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Palliative Care & Pain Management

Palliative Care & Pain Management
1. WHO¿¡¼­ ¸»ÇÏ´Â Palliative managementÀÇ Á¤ÀÇ¿Í ¸ñÇ¥
¨ç Á¤ÀÇ :curetive treatment¿¡ ¹ÝÀÀÇÏÁö ¾Ê´Â ÁúȯÀ» °¡Áø ȯÀÚ¿¡ ´ëÇÑ Àû±ØÀûÀÎ º¸»ìÇËÀ» ¸»ÇÑ´Ù.¿©±â¿¡´Â ÅëÁõÁ¶Àý ¹× ±âŸ ´Ù¸¥ Áõ»óÀÇ Á¶ÀýÀÌ Æ÷ÇԵǸç, ½É¸®Àû, »çȸÀû, Á¤½ÅÀû¹®Á¦µéµµ Áß¿äÇÏ°Ô ´Ù·ç¾îÁ®¾ßÇÑ´Ù.
¨è ¸ñÇ¥ : ȯÀÚ ¹× ±× °¡Á·À» À§ÇÑ ÃÖ´ëÇÑÀÇ °¡´ÉÇÑ »îÀ» ÁúÀ» Çâ»ó½ÃŰ´Â °ÍÀÌ ¸ñÇ¥À̸ç, ÁúȯÀÇ ÃʱâºÎÅÍ ´Ù¾çÇÑ ¸éµéÀ» °í·ÁÇÑ´Ù. Áï palliative management´Â
(¤¡) »îÀ» À¯Áö½Ã۸ç Á×À½À» Á¤»óÀûÀÎ °úÁ¤À¸·Î ¹Þ¾ÆµéÀÌ°Ô Çϸç
(¤¤) Á×À½À» ¾Õ´ç±â°Å³ª ¿¬±â½ÃŰÁö ¾ÊÀ¸¸ç
(¤§) ÅëÁõ¿ÏÈ­ ¹× ´Ù¸¥ ¾î·Á¿î Áõ»óµéÀ» °æ°¨½Ã۸ç
(¤©) ȯÀÚÀÇ Á¤½ÅÀû ¹× ½É¸®Àû Ãø¸é±îÁöµµ °í·ÁÇÏ´Â Ä¡·á¸¦ Çϸç
(¤±) ȯÀÚ°¡ Á×À» ¶§±îÁö Ȱ±âÀÖ°Ô »ì¾Æ°¥ ¼ö ÀÖ´Â ÁöÁö½Ã½ºÅÛÀ» Á¦°øÇϸç
(¤²) ȯÀÚÀÇ °¡Á·µé¿¡°Ôµµ ȯÀÚ°¡ ¾ÆÇµ¿¾È ±×¸®°í °¡Á·Áß ÀÏ¿øÀÌ Á״µ¥ ´ëÇÑ ½½ÇÄÀ» À̰ܳ¾ ¼ö ÀÖ´Â ÁöÁö½Ã½ºÅÛÀ» Á¦°øÇÑ´Ù.
¨é ¹æ»ç¼± Ä¡·á, Ç×¾ÏÄ¡·á, ¼ö¼úµîÀ» ÅëÇØ¼­ Áõ»ó¿¡ ´ëÇÑ Ä¡·á À̵æÀÌ ºÒÀÌÀÍÀ» ´É°¡Çҽô À̵鵵 palliative managementÀÇ ÀϺκÐÀ¸·Î »ç¿ëÇÒ ¼öÀÖ´Ù. Investigative procedure´Â ÃÖ¼ÒÈ­ ÇØ¾ßÇÑ´Ù. ¸¸¾à ȯÀÚ°¡ cancer therapy¿¡ Àß ¹ÝÀÀÇÑ´Ù¸é Áõ»ó°æ°¨¿¡ Å« µµ¿òÀ» ÁÙ ¼öÀÖÀ¸³ª, ȯÀÚ°¡ Àß ¹ÝÀÀÇÏÁö ¾Ê´Â °æ¿ì¶ó¸é ÀÌ·¯ÇÑ Ä¡·á°¡ ȯÀÚÀÇ »óÅÂÀ» ´õ¿í ³ª»Ú°Ô ¸¸µé ¼öÀÖ´Ù. Áï ȯÀÚÀÇ »óŸ¸ ¾ÇÈ­µÇ¸ç, Ä¡·áÈ¿°ú°¡ plateau¸¦ ÀÌ·ê½Ã´Â Ä¡·á¿¡ ´ëÇØ Àç°íÇØ¾ßÇÑ´Ù.
¨ê Palliative care¿¡¼­ ¿ä±¸µÇ¾îÁö´Â ±â¼úÁß Çϳª´Â noninstrucitveÇØ¾ßÇÑ´Ù´Â °ÍÀ̸ç, primary physicianÀ» Áß½ÉÀ¸·ÎÇØ¼­ specialist palliative medical and nursing staffÀÇ µµ¿òÀ» ¹Þ¾Æ¾ßÇÑ´Ù. ȯÀÚ°¡ chronic phase¿¡¼­ detoriotating late phase·Î ³Ñ¾î°¡´Â ½Ã±â¿¡´Â °©ÀÚ±â ȯÀÚÁÖº¯À» ¹Ù²Ù´Â °ÍÀº ÁÁÁö ¾ÊÀ¸¸ç, ȯÀÚ¿ÍÀÇ Ä¡·á°ü°è¸¦ Áö¼ÓÇÏ´Â °ÍÀÌ Áß¿äÇÏ´Ù.

2. palliative careÀÇ 4´Ü°è
¨ç Áø´Ü : ȯÀÚÀÇ Áõ»ó ¹× ´Ù¸¥ ¹®Á¦¸¦ È®ÀÎÇϰí, Á¾¾çÀÇ nature¿Í extent¸¦ È®ÀÎÇϸç Ȥ ´Ù¸¥ Áúȯ¿¡ ÀÇÇÑ Áõ»óÀº ¾Æ´ÏÁö »ìÆì¾ßÇϸç, ȯÀÚ°¡ óÇϰí ÀÖÀ¸¸ç ÁöÁö±â¹ÝÀ¸·Î »ï°íÀִ ȯ°æÀ» ÆÄ¾ÇÇϰí, ȯÀÚ°¡ °¡Áö°í ÀÖ´Â °³ÀÎÀû ¸ñÇ¥¸¦ ÆÄ¾ÇÇÑ´Ù. ¶ÇÇÑ È¯ÀÚ°¡ µ¿ÀÇÇÑ´Ù¸é ȯÀÚ°¡Á·°úÀÇ »óÈ£±³°¨µµ ÇÊ¿äÇÏ´Ù.
¨è °¡´ÉÇÑ Ä¡·á¹æ¹ýÀ» ¼³¸í: öÀúÇÑ Áø´Ü°úÁ¤À» °ÅÄ£ ÈÄ¿¡´Â Ä¡·á¹æ¹ýÀ» °áÁ¤ÇÏ°Ô µÈ´Ù.
¨é Ä¡·á¹æ¹ýÀÇ Àû¿ë : ȯÀÚÀÇ »îÀÇ Áú ¹× ÀÚÀ¯·Î¿î »îÀ» °í·ÁÇØ¾ßÇÑ´Ù. Áï ÀÇ·áÁø¿¡ ´ëÇÑ ÀÇÁ¸µµ, ȯÀÚÀÇ ½Ã°£, ȯÀÚÀÇ ÀÚº», ȯÀÚÀÇ ¿¡³ÊÁö¸¦ ÃÖ¼ÒÇѵµ·Î ¿ä±¸ÇÏ´Â ±×·± ¹æ¹ýÀ» ¼±ÅÃÇØ¾ßÇÑ´Ù. ÀÏ´Ü Ä¡·á¹æ¹ýÀ» °áÁ¤Çϸé ȯÀÚ¿¡°Ô ±×Ä¡·á¸¦ ÅëÇØ ¾òÀ» ¼ö ÀÖ´Â À̵æ°ú ºÒÀÌÀÍ¿¡ ´ëÇØ ¼³¸íÇØÁÖ¾î¾ßÇÑ´Ù.
