疼痛的診斷和治療(英文)課件

1、 Diagnosis and treatment of PainLiu Hui Anesthesiology Department, West China Hospital, Sichuan University. 疼痛學【目的要求】：1. 掌握術后鎮(zhèn)痛重要性及病人自控鎮(zhèn)痛應用2. 掌握慢性疼痛治療的基本方法及治療原則3掌握癌痛藥物治療的三階梯原則4. 熟悉疼痛的惡性循環(huán)及傳導通路，神經(jīng)阻滯治療疼痛的機理；5. 了解疼痛的簡史、分類、機理和測量評估【講授內(nèi)容】：疼痛基本知識（概念、發(fā)展簡史、疼痛的測定與評估、發(fā)生機理及傳導通路）慢性疼痛的治療方法及原則，神經(jīng)阻滯治療疼痛的機理及適應癥、禁忌癥癌

2、痛治療方法術后鎮(zhèn)痛：定義、術后疼痛對機體的影響、術后鎮(zhèn)痛的意義及方法；病人自控鎮(zhèn)痛：定義、方法、分類及適應癥、基本術語及意義?！局攸c難點】：難點：疼痛的發(fā)病機理及傳導通路；重點：1.疼痛的惡性循環(huán)及神經(jīng)阻滯治療疼痛的機理； 2.慢性疼痛的治療方法及癌痛的三階梯藥物治療； 3.術后疼痛對機體的影響及術后鎮(zhèn)痛的意義。四、【講授時數(shù)】：2 3學時五、【參考書】：疼痛診療學 第一版 IntroductionCome as you be bornIntroductionAccompany with you all your lifePain: a fashionable topicIntruductio

3、n Every person may experience pain at some time, in some extent, for some reason. Pain is one of the most important part of our sensation, which warn us of kinds of injuries/risks so that we can avoid or deal with these injuries/risks. Pain also cause us unpleasant feeling, influence on our physiolo

4、gical function and life quality, even threat on our lives. This make pain an important problem to be treated clinically. It is necessary for us medical students to have a good understanding of pain. Intruduction每一個人生命過程中會由于不同原因在不同時期不同程度受到疼痛的折磨，嚴重時會影響生理機能和生命質(zhì)量，甚至危及生命安全。有的時候疼痛本身就是一種?。ㄈ缛嫔窠?jīng)痛），或者引起疼痛的原發(fā)

5、疾病已不那么重要（如晚期癌痛），使疼痛治療成為唯一的選擇 The development of pain management3500 DC Egyptian used opioidHistory of pain =history of medicineAdvance in the field of painBasic researchMore targeting,less toxic drugsPCA Microinvasive techniques國際疼痛研究會和WHO提出：疼痛是人體第五大生命體征;慢性疼痛是一種疾??；解除疼痛是患者的基本權利。The history of pain ma

6、nagementDefinition of Painpain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.Teaching OutlineBasic aspect AnatomyInjury and painProcessing of painPain in generalClinical aspectEffect on bodyClassificationPain

7、 assessment and diagnosisPain treatmentAdvancement in pain management13Basic aspect of PainInjury and painTRAUMAPOTENTIAL INJURYINTOXICATIONSURGERYINFECTIONTUMORDEGENERATIONASIC/BNCThe Model of Pain by DescartesClinical aspect of painTeaching OutlineBasic aspect AnatomyInjury and painProcessing of p

8、ainPain in generalClinical aspectClassification Effect on bodyPain assessment and diagnosisPain treatmentAdvancement in pain management22classificationGood gain pain：physiological pain（good pain）“good pain”alarmingprotectionNo good gain pain：pathophysiological pain（bad pain） bad pain except alarimin

9、g，pain is of no goodWe would like with no pain system if we had other alarming systemshyperalgesia對傷害性刺激敏感性增強和反應閾值降低allogesia非痛刺激引起。自發(fā)痛-損傷區(qū)域Bad pain壞痛elimination消除SensitizationGottschalk A, Smith DS. Am Fam Physician. 2019;1979-84. InjuryPain Intensity10 8 6 4 2 0Stimulus IntensityNormalPainResponse

10、AllodyniaHyperalgesiaclassfication從病程分acute painchronic pain從人體的部位分headachecervical-shouder painthoracico-abdominal painlow back pain從疼痛的來源分皮膚痛muscles pain、tendons pain、ligaments pain arthralgiabone painvisceral painneuropathic pain（central pain）pathogenic classfication無菌性炎癥(inflammation pain)椎管內(nèi)外或關

