癌痛的滴定治疗策略.pptVIP

阿片药物滴定 --关键点 The main reason that adequate doses are withheld by doctors or nurses is the fear of respiratory depression. Opioids used for people who are not in pain, or in doses larger than necessary to control the pain, can slow and indeed stop breathing. The principle is that the dose has to be titrated to the effect (Figure 4). The effect is pain relief. If the dose given has not produced pain relief (the patient is still complaining of pain), and it has all been delivered and absorbed, then it is safe to give another dose. This subsequent dose may be smaller than the first. If it too doesnt succeed then the process can be repeated.The principle is that the dose has to be titrated to the effect. The effect is pain relief. Doses larger than necessary to control the pain can cause serious adverse effects. If the dose given has not produced pain relief because the patient is still complaining of pain, and it has all been delivered and absorbed, then it is safe to give another dose, which may be smaller than the first. www.medicine.ox.ac.uk/bandolier * * * 奥斯康定的滴定与速效吗啡相同 奥施康定滴定效果国内研究表明：90%的患者仅需1-2轮滴定至完全无痛，没有患者滴定超过4轮（4小时） 癌痛的滴定治疗策略 什么是癌痛？ 肿瘤患者感受到的疼痛和不适 包括肿瘤导致的疼痛、治疗导致的疼痛、与肿瘤无关的疼痛 流行病学：癌痛现状十分严峻 新诊断患者1,2 积极治疗期1,2 癌症晚期1,2 完成治疗患者3 25% 33% 75% 33% 1. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 6th ed. 2008. 2. Clinical Practice Guidelines in Oncology for Adult Cancer Pain. V. 1.2010. 3. van den Beuken-van Everdingen MH, et al. Ann Oncol. 2007;18: 1437-1449. 癌痛尚未得到足够治疗 癌痛是全球的健康问题 发展中国家发病率高 诊断晚，获得阿片难 超过80%的中、重度疼痛没有得到治疗 尽管医学手段有能力缓解大多数疼痛 Access to Controlled Medications Programme: Framework. World Health Organization; 2007. 在癌痛治疗中存在的问题 全面评估不足 阿片类药物选择不恰当 阿片类药物滴定不规范 阿片类药物剂量不足 副反应治疗不及时 为什么要强调滴定？ 临床首诊患者疼痛治疗存在以下问题 1、首选针剂，剂量过大 2、不滴定直接使用贴剂 3、不评估，不剂量滴定直接使用氨酚羟考酮或曲马多等 时间 阿片 剂量 疼痛完全缓解所需剂量 疼痛 程度 副作用 Modified from www.medicine.ox.ac.uk/bandolier 滴定过程就是发现有效镇痛剂量的过程！ 滴定的概念 NCCN阿片滴定策略 阿片未耐受者：吗啡起始剂量 5-15mg/2-5mg (口服/静脉) 60/15min 评估 PI