¨ê Ä¡·á°á°úÀÇ Æò°¡ : ¾î¶°ÇÑ ÇüÅÂÀÇ monitoringÀº ¹Ýµå½Ã ÇÊ¿äÇѵ¥, ÀÌ´Â ´Ù¸¥ Ä¡·á¹æ¹ýÀÌ ³²¾ÆÀÖÀ½¿¡µµ ºÒ±¸Çϰí ȯÀÚÀÇ ½Ã°£ÀÌ È¿°ú ¾ø´Â Ä¡·á·Î ÀÎÇØ ³¶ºñµÇ¾îÁ®¼­´Â ¾ÈµÇ±â ¶§¹®ÀÌ´Ù. °´°üÀûÀÎ ±âÁØ¿¡ ÀÇÇÑ Ä¡·á°á°ú°¡ ÃøÁ¤µÇ¾îÁ®ÇÑ´Ù.

3.È¿°úÀûÀÎ Pain Management¸¦ À§ÇÑ ´Ü°èÀû ¹æ¹ý
-ÅëÁõÀº ½ÇÁ¦Á¸ÀçÇϴ ȤÀº °¡´É¼ºÀÌ ÀÖ´Â Á¶Á÷¼Õ»ó°ú ¿¬°üµÇ´Â ºÒÄèÇÑ °¨°¢È¤Àº Á¤¼­Àû °æÇèÀ̶ó°í Á¤ÀǵǾîÁø´Ù.(¡°unpleasant sensory and emotional experience associated with actual or poetential tissue damage) ÀÌ·¯ÇÑ ÅëÁõÀº ÁÖ°üÀûÀ̱⠶§¹®¿¡ ÃøÁ¤°ú Ä¡·á¿¡ ¾î·Á¿òÀÌ ÀÖ´Ù.
¨ç 1´Ü°è : ¸»ÃʷκÎÅÍÀÇ À¯ÇØÇÑ ÀÚ±ØÀ» ÁÙÀδÙ.
(¤¡) ÅëÁõÀÇ ½ÃÀÛ, ¾ç»ó, ºÐÆ÷, ¾ÇÈ­¿äÀÎ, ½Ã°£ °æ°ú¿¡ µû¸¥ º¯È­¾ç»ó, Ä¡·á¿¡ ´ëÇÑ ¹ÝÀÀ¿¡ ´ëÇÑ Á¤È®ÇÑ ¹®ÁøÀ» ÇÔÀ¸·Î½á ÅëÁõÀÇ ±âÀüÀ» ÆÄ¾ÇÇÑ´Ù.
(¤¤) À¯ÇØÇÑ ÀÚ±ØÀº soft-tissue distortion or infiltration, bone involvement, neural involvement, muscle spasm, tumor infection, intestinal colic, sheer pressureµî¿¡ ÀÇÇÒ ¼öÀÖÀ¸¸ç, Ä¡·á ¹æ¹ýÀº ÅëÁõÀÇ ¿øÀο¡ µû¶ó ´Ù¸£¸ç, radiation, chemotherapy, antibiotics, regional neural blockage, surgical approach°°Àº specific threrapy°¡ °í·ÁµÇ¾îÁ®¾ßÇÑ´Ù.
(¤§) Bone metastasis´Â Á¾Á¾ ¿°Áõ¹ÝÀÀÀ» ¾ß±âÇÏ¿© prostaglandinÀ» ¹æÃâÇÏ¿© ´Ù¸¥ Àڱؿ¡ ´ëÇÑ Á¶Á÷ÀÇ ¹Î°¨µµ¸¦ Áõ°¡½ÃŰ°Ô µÈ´Ù. ÅëÁõÀÌ bone meta¿¡ ÀÇÇÑ °ÍÀ̸ç, Ư¡ÀûÀÎ bone painÀ» º¸ÀϽô NSAIDs°°Àº prostaglandinÇÕ¼ºÀ» ¹æÇØÇÏ´Â ¾àÁ¦¸¦ »ç¿ëÇÑ´Ù. ÇÏÁö¸¸ ÀÌ·¯ÇÑ ¾àÀº peptic ulcer, excessive alcohol consumption, bleeding diatheses, ¾Æ½ºÇǸ° À̳ª À¯»ç¾àÁ¦¿¡ °ú¹Î¹ÝÀÀÀ» º¸À̴ ȯÀڵ鿡¼­´Â ÁÖÀǸ¦ ±â¿ï¿©¾ßÇÑ´Ù. NSAIDs¸¦ »ç¿ë¸øÇÒ ½Ã´Â acetaminophenÀ» »ç¿ëÇÒ ¼öÀִµ¥ ¸íÈ®ÇÑ ±âÀüÀº ¸ð¸£³ª peripheral action»Ó¾Æ´Ï¶ó central effectsµµ °¡Áö´Â °Í °°´Ù. AcetaminophenÀº alcoholic cirrhosis°°Àº liver damage°¡ ÀÖÀ» ½Ã´Â ¿ë·®À» °¨¼Ò½ÃÄѾßÇÑ´Ù.
(¤©) Acetaminophen ¹× NSAIDsµîÀº »ÀÀÌ¿ÜÀÇ Àå¼Ò³ª ¼ö¼ú ÈÄ ÅëÁõ°æ°¨¿¡µµ ÁÁ±â ¶§¹®¿¡ ´ëºÎºÐÀÇ °æ¿ì¿¡¼­ drug analgesia regimen¿¡ Æ÷ÇԵȴÙ. °æ±¸º¹¿ëÀÌ ¾î·Á¿î °æ¿ì´Â Á÷ÀåÀ» ÅëÇÑ ÀÌ¿ëÀÌ °¡´ÉÇÏ´Ù.
¨è 2´Ü°è:ÅëÁõ ¿ªÄ¡¸¦ Áõ°¡½ÃŲ´Ù.
- Æí¾ÈÇÔ, º¸»ìÇË, °ü½É, ±âºÐÀüȯ, ´Ù¾çÇÑ ½ÅüÀ̿ϵîÀº ÅëÁõ ¿ªÄ¡¸¦ Áõ°¡½Ã۸ç, ¿ì¿ï, ºÒ¾È, ¿Ü·Î¿ò, °í¸³°¨µîÀº ÅëÁõ¿ªÄ¡¸¦ °¨¼Ò½ÃŲ´Ù.
¨é 3´Ü°è: ÁÖÀDZí°í, Á¤È®ÇÑ ¾ÆÆí¼º ÁøÅëÁ¦ÀÇ »ç¿ë
(¤¡) codein,dextropropoxyphen°°Àº weak opoids ³ª, mophine°°Àº strong opioids°¡ acetaminophen À̳ª aspirineµî°ú º´¿ëµÇ¾î »ç¿ëµÇ¾îÁø´Ù. ÀÌ·¯ÇÑ opoids´Â µÇ´Âµ¥·Î »ç¿ëµÇ¾îÁö´Â °ÍÀÌ ¾Æ´Ï¶ó,±ÔÄ¢ÀûÀ¸·Î, Á¤È®ÇÑ ¿ë·®À¸·Î, ¹Ý°¨±â¸¦ °í·ÁÇÑ °íÁ¤µÈ °£°ÝÀ» µÎ°í »ç¿ëµÇ¾îÁ®¾ßÇÑ´Ù.
