手术疼痛药物治疗新理念.pptVIP

Painfree is the basis of enjoyable life! 敬 请 指 正 伤害感受器是感受疼痛的感受器是伤害性刺激信号的换能装置。 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. 因此 超前镇痛的效果有待进一步研究 * 第2p： 一项关于围手术期镇痛方案倾向性的调查显示，患者更倾向于得到较好镇痛的同时不产生恶心等不良反应，舒适镇痛是患者术后镇痛需求，而阿片类药物易引起恶心、呕吐等不良反应，不能满足舒适镇痛的需求，专家共识推荐NSAIDs广泛应用于轻中度术后镇痛方案中 亮点在于：从患者的术后镇痛需求出发，引出阿片类药物无法实现更好镇痛效果 适用人群：迷信阿片类药物的医生，术后只是按需给予弱阿片类药物镇痛的医生 * 阿片类药物只能缓解疼痛症状 抑制痛觉敏化，才能根本镇痛！ 抑制痛觉敏化可以从根本上解除疼痛 影响痛觉敏化的药物 影响药物 1.阿片类药物↑ 2.NSAIDs ↓ 3.NMDA受体拮抗剂↓ 4.α2受体激动剂↓ 电生理学研究已经证实组织损伤能导致脊髓中枢敏化。 兴奋性氨基酸及其受体系统在脊髓中枢痛觉敏化中有重要作用。 兴奋性氨基酸受体 NMDA受体 非NMDA受体 AMPA受体 KA受体 氯胺酮为NMDA受体拮抗剂 可使机械性痛觉过敏反应阈值恢复至 术前水平 NMDA受体拮抗剂对痛觉敏化的影响 Joly等证实，在手术中输注相对大剂量的瑞芬太尼后可触发术后继发性痛觉过敏，而小剂量氯胺酮可起到预防作用。 Guignard等的研究显示，给予氯胺酮可使术中瑞芬太尼的用量和术后吗啡的消耗量降低，并改善疼痛评分。 阿片类药物引起的痛觉过敏 机制与NMDA受体的激活相关 　　研究发现，在术中使用阿片类药物尤其是 短效的瑞芬太尼后，患者苏醒期躁动发生率高， 术后出现痛觉过敏，对镇痛药的需求量明显增加。  Vinik等在志愿者实验中发现，对阿片类药物的镇痛耐受出现在持续输注瑞芬太尼60~90min内。 Angst等发现，在输注瑞芬太尼90min后的30min内，原来存在的皮肤机械性痛觉过敏区域明显扩大。 Hodd等的实验表明，在输注瑞芬太尼后的4h内，由辣椒素所造成的痛觉区域明显扩大