11、節(jié)內(nèi)外軟組織因急性損傷后遺或慢性勞損而引起的損害性疼痛。神經(jīng)病理性疼痛neuropathic pain_機械性壓迫(mechanic pressure)機體生物力學失去平衡，解剖位置改變，肌應力異常引起的神經(jīng)血管受壓性疼痛。（neuropathic pain神經(jīng)病理性疼痛）癌痛(cancer pain )部位分類position classfication淺表痛(superficial pain)由機械性、化學性、物理性的不良刺激引起皮膚、黏膜部位的疼痛。程度劇烈、定位精確多呈局限性如刀割、針刺。Adelta神經(jīng)傳遞。深部痛(deep pain)內(nèi)臟、關節(jié)、胸膜、腹部受刺激而產(chǎn)生的疼痛，常為灼

12、痛，無明顯疼痛部位，不呈局限性。C神經(jīng)傳遞中樞痛(central pain)-疼痛強烈、持久、難忍疼痛的性質(zhì)分類刺痛(pricking pain)灼痛(burning pain)脹痛(distending pain)酸痛(aching pain)絞痛(colicky pain)Treatment of painSignificance of pain treatmentControl pain and facilitate rehabilitation（消除疼痛，促進恢復）Improve body function and life quality（改善機體功能和生活質(zhì)量）Treat orig

13、inal disease（治療原 發(fā)病）疼痛治療的原則明確診斷除痛與病因治療相結合綜合治療確保安全有效常用治療方法藥物療法物理療法心理療法手術療法介入療法、神經(jīng)阻滯療法其他療法疼痛治療可以在疼痛產(chǎn)生過程的各個環(huán)節(jié)進行采用多模式的綜合療法目前，大多數(shù)疼痛是可以得到治療或控制的；而且新的技術不斷發(fā)展Pharmacotherapy for PainCategories of analgesic drugsOpioid analgesicsNonopioid analgesicsAdjuvant analgesicsDrugs for headacheThe first ladder analgesi

14、cs:Nonopioid AnalgesicsAcetaminophen (paracetamol)Nonsteroidal anti-inflammatory drugsNonopioid AnalgesicsAcetaminophen (paracetamol)Minimal anti-inflammatory effectsFewer adverse effects than other nonopioid analgesics Adverse effects Renal toxicity Risk for hepatotoxicity at high doses Increased r

15、isk with liver disease or chronic alcoholismNo effect on platelet functionNSAIDsMechanismInhibit both peripheral and central cyclo-oxygenase(COX), reducing prostaglandin formation2 isoforms of COXCOX-1: Constitutive, physiologicCOX-2: Inducible, inflammatoryCOX Pathway and NSAIDs, COX-2Arachidonic a

16、cid (an fatty acid)COX-1COX-2Normalconstituentbrainkidneyovary uterusInducibleinflammationpainfeverCoxibsNSAIDs(-)(-)gastric cytoprotectionrenal sodium / water balanceplatelet aggregationGlucocorticoids(block mRNA expression)(-)NormalconstituentAnd MI / stroke risk factorsDose-dependent toxicityInto

17、lerability, dyspepsiaGI bleedingUlcers bleeds / perforationsUpper-GIRenalFluid retention, oedema, hypertensionRenal dysfunction / failure acute / chronicHeart failureAnti-platelet effectsAngioedema, bronchospasmContributes to blood lossHypersensitivityNSAIDs - Safety ConcernsOpioid Therapy in Pain R

18、elated to Medical Illness Opioid therapy is the mainstay approach for Acute painCancer painAIDS painPain in advanced illnessesBut undertreatment is a major problemOpioids-Routes of AdministrationOral (pills, liquid)RectalTransdermalTransmucosalSubQ(IM)IVEpiduralIntrathecal=modalities (PCA)Opioids Si

19、de EffectsCommonConstipationNauseaPruritisSedationLess commonRespiratory depressionUrinary retentionMyoclonic jerksDeliriumSeizures其他Local anestheticNeurolytic drugsGlucocorticoid hormoneAdjuvant analgesicsNerve blockWhat is a nerve block?Nerve block is a general term, but it basically means the inj