(¤¤) Morphin
? °¡Àå ÈçÈ÷ »ç¿ëµÇ¾îÁö´Â morphin sulfate soluttion´Â 4½Ã°£ °£°ÝÀ¸·Î ÁÖ¾îÁø´Ù. Áï 6AM, 10AM, 2PM, 6PM, 10PMÀ̸ç 10PM¿¡´Â 2¹èÀÇ ¿ë·®À» ÁØ´Ù.
? Àü¿¡ opoids¸¦ »ç¿ëÇÑ ÀûÀÌ ¾ø´Â °æ¿ì¶ó¸é °æ±¸·Î5-10mgÀ» ½ÃÀÛ¿ë·®À¸·Î Çϸç, Çã¾àÇϰųª °í·ÉȯÀÚµéÀº 3-5mgÀ» ½ÃÀÛ¿ë·®À¸·Î ÇÑ´Ù. ÀÌ·¯ÇÑ ¿ë·®¿¡ ÅëÁõ°æ°¨ÀÌ ¾øÀ¸¸é 1-2°£³»¿¡ ´Ù½Ã °°Àº ¿ë·®À» ¹Ýº¹ÇÑ´Ù.
? ´ÙÀ½ 24-48½Ã°£µ¿¾È¿¡´Â ¸Å 4½Ã°£ ¸¶´Ù Åõ¿©ÇÔÀ¸·Î½á ÀûÀýÇÑ ¿ë·®À» °áÁ¤Çϱâ À§ÇÑ ³ë·ÂÀ» ÇÏ°Ô µÈ´Ù. Correct dose´Â ¸Å 4½Ã°£¸¶´Ù 2mg¿¡¼­ 100mgÀ» ÃʰúÇÒ ¼ö ÀÖÀ¸³ª ´ë°³ÀÇ °æ¿ì 50mg¹Ì¸¸ÀÇ ¿ë·®À» ¸Å 4½Ã°£¸¶´Ù »ç¿ëÇÏ°Ô µÈ´Ù.
? Mophin sulfate solutionÀ» ÀÌ¿ëÇÏ¿© ÇÏ·ç¿¡ µé¾î°¡´Â ÃÑ·®À» °áÁ¤ÇÑ ÈÄ¿¡´Â controlled release morphin tabletsÀ» ÇÏ·ç 2¹ø³ª´©¾î 12½Ã°£ ¸¶´Ù ÁÙ¼öÀÖ´Ù. ÇÏÁö¸¸ ÀÌ·± tabletsÀº »óº¹ºÎ ÁúȯÀÌ ÀÖ¾î Èí¼ö°¡ ¾î·Æ°Å³ª Àå¿îµ¿ÀÌ ¾î·Á¿î ȯÀÚ´Â »ç¿ëµÇ¾î¼­´Â ¾ÈµÇ¸ç, À̰æ¿ì´Â aquous morphin or subcutaneous morphineÀ» »ç¿ëÇÏ´Â °ÍÀÌ Çö¸íÇÏ´Ù.
? IMÀ» ÁÖ¾î¾ß ÇÒ ÇÊ¿ä´Â ¾øÀ¸¸ç, IV·Î Áذæ¿ì´Â ªÀº ½Ã°£µ¿¾È¸¸ analgesiaÈ¿°ú¸¦ º¸ÀÌ°Ô µÈ´Ù. IV·Î »ç¿ëÇϸé À§ÇèÇØÁú ¼öÀÖ´Ù. ±×Áß ÇѰ¡Áö´Â acute tolerance°¡ »ý±ä´Ù´Â °ÍÀÌ´Ù. À̰æ¿ì IV route¸¦ Áß´ÜÇÏ°í ¸Å 4½Ã°£¸¶´Ù subcu·Î ÁÖ´Â °ÍÀÌ µµ¿òÀÌ µÉ ¼öÀÖ´Ù.
(¤§) Morphin toxicity
? MorphineÀ» »ç¿ëÇϰí ù 24½Ã°£ ³»¿¡ significant drowsiness or other morphine toxicity°¡ ¹ß»ýÇϸé morphin levelÀÌ Ä¡·á¿ë·®À» ÃʰúÇßÀ» °¡´ÉÀÌ ³ô´Ù.
? MorphinÀÇ active metaboliteÀÎ morphine6-glucuronide°¡ ´õ¿í °­·ÂÇÑ analgesia·Î ÀÛ¿ëÇϴµ¥, °£±â´ÉÀÌ ¼Õ»óµÈ °æ¿ì ÀÌ·¯ÇÑ morphin metabolites»ý¼ºÀÌ °¨¼ÒÇϰԵȴÙ. ½ÅÀå±â´É¿¡ ³ª»Ü½Ã´Â morphine metabolitesÀÇ ¹è¼³ÀÌ ¹æÇظ¦ ¹Þ°Ô µÇ±â ¶§¹®¿¡ À̰æ¿ì¿¡ ¿ë·®°¨¼Ò°¡ ÇʼöÀûÀÌ´Ù.
? ºÎÀÛ¿ëÀº ´ë°³ ÇÇÇÒ ¼ö ÀÖ´Â °æ¿ì°¡ ¸¹Àºµ¥ , °¡·É constipation°°Àº ºÎÀÚÀÛ¿ëÀº laxative¸¦ º´¿ëÇÔÀ¸·Î½á ´ë°³ ¿¹¹æÇÒ ¼ö ÀÖ´Ù. Nausea´Â ȯÀÚ°¡ ÀÌ¹Ì constipatedµÈ °æ¿ì°¡ ¾Æ´Ï¶ó¸ç µå¹®µ¥ serum levelÀÌ ±Þ¼ÓÈ÷ Áõ°¡ÇÏ´Â °æ¿ì¿¡ ¹ß»ýÇÒ ¼ö ÀÖ´Ù.
(¤©) Morphin¿¡ ´ëÇÑ ±Ù°Å¾ø´Â »çȸÀû Åë³ä(myth) : morphineÀ» ¿Ã¹Ù¸£°Ô »ç¿ëÇϱ⸸ ÇϸéÁ×À½À» ¾Õ´ç±â°Å³ª addictionÀ» À¯¹ßÇÏÁö ¾ÊÀ½¿¡µµ ºÒ±¸ÇÏ°í ¸¹Àº À߸øµÈ Åë³äÀÌ Á¸ÀçÇÑ´Ù. µû¶ó¼­ ´ÙÀ½ »çÇ×À» ÁÖÁö½ÃÄѾßÇÑ´Ù.
? ÁÖÀDZí°Ô ¿ë·®À» °áÁ¤ ¹× monitoring¿¡ ÀÇÇØ¼­ addictionÀº ¹ß»ýÇÏÁö ¾Ê´Â´Ù. (À°Ã¼Àû ÀÇÁ¸Àº ¹ß»ýÇÒ ¼öÀÖ´Ù.)
? morphineÀ» »ç¿ëÇÏ´Â °ÍÀÌ È¯ÀÚ°¡ Á׾°í ÀÖÀ½À» ÀǹÌÇÏ´Â °ÍÀÌ ¾Æ´Ï¶ó, ´ÜÁö Çö½ÃÁ¡¿¡¼­ ÅëÁõÀ» Á¶ÀýÇϱâ À§ÇÑ °¡Àå ÀûÀýÇÑ ¹æ¹ýÀÎ °ÍÀÌ´Ù. Opoids¸¦ »ç¿ëÇÒ Áö ¾ÈÇÒÁö¸¦ °áÁ¤ÇÏ´Â °ÍÀº ȯÀÚÀÇ ¿¹Èİ¡ ¾Æ´Ï¶ó ÅëÁõÀÇ Á¾·ù ¹× Á¤µµÀÌ´Ù.
