesthetics such as benzocaine or diclonine before eating and as needed to control pain. • Avoid irritants (e.g., alcohol and tobacco) • Use analgesics to control pain: 1.5 hours before meals; at regular intervals around-the-clock if pain is constant. • Xylocaine viscous 2% solution: Swish 15ml for 30 seconds, then spit out (q3h maximum).

  23. PROMOTE COMFORT AND MINIMIZE PAIN(II) • Analgesic cocktail: 1 to 2 tbsp 15 minutes ac and hs; hold for 2 minutes in mouth, then spit out. (To prepare: Maalox (antacid), 345 ml; xylocaine viscous, 79 ml; Benadryl Elixir, 47 ml.) • Choline salicylate (Teejel) or benzydamineHCl 5% (NSAID) applied to affected area (benzydamine is not currently available in the United States). • Avoiding thermally, mechanically, or chemically irritating foods.

  24. MANAGE INFECTION(I) • Monitor the patient’s temperature every 4 hours and report any elevation over 38°c. • Use local or systemic antibiotics,antifungals,and antiviral agents as prescribed. • Infections of the oral cavity can be bacterial, fungal, or viral in origin, and the antibiotic should be selected based on the causative organism. • Antibiotics can be applied topically in ointments (e.g., bacitracin or acyclovir), swishes or pastilles (e.g., nystatin), or troches (e.g.,clotrimazole).

  25. MANAGE INFECTION(II) • Sensitive,systemic antibiotics may also be indicated, especially in the immunocompromised individuals. • The prophylactic use of the antiviral agent acyclovir or antifungal agents is recommended in individuals who are seropositive to the herpes simplex virus and at high risk for immunosuppression, such as prior to a bone marrow transplant. Note: It is critical to perform an oral culture to identify the causative organism in immunosuppressed individuals.

  26. CONTROL BLEEDING • Monitor vital signs every 4 hours. • Assess platelet function from a complete blood count (CBC). • Inspect mucosa and report any bleeding. • Rinse mouth with ice water and/or apply pressure to an area of uncontrolled bleeding using a piece of gauze dipped in ice water or a wet tea bag that has been frozen. • Consult with the physician regarding the need for thrombin or aminocaproic acid (use with caution in persons with thrombocytopenia as disseminated intravascular coagulation may result).

  27. 總結 • 黏膜炎在癌症治療中常見，常帶來不良併發症，延長住院時間，增加醫療支出，甚至造成醫療中斷，病人死亡。 • 黏膜炎是一個上皮幹細胞複雜的生理病理交復作用的動態過程。 • 目前預防與治療上並沒有特別有效的方 法，不過許多的治療藥物正在進行臨床試驗。 • 單一藥物或單一處理步驟並不能滿足黏膜炎的病人必需事先歸劃針對個人需求處理

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