20、ection of a local anesthetic or a neurolytic agent into or near a peripheral nerve, a sympathetic nerve plexus, or a local pain-sensitive trigger point.什麼是神經(jīng)阻滯(nerve block)是指在末梢的腦脊髓神經(jīng)節(jié)，腦脊髓神經(jīng)，交感神經(jīng)節(jié)等神經(jīng)內(nèi)或附近注入藥物或用物理方法使針觸到神經(jīng)給予刺激，阻斷神經(jīng)傳導功能。疼痛臨床是指以神經(jīng)阻滯為主的麻醉學方法診療疼痛性疾病的一門學科。既要找出病因，又要使患者達到治療的目的。 腦脊髓 壓迫血管 感覺神經(jīng)

21、血管收縮 組織缺血、缺氧 致痛物質(zhì) 肌肉收縮交感神經(jīng)運動N 疼痛的惡性循環(huán) cortexSpinal cord sensory nerve vasoconstrictionischemia hypoxia(tissue) pain substance muscular contractionsympathetic nerve motor nerve Mechanisms:：interrupting pain sensory pathways Interrupting vicious circle of pain Improving vascular/ nutrition supply Anti

22、-inflammatory effect trauma injury herpes zoster painBlood vessel compressedVicious Cycle of Pain神經(jīng)阻滯奏效的機理： 阻斷疼痛的傳導通路 阻斷疼痛的惡性循環(huán) 改善血行狀態(tài) 抗炎癥作用神經(jīng)阻滯療法的位置1 藥物療法2手術療法3神經(jīng)阻滯療法：又稱為第三療法 神經(jīng)阻滯療法 藥物療法 手術療法 SurgeryNerve block(Micro-invasive therapy)PharmacotherapyTherapies of chronic painQuantization of pain inte

23、nsity疼痛測定和評估的意義準確判定疼痛特征,指導用藥和治療方法.及時調(diào)整治療方案判斷治療效果判斷預后If you dont measure it, you cant improve itSingle dimension of pain assessment visual analogue scale, VASnumeric rating scale, NRSverbal rating scale, VRS faces pain rating scaleMulti-dimension tools McGill Pain Questionnaire, MPQBrief pain invento

24、ry, BPIVisual analogue scale(VAS)Numeric pain intensity scaleVerbal descriptive rating scale（VRS）0 no pain1 slight pain2 moderate pain3 severe painVerbal rating scales,VRS(口述描繪評分法)無痛輕微痛中度痛重度痛極重度痛Wong-Baker faces pain rating scaleMcGill pain questionnaireObjective pain assessment Pain thresholdTherma

25、l radiation,TRElectrical stimulation,EScold stimulation drug stimulation Physiological parameterstidal volume heart rate and blood pressure hormone examination Evoked potential,EP Image examination Psychological examination行為測定法6點行為評分法(behavioral rating scale,BRS-6)疼痛日記評分法(pain diary scale,PDS)生理指標和

26、生化指標Objective of life？Painless，無痛Happiness，快樂 術后鎮(zhèn)痛(post-operative analgesia)術后疼痛是一種急性疼痛，指機體對疾病本身和手術造成的組織損傷的一種復雜的生理反應，它表現(xiàn)為心理和行為上一種不愉快的經(jīng)歷。post-operative pain an unpleasant sensory and emotional experience associated with the disease itself or tissue damage caused by the surgeryOne kind of acute painIt

27、 is a complex process influenced by both physiological and psychological factors Management of postoperative pain has generally been shown to be inadequate Acute painSignals of diseasesFor insult of tissue intactAdaptive,of goodAlarm for early treatmentOne symptom of disease traumasurgeryAcute phase

28、 of infectionAcute pain（Post-Operation Pain）Psychological status：exciting, agitation,sc-reaming, depression if at pain state for a long timeNeuroendocrine system：increased secretion of catecholamineCirculation system：rapid or slow P related to intensity of pain,even cardiac arrest. BP increase or de

29、crease, collapse, shock or cardiac vascular accidentRespiratory system：rapid with small VTDigestive system：nausea and vomiting, malfunctioningImmuno system ：Delayed healingGenitourinary - urinary retention 凝血功能術后鎮(zhèn)痛的意義：減輕患者手術后痛苦提高防止圍術期并發(fā)癥能力提高圍術期安全性縮短住院日，提高出院率，節(jié)省住院費用促進早日康復術后鎮(zhèn)痛的原則明確病因鎮(zhèn)痛藥物和方法選擇：安全、有效、簡便