? MorphineÀ» »ç¿ëÇÑ´Ù°í ÇØ¼­ ´ÙÀ½¿¡ Áúº´ÀÌ ´õ¿í ¾ÇÈ­µÇ¾úÀ» °æ¿ì¿¡ »ç¿ëÇÒ ¼ö ÀÖ´Â analgesia°¡ ¾ø´Ù´Â °ÍÀ» ÀǹÌÇÏ´Â °ÍÀÌ ¾Æ´Ï´Ù.
? MorphineÀ» ¿Ã¹Ù¸£°Ô »ç¿ëÇÏÁö ¾ÊÀ¸¸é tolerance°¡ ¹®Á¦°¡ µÉ ¼öÀÖ´Ù. ÇÏÁö¸¸ ¿Ã¹Ù¸£°Ô »ç¿ëÇϰí ÀÖ´Â µ¿¾È¿¡ ¿ë·®À» ¿Ã·Á¾ß ÇÒ Çʿ伺ÀÌ ¹ß»ýÇϸé ÀÌ´Â morphine effectiveness°¨¼Ò¶ó±â º¸´Ù´Â À¯ÇØÇÑ ÅëÁõÀÚ±ØÀÌ Áõ°¡ÇßÀ½À» ÀǹÌÇÏ´Â °ÍÀÌ´Ù.
(¤±) Other strong opoids
? Oxycodone: morphine°ú ºñ½ÁÇÑ ÁøÅëÀ» º¸À̸ç 5-15mgÀ» ¸Å 4-6½Ã°£¸¶´Ù ÁØ´Ù. ¾î¶²È¯ÀÚµéÀº morphinº¸´Ù oxycodone¿¡ ´õ tolerableÇÏ´Ù.
? Meperidine(pethidine): palliative care¿¡¼­ÀÇ °¡Ä¡´Â ¾ø´Ù. °í¿ë·®¿¡¼­ À̾àÀº nerotoxicÇϰí,ȯÀÚ¿¡°Ô distress¸¦ ´õÇÒ ¼öÀÖ´Ù.
? Heroin :morphine¿¡ ºñÇØ ³ªÀº °ÍÀÌ ¾øÀ¸¸ç, È¿´ÉÀº morphinÀ¸·ÎÀÇ metabolism¿¡ ´Þ·ÁÀÖ´Ù.
? Methadone: ¹Ý°¨±â°¡¸Å¿ì ±æ¸ç, ÁøÅëÈ¿°úº¸´Ù ÁøÁ¤ÀÛ¿äÀÌ ´õ¿í °­ÇÒ ¼öÀ־ »ç¿ëÀÌ ¾î·Æ´Ù.
? Fentanyl patch´Â ¾Ë¸Â°Ô »ç¿ëµÇ¾îÁö¸é ¸Å¿ì Æí¸®ÇÏ´Ù.
? Mild pain¿¡´Â codeineÀ» aspirine, acetaminophen ȤÀº dextropropoxypheneµî°ú º´¿ëÇÏ´Â °ÍÀÌ usefulÇÏ´Ù.
? Opoids´Â ÇÑ ¹ø¿¡ ÇѰ¡¾¿¸¸ »ç¿ëÇØ¾ßÇÏ¸ç µÎ°¡Áö ÀÌ»óÀ» º´¿ëÇÏ´Â °ÍÀº ¾î¸®¼®À¸¸ç, ºÒÇÊ¿äÇϰí, À§ÇèÇÒ ¼öÀÖ´Ù. OpoidsÀÇ Á¾·ù¸¦ ¹Ù²Ù´Â °ÍÀº Á¤´çÇÏ´Ù.
? Opoids¸¦ laxative¾øÀÌ »ç¿ëÇϸé fecal impaction¿¡ ÀÇÇÑ andominal pain°ú ÇÔ²² diarrhea, nausea, abdominal distension,µîÀÌ ¹ß»ýÇÑ´Ù.
? Bone meta, nerve irritation, extreme muscle spasmµî¿¡ ÀÇÇÑ ÅëÁõÀº opoids¿¡ ºñ±³Àû ¹ÝÀÀÇÏÁö ¾Ê´Â´Ù.
¨ê 4´Ü°è: neuropathic painÀ» ÀνÄÇϰí ÀûÀýÈ÷ Ä¡·áÇÑ´Ù.
(¤¡) Neuropathic painÀº Áúȯ ¹× Ä¡·á¿¡ ÀÌÂ÷ÀûÀ¸·Î ¸»ÃʽŰæÀÌ Àڱعްųª ÆÄ±«µÇ´Â °æ¿ì¿¡ ¹ß»ýÇÒ ¼öÀÖ´Ù.ÀÌ·¯ÇÑ ÅëÁõÀº burning, lancinating, anesthetic, hyperestheticÇÒ ¼öÀÖ´Ù.
(¤¤) ÅëÁõÀÌ neuropathicÇÏ´Ù¸é opoids¿¡ ´õÇÏ¿© tricyclic antidepressant, anticonvulsants, corticosteroids, oral anesthetic agentsµîÀ» °°ÀÌ »ç¿ëÇÏ°Ô µÇ³ª ÀϹÝÀûÀ¸·Î Á¶ÀýÀÌ ¾î·Æ´Ù. ÅëÁõ Á¶Àý Àü¹®Àǰ¡ ¸Å¿ì À¯¿ëÇÏ´Ù.regional blockade with local anesthetic techniques °¡ °¡Ä¡ ÀÖÀ» ¼öÀÖÀ¸¸ç, ¼±ÅÃµÈ È¯ÀÚ¿¡¼­´Â epidural morphine with marcaineÀÌ usefulÇÏ´Ù.

4. lumbosacral plexopathy
¨ç lumbosacral plexus´Â iliopsoa muscleÀÇ ³»Ãø, cervixÀÇ ¿ÜÃø¿¡ À§Ä¡ÇÏ´Â retroperitoneal space¿¡ Àֱ⠶§¹®¿¡ cervical tumors¿¡ ÀÇÇØ ħ¹üµÉ ¼öÀÖ°í, ȤÀº pelvic abscess or hematoma¿¡ ÀÇÇØ compressed µÉ ¼ö ÀÖ´Ù. ¹æ»ç¼± Ä¡·á¿¡ ÀÇÇÑ lumbosaral plexusÀÇ fibrosisµµ º¸°íµÈ ¹ÙÀÖ´Ù.
¨è PlexusÀÇ lumbar portion(L1-4)Àº femoral nerve¸¦ Çü¼ºÇϸç abdominal aortaÀÇ °¡Áö¸¦ ÅëÇØ blood supply¹ÞÀ¸¸ç, sacral portion(L5-S3)Àº sciatic nerve¸¦ Çü¼ºÇϸç internal iliac arteryÀÇ °¡Áö¸¦ ÅëÇØ blood supply¹Þ´Â´Ù.
