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研究生:劉榮東
研究生(外文):Jung-Tung
論文名稱:意識障礙的甦醒治療
論文名稱(外文):Regaining the consciousness on long term comatose patients
指導教授:林則彬林則彬引用關係
學位類別:博士
校院名稱:中山醫學大學
系所名稱:醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
論文頁數:67
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目的:
本研究旨在使用臨床上治療頑固型神經痛(Intractable
pain)已三十年的神經刺激器,利用其增加對應區組織血流量的特性,刺激正中神經,促使腦血流量增高,再合併高壓氧的治療,藉由治療後的結果與分析,來探討植物人恢復意識的可能性。由於國外文獻均只對臨床的表現做陳述,較為主觀。本論文則以較為客觀的核子醫學及生化檢測証明治療的效果。
背景:
植物人的形成大多數是因為腦部受傷後得不到充足的養分,而使得殘存細胞陸續死亡或無法發揮應有的功能。如果此種情況得不到即時的改善,病患可能會持續昏迷,當細胞數目減少到某種程度,病人意識再也無法恢復,即所謂的植物人。以往國內神經科的醫師將常規的治療完成後,即迫使病人轉至復健部門或是護理之家,這也許是受制於健保給付的不確定性,或是認為治療已達終點,無需再進行進一步的處置。不論是那一種原因,總之醫療尚未發揮到盡頭,病人就無奈的被放棄。本篇論文所闡述的是利用治療神經性疼痛(Neuropathic pain)的神經刺激器結合高壓氧的治療,重新喚醒長期昏迷甚或植物人的意識。
方法與材料:
神經刺激器分為體內及體外兩種,體內刺激器必須藉由手術的方法植入到體內,一種是將刺激器置於高位頸脊髓處;另一種體外刺激器則置於右手正中神經。本文採取在右手正中神做體外刺激,然後與高壓氧合併治療。以治療三個月為療程,比較各組病患,那一種方法對病人意識改變的程度較大?除了主觀認定意識及臨床症狀的改變外,也利用核醫SPECT(Single Photon Emission Computed Tomography)的方法,檢測腦組織灌注量(Cerebral perfusion)是否有改變?本研究共選擇81位昏迷的病患,其中有40位病患為對照組,即不做任何電刺激及高壓氧的治療。以統計學的公式算出P值,探討彼此間的差異。
結果:
研究結果發現,利用低能量電流刺激周邊的正中神經對腦組織的灌注量不論是否合併高壓氧都有不同程度的增加;單以高壓氧來治療長期意識障礙的病患,臨床上並無明顯的效果,但與神經刺激器合併使用,則有加成的作用。其中以正中神經刺激加上高壓氧的效果高過於僅用正中神經刺激的一組。對於沒有做神經刺激或高壓氧治療的病人則無明顯進步,這証明神經刺激治療是必要而有效的,而且結果說明,越早進行治療,成功的機會也越高。
期望及未來:
任何原因所造成的腦部傷害,若無法在期盼的時間內清醒,都有可能變成植物人。但本文所得到的結論,只要對於「腦細胞」給予即時的疏救就可避免悲劇的發生(14)。事實上,急救所使用的醫材極為普遍,也就是使用多年的神經刺激器。但由於神經刺激器被拿來治療疼痛。事實上神經刺激器除了控制疼痛之外,它還有增加腦血流量,活化腦部的功能,藉以恢復意識。本篇所討論的只是將刺激器置正中神經,藉腦血流量的增加使病人恢復意識且對人體無嚴重副作用。
植物人甦醒後,都會呈現智力或神經功能衰退的情形,病患需要長期的復健,家庭是否有能力照顧處處需人看顧的病患,必需由家屬審慎評估,否則「喚醒意識」將變得毫無意義。但是,這種決定絕不能由挾醫學倫理之名的衛道人士甚至醫師代為決定。不論是國健局或是健保局對於意識障礙的病患似乎應投入些「關愛」,而非交由社福單位安置。如此,病患的權益才能充分獲得保障。

Purpose:
Vegetative state or long term comatose patients are regarded as relative hopeless clinically. They are often referred to nursing home for basic care when clinical medication is over. There are few people to regain the consciousness, certainly, no possibility to back the normal life. This situation could be verified through the establishing the nursing home everywhere in Taiwan. This study was performed to describe using a peripheral nerve either combine with hyperbaric oxygenation(HBO) or not to regain the consciousness from a long term comatose patients.
Background:
Because neuromodulation and hyperbaric oxygen therapy have emerged some promise in treating patients with states of reduced consciousness, we evaluated the individual effect after a therapies in combinations of median nerve stimulation(MNS)with HBO, MNS only and control group in long term comatose patients.
Methods:
Eight-one cases enrolled in our study, 27 patients received the median nerve stimulation combined with HBO, 14 patients received median nerve stimulation only, 40 cases kept with basic care. SPECT study was performed to evaluate the cerebral perfusion. Catecholamine and neurotransmitter collected and quantified from cerebrospinal fluid(CSF). The change of Glasgow coma scale(GCS), Glasgow outcome scale(GOS), respiration type and intake route were accessed to be a scale of life quality. Significant P-value was accessed with Paired student t-test or Wilcoxon signed-rank sum test.
Results:
MNS combined with HBO has better result than those patients with MNS only. Comparing to control group, neuromodulation therapy is optimal option for those of long term regardless with HBO or not. 
Conclusion:
In fact, many patients were abandoned by physician because much information were ignored. I present this article to describe the result of coma in resuscitation by using hyperbaric oxygen and neuromodulation. Through the observation of patient’s consciousness change, we believe that neuromodulation and HBO is the best and necessary method to resuscitate the patients’ consciousness.

壹、前言 ……………………………………1
貳、方法與材料 ……………………………5
一、意義障礙定義的釐清……………………5
二、神經刺激器的種類………………………6
三、材料………………………………………9
四、方法………………………………………13
五、評估………………………………………15
六、案例的收集………………………………17
叁、結果 ………………………………………18
一、神智的變化 ………………………………18
二、腦灌量的變化 ……………………………20
三、Cetacholamine的變化 ……………………23
四、體重的變化 ………………………………24
五、呼吸途徑的改變 …………………………24
六、進食路徑的改變 …………………………25

肆、討論…………………………………………26
高壓氧的療效 ……………………………28
脊髓電刺激的療效 ………………………30
正中神經電刺激的療效……………………30
腦萎縮的機轉 ……………………………31
治療的時期 ………………………………37
藥物的療效 ………………………………39
腦深部電刺激的療效 ……………………43
伍、倫理討論 …………………………………46
陸、結論 ………………………………………53
柒、圖表 ………………………………………56
捌、參考文獻 …………………………………60

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