外科常见疾病的合理用药.ppt

* * 术后疼痛不仅影响患者的生活质量，还可能带来一系列的生理影响，如图所示（以下内容主要为增进对本张幻灯片的理解，可酌情删减）。 手术后的内分泌改变所导致的水和电解质代谢异常主要表现为水钠潴留，功能性细胞外液减低，液体向细胞内转移； 此外，疼痛造成交感神经兴奋性增强会导致心脏做功增加和氧消耗增加，同时，血压也有可能升高，甚至可能导致脑卒中和心肌缺血； 在肺功能方面，研究证实，即使不做手术，2小时以上的全身麻醉和机械通气也可能会导致肺不张；另外膈肌功能减退导致不能有效咳嗽，不能清除呼吸道分泌物也可能造成肺不张和肺炎； 第四方面，术后疼痛可能导致静脉淤滞、血液粘稠度增高，加上术后活动减少，将增加深静脉栓塞甚至肺动脉栓塞的危险； 第五方面，术后疼痛可减低胃肠道蠕动，增加恶心、呕吐、麻痹性肠梗阻的发生机会，同时也是延长住院时间、增加医药费用的主要原因之一； 第六方面，如果术后疼痛治疗不充分会导致外周或中枢敏化，进而导致急性疼痛转化为慢性疼痛。 * * 250 patients who had undergone surgical procedures (in- and outpatient) in the past year completed a questionnaire about their experiences with pain before and after surgery. The most common concern that patients expressed prior to surgery was experiencing pain (59%), which was cited more often than concerns about whether the surgery would improve their condition (51%) or whether they would fully recover (46%). 58% of the sample reported pain prior to surgery. Despite receiving treatment for pain, 82% reported pain in the immediate postsurgical period (end of surgery up to 2 weeks after discharge) and 75% reported pain after discharge. More than two thirds of patients reported pain of moderate to severe intensity, and extreme pain was reported by 18% overall and 8% after discharge. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97:534-540. * * * * 对乙酰氨基酚从结构上而言并非NSAIDs，几乎无抗炎作用，抑制前列腺素作用以中枢为主 ，但因有解热止痛作用也被录入非甾体类抗炎药。 参考文献： 孙燕等，《麻醉药品临床使用与规范化管理培训教材》，2004:28-29 * Opioid analgesics are generally considered a “gold standard” for analgesic efficacy, but physician and patient concerns about their potential side effects may actually contribute to the global problem of the undermanagement of pain.1-3 References: 1. Moreland LW, St. Clair EW. The use of analgesics in the management of pain in rheumatic diseases. Rheum Dis Clin North Am. 1999;25:153-191. 2. Atcheson R, Rowbotham DJ. Pharmacology of acute and chronic pain. In: R