¨é ÅëÁõÀÌ °¡Àå ¸ÕÀú ³ªÅ¸³ª´Â ¡ÈÄÀ̸ç, °¨°¢À̻󺸴٠¼öÁÖ È¤Àº ¼ö°³¿ù ¼±ÇàÇÑ´Ù, ÅëÁõÀº lumbosacral region¿¡ ±¹Çѵǰųª °¨°¢½Å°æÀÇ ºÐÆ÷¸¦ µû¶ó leg·Î ¹æ»çÇÒ ¼öÀÖ´Ù. ¾ç»óÀº sharp, shooting, lancinating, continuous burning dysesthesiaµîÀÌ´Ù.
¨ê L3-S3°¡ ħ¹üµÇ¸é foot-drop, pelvic tilt °¡ ÀÖÀ» ¼öÀÖÀ¸¸ç, thigh, sole, perineumÀÇ sensory loss°¡ ÀÖÀ» ¼ö ÀÖ´Ù. L1?4°¡ compressionµÇ¸é hip flexor weakness°¡ »ý±â°í climbing stepsÀÌ ¾î·Á¿öÁü°ú ÇÔ²² anterior thigh¿¡ paresthesia°¡ »ý±ä´Ù.
¨ë Ä¡·á
(¤¡) underlying cause¸¦ Á¦°ÅÇÏ´Â °ÍÀ¸·Î¼­ ¹æ»ç¼±Ä¡·á, Ç×¾ÏÄ¡·á, ¼ö¼úµî°ú °°Àº antitumor therapy¸¦ Æ÷ÇÔÇÑ´Ù.
(¤¤) Edema¸¦ °¨¼Ò½Ã۱â À§ÇÑ dexamethasone, acetaminophen, NSAIDsµîÀ» »ç¿ëÇÒ ¼öÀÖ´Ù.
(¤§) ÅëÁõ°æ°¨À» À§ÇÑ opoids¸¦ »ç¿ëÇϸç, lacinating neuropathic pain¿¡¼­´Â anticonvulsants¸¦, continous or burning dysesthesias¿¡¼­´Â antidepressants¸¦ »ç¿ëÇÑ´Ù. ÀÌȸ¿¡µµ transcutaneous electronic nerve stimulation°°Àº ¹æ¹ýÀ» »ç¿ëÇÒ ¼öµµ ÀÖ´Ù.




5. psoas muscle spasm
¨ç lumbosacarl plexusÀÇ lumbar part´Â psoas muscle³»ºÎ¿¡ ÀÖ´Ù. Tumor infiltrationÀ̳ª ´Ù¸¥ º´º¯¿¡ ÀÇÇÑ ¾Ð¹Ú¿¡ ÀÇÇØ muscle spasmÀÌ »ý±â¸é severe painÀÌ ¹ß»ýÇÒ ¼öÀÖ´Ù.
¨è ÅëÁõÀº abdomen, iliac, inguinal region¿¡¼­ ¹ß»ýÇϸç, hip or posterior thigh·Î ¹æ»çÇÑ´Ù. ¸¸¾à lumbosacral plexus°¡ Æ÷ÇÔµÇ¸é Æ÷ÇÔµÈ nerve roots¿¡ µû¶ó¼­ neuropathic painÀÌ ¹ß»ýÇÏ°Ô µÈ´Ù. Áï hipÀº Á¾Á¾ fixed flexed position¿¡ ÀÖ°Ô µÇ¸ç, hipÀÇ extension or internal rotationÀÌ ¸Å¿ì painfulÇϰųª °¡´ÉÇÏÁö ¸øÇÒ ¼öÀÖ´Ù.
¨é Ä¡·á´Â aggravating factors¸¦ Á¦°ÅÇÏ´Â °ÍÀ¸·Î¼­, ¹æ»ç¼± Ä¡·á, Ç×¾ÏÄ¡·á, ¼ö¼ú °°Àº antitumor treatmentµîÀ» Æ÷ÇÔÇÑ´Ù. Á¶±â¿¡ Ä¡·á¸¦ ÇÏ´Â °ÍÀÌ myopathy risk¸¦ ÁÙÀ̸ç, chronic pain problemÀ» ÁÙ¿©ÁÙ ¼ö Àִµ¥ ´ÙÀ½°ú °°Àº ¹æ¹ýÀ» Æ÷ÇÔÇÑ´Ù.
(¤¡) Acetaminophen or NSAIDs¸¦ »ç¿ëÇÏ¿© local noxious stimuli¸¦ ÁÙ¿©ÁØ´Ù.
(¤¤) ÁÖÀDZí°Ô Á¤È®ÇÑ ¿ë·®ÀÇ opoids¸¦ »ç¿ëÇÑ´Ù.
(¤§) Muscle relaxant·Î¼­ diazepam 2-5mg À» ¸Å 6-8½Ã°£ ¸¶´Ù ÁÜÀ¸·Î½á muscle spasmÀ» ÁÙÀδÙ.
(¤©) ±Ý±â°¡ ¾Æ´ÑÇÑ dexamethasoneÀ» ÀÌ¿ëÇÏ¿© tumor edema¸¦ ÁÙÀδÙ.
(¤±) Lumnbosacral plexopathy°¡ ÀÖÀ¸¸é À̸¦ Ä¡·áÇÑ´Ù.

6. Cancer ȯÀÚ¿¡¼­ÀÇ Nausea
table 37.2
¨ç Nausea with or without vomitingÀº medulla oblongata¿¡ À§Ä¡ÇÑ reticular formation¿¡ ÀÖ´Â vomiting cneter¿¡ ÀÇÇØ mediatedµÇ¸ç,À̺ÎÀ§´Â histamine receptor°¡ dzºÎÇÏ´Ù. ÀÌ·¯ÇÑ vomiting center¿¡ ¿µÇ×À» ÁÖ´Â connectionÀº ´ÙÀ½°ú °°À¸¸ç, À̵éÀº ¼­·Î caual pathway·Î ÀÛ¿ëÇÑ´Ù.
(¤¡) Cerebral cortex( e.g: anxiety-conditioned responses)
(¤¤) Vestibular center (À̺ÎÀ§´Â histamine receptor°¡ dzºÎÇÏ´Ù. Morphin¿¡ ÀÇÇÑ nauseaµîÀÌ Æ÷ÇԵȴÙ.)
(¤§) Chemosensitive trigger zone(CTZ): À̺ÎÀ§´Â dopamine receptors°¡ dzºÎÇϸç, chemotherapeutic agents, hypercalcemia, uremiaµî¿¡ ÀÇÇØ À¯¹ßµÇ´Â nausea°¡ ¿©±â¿¡ ¼ÓÇÑ´Ù.)
(¤©) Gastrointestinal tract(gastric stasis, intestinal obstruction, fecal impaction, abnormalities of gut motalityµî¿¡ ÀÇÇÑ nausea°¡¼ÓÇÑ´Ù.)
¨è Anxiety°¡ ½ÉÇҽô anxiolytics°¡ nausea¸¦ ÁÙ¿©ÁÙ ¼öÀÖÀ¸¸ç, vestibular mechaniamsÀÌ Àǽɵǰųª Ưº°ÇÑ pathway°¡ ¾øÀ» ½Ã¿¡´Â vomiting center and vestibular center¿¡ Á÷Á¢ÀÛ¿ëÇÏ´Â nonsedating antihistaminee(cyclizine, meclozine)µîÀÌ À¯¿ëÇÒ ¼öÀÖ´Ù. ProchlorprerazineÀº muscarinic and histamine receptorsµÑ´Ù¿¡ affinity¸¦ º¸¿© specific ÇÏÁö´Â ¾ÊÀ¸³ª À¯¿ëÇÒ ¼öÀÖ´Ù.
