课件：癌症三阶梯止痛-.ppt

* * 即释吗啡滴定方案：第一天固定量：盐酸吗啡5-10mg q4h，疼痛不缓解或很少缓解，于两次用药之间给予解救量2.5-5mg q4h。次日固定量＝前日总固定量＋前日总解救量，分6次口服。次日解救量总固定量的10％。依法逐日调整，直至疼痛消失或稳定在2级以下。 控释吗啡滴定方案：第一天：10-30mg q12h，次日疼痛无缓解或很少缓解，依首次总量的30％-50％逐渐增加剂量。 芬太尼贴剂：25ug/h，同时口服即释吗啡 10mg q4hx2次。或即释吗啡达稳定日剂量后，将其日剂量x1/2，即为多瑞吉贴剂用量（即ug/h q72h） * COMPREHENSIVE PAIN ASSESSMENT History Pain Intensity Location Quality Somatic: pain in skin, muscle, bone described as aching, stabbing, throbbing, pressure Visceral: pain in organs or viscera described as gnawing, cramping, aching, sharp Neuropathic: pain caused by nerve damage described as sharp, tingling, burning, shooting History: onset, duration, course, aggravating, associated symptoms, and alleviating factors Etiology Cancer Cancer therapy or procedures Coincidental or noncancer Response to prior therapy Benefits, side effects, and allergies Medical Current medications including prescribed, over the counter, complimentary and alternative therapies Oncologic Other significant medical illnesses Psychosocial Patient distress Family and other support Psychiatric history including current or prior history of substance abuse Special issues relating to pain Meaning of pain for patient/family Patient/family knowledge and beliefs surrounding pain Risk factors for undertreatment of pain Pediatric, geriatric, communication barriers, history of substance abuse, neuropathic pain, minorities, female, cultural factors Physical examination Relevant laboratory and imaging studies * * 对于慢性疼痛，目前在使用长效药物治疗持续性疼痛的同时，还使用口服即释型阿片类等治疗突发性疼痛。但由于需要半小时甚至更长的时间才能达到峰药浓度，当药物起效时突发性疼痛已经消失。再次发生突发性疼痛时，再次服药，但由于起效时间过长，可能还是无法达到良好镇痛。此后叠加的药物浓度使患者处于用药过度状况，产生呼吸抑制和过度镇静等并发症。这种血浆药物浓度不能与疼痛模式相吻合的情况使疼痛不能得到良好控制。 * 理想的疼痛治疗是镇痛用药的药代动力学与疼痛的发生相吻合。 * 癌症疼痛的分类和处理 分类 肿瘤直接引起 肿瘤侵犯骨骼 侵犯或压迫神经 空腔器官梗阻或实体器官管道梗阻 血管阻塞或受侵 粘膜溃疡或