¨é Chemosensitive trigger zone(CTZ)¿Í ¿¬°üµÇ´Â nauseaÀÎ °æ¿ì´Â dopamine receptor¿¡ high affinityº¸ÀÌ´Â haloperidol°°Àº ¾àÁ¦°¡ ÇÊ¿äÇѵ¥ ¹ã¿¡ 3mgÀÌÇÏÀÇ ¿ë·®ÀÌ ÃæºÐÇÒ ¼öÀÖ´Ù. Ç×¾ÏÄ¡·á¿¡ ÀÇÇÑ nauseaÀÎ °æ¿ì »õ·Î¿î¾àÁ¦ÀÎ ondansteroneÀÌ ¼Ò°³µÇ¸é¼­ ¹®Á¦°¡ ´úÇÏ°Ô µÇ¾ú´Âµ¥, À̾àÀº 5HT(serotonin)receptor agonist·Î ÀÛ¿ëÇÑ´Ù. ÇÏÁö¸¸ constipation°°Àº side effect¿¡ ÁÖÀǸ¦ ±â¿ï¿©¾ßÇÑ´Ù.
¨ê Àå¿îµ¿ °¨¼Òµî°ú °°ÀÌ ¼ÒÈ­±â°ü¿¡ ´ëÇÑ ÀÚ±ØÀ¸·Î ÀÎÇÑ nauseaÀÎ °æ¿ì´Â metoclopramide or domperidone°°Àº gastrokinetic antinauseants¿¡ ¹ÝÀÀÇϴµ¥,ÀÌ·¯ÇÑ ¾àÁ¦´Â gastric emptyingÀ» Áõ°¡½Ã۰í, Àå¿îµ¿À» Ç×Áø½ÃŲ´Ù. ÇÏÁö¸¸ high G-I obstructionµî¿¡ ÀÇÇÑ °æ¿ì¿¡´Â ÀÌ·¯ÇÑ ¾àÁ¦°¡ vomitingÀ» ¾ÇÈ­½ÃŲ´Ù.
¨ë DexamethasoneÀº ¾Ë·ÁÁöÁö ¾ÊÀº ±âÀüÀ¸·Î nausea¸¦ ¾ïÁ¦Çϱ⠶§¹®¿¡ ¾î¶² ¾àÁ¦¸¦ ÀÌ¿ëÇÑ chemotherapy Àü¿¡ premedicationÀ¸·Î »ç¿ëµÈ´Ù. ÇÏÁö¸¸ °¡´ÉÇÑ ¼Ò·®À» »ç¿ëÇØ¾ßÇÏ¸ç ´Ù¸¥ ¾àÁ¦¿¡ ºÎ°¡ÀûÀ¸·Î »ç¿ëµÇ¾îÁ®¾ßÇÑ´Ù. 2mgÁ¤µµÀÇ Àú¿ë·®Àº G-I tract¿¡¼­ÀÇ tumor involvement ƯÈ÷ hepatic meta³ª motility disturbance¿¡ ÀÇÇÑ °æ¿ì¿¡ nausea¸¦ °¨¼Ò½ÃÄÑÁØ´Ù. ÇÏÁö¸¸ 1ÁÖ³»¿¡ È¿°ú°¡ ¸íÈ®ÇÏÁö ¾ÊÀ¸¸é Áß´ÜÇÑ´Ù. ¶ÇÇÑ È¯ÀÚ°¡ acute pertic ulcer, Tb, DMÀÇ °ú°Å·ÂÀÌ ÀÖÀ» ½Ã´Â ÁÖÀÇÇÑ´Ù.

7. Bowel obstruction
-´ÙÀ½ ¼¼°æ¿ì·Î ³ª´©¾î »ý°¢ÇÒ ¼öÀÖ´Ù.
¨ç Comlete Bowel Obstruction: ¼ö¼úÀû ±³Á¤Àº obstructionºÎÀ§, cancer extent, estimated time of survivalµî¿¡ ÀÇÇØ ¿µÇâ¹Þ´Â´Ù. ¼ö¼úÀû ¹æ¹ýÀÌ ÀûÀÀÀÌ µÇÁö ¾ÊÀ»½Ã´Â ´ÙÀ½°ú °°Àº ³»°úÀû Ä¡·á¸¦ ÇÑ´Ù.
(¤¡) ÅëÁõÀ» °æ°¨½Ã۰í, tumor edema¸¦ °¨¼Ò½Ã۱â À§ÇÑ steroids¸¦ »ç¿ëÇÔÀ¸·Î½á, reversibilty°¡ ÀÖ´Â Áö °áÁ¤ÇÑ´Ù.
(¤¤) ¸¸¾à irreveribleÇÏ´Ù¸é Ä¡·á ¸ñÇ¥´Â ´ÙÀ½°ú °°´Ù.
? Parenteral fluids¸¦ °¨¼Ò½ÃŰ°Å³ª Áß´ÜÇÔÀ¸·Î½á G-I secretionÀ» °¨¼Ò½ÃŲ´Ù.
? Hyoscine hydrobromide(10-20mgÀ» ¸Å 4½Ã°£¸¶´Ù subcu )°°Àº anticholinergic agents¸¦ »ç¿ëÇÔÀ¸·Î½á spasmodic painÀ» °¨¼Ò½Ã۰í bowel capacity¸¦ Áõ°¡½ÃŲ´Ù. ÇÏÁö¸¸ À̾àÀº blood-brain barrier¸¦ Åë°úÇÏ¿© drowsiness¸¦ ¾ß±âÇÒ ¼ö ÀÖ´Ù. Pain controlÀ» À§ÇÑ morphineÀ» subcu·Î »ç¿ëÇÒ ¼öµµ ÀÖ´Ù.
? Haloperidol°°Àº antiemeticÀ» »ç¿ëÇØ¼­ nausea¸¦ °¨¼Ò½Ã۴µ¥ , bed time¿¡ 0.5mgÀ» »ç¿ëÇϸç, ¿ë·®À» Áõ°¡½ÃÄÑ 1.5mg-3mgÀ» ÇÏ·ç 2¹ø¿¡ °ÉÃÄ subcu·Î ³ª´©¾î ÁÙ ¼ö ÀÖ´Ù.metaclopromideµµ ÁÖÀDZí°Ô »ç¿ëµÇ¾îÁú ¼öÀÖÀ¸³ª ¸¸¾à obstructionÀÌ highÇÏ´Ù¸é vomitingÀ» ¾ÇÈ­½ÃŲ´Ù. ÇÏÁö¸¸ lower obstructionÀÎ °æ¿ì´Â gastric emptyingÀ» µµ¿ÍÁÜÀ¸·Î½á upper gut empty¸¦ À¯ÁöÇÒ ¼öÀÖ°Ô ÇØÁØ´Ù.
(¤§) ObstructionÀÌ highÇϸç large-volume vomitingÀ» º¸ÀϽô somatostatin 300-600mgÀ» 24½Ã°£¿¡ °ÉÃÄ subcu·Î ÁÜÀ¸·Î½á intestinal secretionÀ» °¨¼Ò½Ãų ¼öÀÖ´Ù.
(¤©) À§¿Í °°Àº ¹æ¹ýÀ» ÀÌ¿ëÇÏ¸ç ´ë°³ÀÇ È¯ÀÚ¿¡¼­ ÅëÁõ ¹× Áõ»óÀÌ Á¶ÀýµÇ¸ç, drinkingÀ» °¡´ÉÇϰÔÇϰí, ¼Ò·®ÀÇ À½½ÄÀ» nausea¾øÀÌ ¸ÔÀ» ¼öÀÖµµ·Ï ÇØÁØ´Ù. À̰æ¿ì vomitingÀº 24-72½Ã°£¿¡ ÇÑÂ÷·Ê²Ã·Î ¹ß»ýÇÑ´Ù.
(¤±) À§¿Í °°Àº ¹æ¹ý¿¡µµ ºÒ±¸Çϰí vomitingÀÌ Áö¼ÓµÉ½Ã´Â skinny nasogastric tube¸¦ °í·ÁÇÒ ¼ö ÀÖÀ¸¸ç, decompression êËúª¼­ venting gastrostomy¸¦ °í·ÁÇÒ ¼öÀÖ´Ù.
¨è Partial Obstruction: motility disorder¿Í ±¸ºÐÀÌ ¾î·Á¿ì³ª more vomiting, more pain, characteristic bowel sounds¸¦ º¸ÀδÙ.
(¤¡) Single-level bowel obstruction¸¸ ÀÖÀ» ½Ã´Â ¼ö¼úÀ» °í·ÁÇÑ´Ù.
(¤¤) ¼ö¼úÀÌ ÀûÀýÄ¡ ¾Ê°í, tumor¿¡ ÀÇÇÑ obstructionÀÎ °æ¿ì´Â ´ÙÀ½ ¹æ¹ýÀ» ½ÃµµÇÑ´Ù.
? Steroids
? Metoclopramide to empty the stomach(vomitingÀÌ ¾ÇÈ­µÇ¸é Áß´ÜÇÑ´Ù.)
? Complete obstruction°ú µ¿ÀÏÇÏ°Ô Antiemetics, antispasmodics, analgesia¸¦ »ç¿ëÇÑ´Ù.
? Gentle enema to empty the rectum and lower bowel
¨é Motility Disorders
(¤¡) opoids³ª ´Ù¸¥ ¾àÁ¦¿¡ ÀÇÇÑ constipationº¸´Ù ´õ ½É°¢ÇÑ constipationÀÌ ÁøÇàÇÏ´Â °æ¿ì Áø´ÜÀ» ÇÒ ¼öÀÖÀ¸¸ç, ÀÓ»óÀûÀ¸·Î ´ë°³ vomitingÀ» µå¹°¸ç , ´ë°³ ÅëÁõÀÌ ¾ø°í, ´ÜÁö minimal obdominal distensionÀ» º¸À̰ųª bowel sound ¼Ò½ÇÀ» º¸ÀδÙ.
(¤¤) Motility disorder´Â tumor°¡ Á÷Á¢ÀûÀ¸·Î myenteric plexus or bowel wallÀ» ħ¹üÇ߰ųª, ¹æ»ç¼± Ä¡·á, Ç×¾ÏÄ¡·á¿¡ ÀÇÇÑ secondary autonomic neuropathyµî¿¡ ÀÇÇØ ¾ß±âµÉ ¼öÀÖ´Ù.
(¤§) Ä¡·á´Â cisapride°°Àº prokinetic agents ¿Í senna°°Àº stimulant¸¦ ÀÌ¿ëÇÏ¿© Àå¿îµ¿À» ÀÚ±ØÇÏ´Â °ÍÀÌ´Ù. Rectum and lower colonÀº enemas¸¦ÇÏ¿© ºñ¿öÁØ´Ù. ¸¸¾à single loop¸¸ Æ÷ÇÔµÈ °æ¿ì¶ó¸é surgical resectionÀÌ ÀûÀýÇÒ ¼öÀÖ´Ù.

8. Diarrhea, Fistula, TenesmusÀÇ management
¨ç diarrhea : advanced gynecologic cancer¿¡¼­ diarrhea°¡ ¹ß»ýÇÏ¸é ´Ù¸¥ ¿øÀÎÀÌ ¹àÇôÁö±â Àü±îÁö´Â fecal impactionÀÇ signÀÌ¶ó °£ÁÖÇÑ´Ù. Ture irritative diarrhea¶ÇÇÑ tumor°¡ bowelÀ» involveÇÑ °æ¿ì¿¡ ¹ß»ýÇÒ ¼öÀÖ´Ù. ÀÌ·¯ÇÑ È¯ÀÚµéÀº loperamide°¡ À¯¿ëÇÒ ¼öÀÖ´Ù.
¨è Diarrhea°¡ rectovaginal fistula¿¡ ÀÇÇÑ °ÍÀ̸ç,¼ö¼úÀû ¹æ¹ýÀÌ °¡´ÉÇÏÁö ¾ÊÀ»½Ã´Â vagina¸¦ û°áÈ÷ Çϰí ȯÀÚÀÇ distress¸¦ ÁÙ¿©ÁÖ´Â nursingÀÌ ÇÊ¿äÇÏ´Ù.
¨é Bowel and bowel, bowel and skinµîÀÇ fistular´Â ȯÀÚ¿¡°Ô ¾öû³­ distress¸¦ ¾ß±âÇÒ ¼öÀÖ´Ù. ÀÌ·¯ÇÑ fistula°¡ tumor recurrence¿¡ ÀÇÇÑ °ÍÀÌ ¾Æ´ÑÇÑ ¼ö¼úÀû ¹æ¹ýÀ» °í·ÁÇØ¾ß¸¸ÇÑ´Ù.¸¸¾à ¼ö¼úÀû ¹æ¹ýÀÌ °¡´ÉÇÏÁö ¾ÊÀ» ½Ã´Â ´ÙÀ½°ú °°Àº ¹æ¹ýÀÌ À¯¿ëÇÒ ¼öÀÖ´Ù.
(¤¡) Bulking agent¸¦ »ç¿ëÇÔÀ¸·Î½á soft,formed stoolÀ» À¯ÁöÇÑ´Ù.
(¤¤) ¾î¶² °æ¿ì¿¡¼­´Â somatostatinÀ» ÀÌ¿ëÇÏ¿© bowel secretionsÀ» °¨¼Ò½ÃŲ´Ù.
(¤§) ±«»ç¿¡ ÀÇÇÑ distressing odor°¡ ÀÖÀ»½Ã¿¡´Â ±¹¼ÒÀûÀΠȤÀº Àü½ÅÀûÀÎ metronidazoleÀÌ ÀÌ·¯ÇÑ odor¸¦ ÁÙ¿©ÁØ´Ù.
(¤©) ¿À¿°À» ÁÙÀ̱â À§ÇÑ catheter or appliances»ç¿ë
(¤±) skin care
(¤²) constant emotional support
¨ê tenesmus : anticholinergic agents, calcium channel blockers°°Àº antispasmodicsÀÇ »ç¿ëÀÌ µµ¿òÀ» ÁÙ ¼öÀÖÀ¸¸ç, Á¾Á¾ neropathic pain¿¡ »ç¿ëµÇ¾îÁö´Â ¾àÁ¦°¡ µµ¿òÀ» ÁÙ ¼ö ÀÖ´Ù.

9. cancerȯÀÚ¿¡¼­ÀÇ abdominal distension and ascites
¨ç intractable ascites¿¡ ÀÇÇÑ abdominal distensionÀº major distress¸¦ ¾ß±âÇÑ´Ù. ÀÌ·¯ÇÑ °æ¿ì¿¡ recurrent paracentesis´Â Á¦ÇÑÀûÀÌÁö¸¸ definite ¿ªÇÒÀ» °®À» ¼öÀÖ´Ù. Ãʱ⿡´Â spironolactone 5-150mgÀ» ¸ÅÀÏ »ç¿ëÇØÁÖ´Â °ÍÀÌ À¯¿ëÇÒ ¼öÀÖ´Ù. Á¾Á¾ corticosteroids¸¦ ¸Å¿ì ³·Àº ¿ë·®À¸·Î »ç¿ëÇØÁÖ´Â °ÍÀÌ º¹¼öÀÇ »ý¼ºÀ» °¨¼Ò½Ã۱⠶§¹®¿¡ ½ÃµµÇغ¼¸¸ÇÏ´Ù.
¨è ȯÀÚ°¡ ´À³¢´Â ºÒÆí°¨Àº acetaminophen °ú low dose of opoid¸¦ º´¿ëÇÔÀ¸·Î½á Àß Á¶ÀýµÉ ¼öÀÖ´Ù. Systemic or intraperitoneal cytotoxicsÀº °í·ÁÇØº¼¸¸Çϳª ½ÇÁ¦ÀûÀ¸·Î ¸»±âȯÀÚ¿¡¼­ÀÇ potentialÀº Á¦ÇÑÀûÀÌ´Ù.µû¶ó¼­ ȯÀÚÀÇ ½Ã°£°ú ¿¡³ÊÁö¸¦ ³¶ºñÇÏÁö ¾Êµµ·Ï ÁÖÀÇÇØ¾ßÇϸç, distress¸¦ Áõ°¡½ÃŰÁö ¾Êµµ·Ï ÁÖÀÇÇØ¾ßÇÑ´Ù.

10. dyspnea
¨ç dyspnea´Â ÈçÇϸç, ´ë°³ history, physical exam, chest x-rayÅëÇØ¼­ ¿øÀÎÀ» °¨º°ÇÒ ¼öÀÖ´Ù.
¨è Dyspnea°¡ irreversibleÇϸç, medical management°¡ ¿ä±¸µÇ´Â °æ¿ì¿¡´Â morphinÀ» ÁÖÀDZí°Ô »ç¿ëÇÔÀ¸·Î½á Áõ»óÀ» »ó´ç·® È£Àü½Ãų ¼ö ÀÖ´Ù. °æ±¸ morphins 2-5mgÀ» ¸Å 4½Ã°£¸¶´Ù Áֱ⠽ÃÀÛÇÏ¿© ´õ ÀÌ»ó À̵æÀÌ ¾øÀ»¶§±îÁö Áõ·®ÇÑ´Ù. ½ÇÁ¦ÀûÀ¸·Î ´ë°³ ¾à 10mgÀ» 4½Ã°£¸¶´Ù (with or witout corticosteroids in low dosage)ÁÖ°Ô µÈ´Ù.
¨é MorphineÀº central mechanism ¹× peripheral effects¿¡ ÀÇÇØ dyspnea¸¦ È£Àü½Ãų ¼öÀÖ´Ù. ¸¸¾à ȯÀÚ°¡ ÀÌ¹Ì ÅëÁõÁ¶ÀýÀ» À§Çؼ­ morphinÀ» »ç¿ëÇϰí ÀÖÀ½¿¡µµ ºÒ±¸Çϰí tumor progression¶§¹®¿¡ dysnea°¡ ¹ß»ýÇÑ °æ¿ì¶ó¸é morphineÀ» 30-50%Áõ·®ÇÑ´Ù. ÀÌ·¯ÇÑ medial therapy°¡ optimalÇÑ °æ¿ì¶ó¸é, ½ÉÁö¾î wide spread lung meta°¡ ÀÖ´Â °æ¿ì¶óµµ oxygenÀº ÇÊ¿äÄ¡ ¾ÊÀ¸¸ç, µµ¿òÀÌ µÇÁöµµ ¾Ê´Â´Ù. Anxious patient¿¡¼­´Â benzodiazepines(2mg diazepam orally or 0.5mg lorazepam sublingually)°¡ ¸Å¿ì À¯¿ëÇÒ ¼öÀÖ´Ù.

11. urinary tract symptoms
¨ç Far-advanced gynecologic cancerȯÀÚ¿¡¼­ urinary tract symptomsÀº ÈçÇÏ´Ù. Hydronephrosis¿Í ±×¿¡ µû¸£´Â infection, pain, obstructive nephropathyµîÀº nephrotomy ³ª stent insertion°°Àº ±â°èÀû ¹æ¹ýÀ» Á¤´çÈ­ ½Ãų ¼öÀÖ´Ù.
¨è Oral dexamethasone 4mgÀ» ¸ÅÀÏ 3-5Àϰ£ »ç¿ëÇØÁÜÀ¸·Î½áµµ uerters patency¸¦ À¯ÁöÇÏ¿© serum creatinine levelÀ» ÀǹÌÀÖ°Ô °¨¼Ò½Ã۰í,quality of life¸¦ Çâ»ó½Ãų ¼öÀÖ´Ù.
¨é ¹æ±¤Áõ»óÀÌ ÀÖ´Â °æ¿ì¿¡ detrusor irritability¸¦ °¨¼Ò½Ã۱â À§Çؼ­ NSAIDs¸¦ »ç¿ëÇÒ ¼öÀÖÀ¸¸ç, bladder contractility¸¦ °¨¼Ò½Ã۱â À§ÇØ anticolinergic actionÀ» °®´Â drugs¸¦ »ç¿ëÇÒ ¼öÀÖ´Ù.

12. Edema
¨ç venous or lymphatic obstruction¿¡ ÀÇÇØ ¾ß±âµÇ´Â leg swellingÀº distressingÇÒ ¼öÀÖÀ¸¸ç, small dose of diuretics³ª legÀÇ top¿¡¼­ºÎÅÍ trunkÂÊÀ¸·ÎÀÇ ¸¶»çÁö¹æ¹ýÀ» ÅëÇØ ¹ÝÀÀÀ» º¸ÀÏ ¼öÀÖ´Ù.
¨è Edema°¡ minimalÇÑ °æ¿ì´Â Àü¹®°¡¿¡ ÀÇÇÑ systemic bandage of legs¿¡ ÀÇÇØ ȯÀÚÀÇ ºÒÆíÀÌ ¿ÏÈ­µÉ ¼öÀÖ´Ù. ÇÏÁö¸¸ grossly edematous legs¶ó¸é venous circulationÀÌ ¿ÀÈ÷·Á ´õ¿í Â÷´ÜµÉ ¼öÀֱ⠶§¹®¿¡ compression bandages´Â »ç¿ëµÇ¾î¼­´Â ¾ÈµÈ´Ù.

13. hypercalcemia
¨ç Á¾Á¾ bony metastasis¿Í ¿¬°üµÇ¾î cancerȯÀÚ¿¡¼­ ¹ß»ýÇÒ ¼öÀÖ´Ù.ÀÌ·¯ÇÑ hypercalcemia´Â aggravating bone pain, letherge, weakness, constipation to severe nausea, vomiting, confusion°°Àº Áõ»óÀÇ potent cause·Î ÀÛ¿ëÇÒ ¼öÀÖ´Ù. ´ë°³ ÀÌ·¯ÇÑ Áõ»óµéÀº °¡¿ªÀûÀÌ´Ù
¨è Ä¡·á´Â pamidronate 30-60mgÀ» 250mlÀÇ crystalloid¿¡ ¼¯¾î¼­ 4-8½Ã°£¿¡ °ÉÃÄ ÁÖÀÔÇÏ´Â °ÍÀÌ´Ù. Áõ»óÀÇ ¿ÏÈ­´Â Ä¡·á°³½ÃÈÄ 2-3ÀÏ ³»¿¡ ¿¹»óµÇ¸ç pamidronateÀÇ ¹Ýº¹ÁÖÀÔ¿¡ ÀÇÇØ 2-3ÁÖ°£ È¿°ú°¡ Áö¼ÓµÈ´Ù.