30、易性行、對機體干擾小。根據(jù)疼痛強度選用藥物和方法鎮(zhèn)痛藥物從最低有效量開始，定時評估和調(diào)整方案，個體化用藥術后鎮(zhèn)痛的方法口服給藥椎管內(nèi)給藥蛛網(wǎng)膜下隙鎮(zhèn)痛硬膜外脛鎮(zhèn)痛胃腸外給肌肉注射靜脈注射PCA其它術后鎮(zhèn)痛的治療目的 解除術后病人疼痛的同時，沒有更多的副反應并降低術后并發(fā)癥的發(fā)生率。傳統(tǒng)的術后鎮(zhèn)痛方法肌注鎮(zhèn)痛藥缺點：（1）不靈活 （2）依賴性 （3）不及時不靈活病人之間對藥物的需要量可能相差十倍以上依賴性必須叫護士，護士確信病人需要鎮(zhèn)痛不及時必須由兩名護士準備、核對藥物，并肌注，藥物吸收入血管還需一定的時間擴散至大腦的作用位置才能產(chǎn)生鎮(zhèn)痛效果。最終導致鎮(zhèn)痛不夠。病人自控鎮(zhèn)痛技術（patient-

31、controlled analgeria ，PCA） 病人根據(jù)自己的鎮(zhèn)痛需要自己控制給藥，在方便快捷、反應迅速的同時，對鎮(zhèn)痛藥用量的個體差異性降低到最小的程度。術后鎮(zhèn)痛的主要方法Patientcontrolled analgesia (PCA) is a means for the patient to selfadminister analgesics (pain medications) intravenously(other routes) by using a computerized pump, which introduces specific doses into an intr

32、avenous (other routes) line.What is PCAPatient-controlled analgesia(PCA)PCA既為一種新型鎮(zhèn)痛給藥法 PCA特點：1. 病人不必打擾醫(yī)護人員，可以自行控制給藥2鎮(zhèn)痛效果迅速，鎮(zhèn)靜程度輕3利于病情恢復4能克服藥效學和藥動學的個體差異5鎮(zhèn)痛效果好、簡便、安全PCA: combination of single dose and continuing drug administration （1）load dose: （2）background dose: （3）bolus: （4）lock time: prevents acc

33、idental overdose Terms in PCAPCA的專用術語負荷劑量（loading dose） 給予負荷劑量旨在迅速達到鎮(zhèn)痛所需 的血藥濃度，稱之為“最小有效鎮(zhèn)痛濃度”（MEAC）使病人迅速達到無痛狀態(tài)。單次給藥劑量（bolus） PCA裝置有病人控制間斷給藥。這種給藥方式也稱PCA給藥或維持給藥。病人通過PCA裝置上的特殊按鈕給藥。PCA所采用的小劑量多次給藥的目的在于維持一定的血漿鎮(zhèn)痛藥濃度，但又不產(chǎn)生過度鎮(zhèn)靜作用。鎖定時間（lockout time，LT）指的是該時間內(nèi)PCA裝置對病人再次給藥的指令不作反應。鎖定時間可防止病人在前次給藥完全生效之前再次給藥，是一種自我保護

34、措施。最大用藥量（maximal dose）是PCA裝置的另一自我保護措施：有1小時限制和4小時限制量。連續(xù)背景輸注給藥（basal infusion 或background infusion）（1）持續(xù)給藥 （2）連續(xù)給藥+PCA （3）PCA給藥基礎上的連續(xù)給藥PCA分類：根據(jù)給藥途徑不同靜脈PCA（PCIA），硬膜外PCA（RCEA），皮下PCA（PCSA），外周神經(jīng)阻滯PCA（PCNA）PCA臨床應用范圍：術后急性疼痛的治療腫瘤疼痛病人的治療內(nèi)科疼痛病人分娩鎮(zhèn)痛兒童病人鎮(zhèn)痛燒傷和創(chuàng)傷疼痛治療將PCA作為一種研究手段或工具PCA的優(yōu)點避免反復肌肉注射給病人帶來的痛苦可使病人積極參與疼痛治

35、療，減少焦慮，并使鎮(zhèn)痛所需的藥量減少能容易和精確地滿足病人的鎮(zhèn)痛需要，及時有效的鎮(zhèn)痛盡快恢復病人生理機能分娩鎮(zhèn)痛（labor pain ）自學 慢性疼痛的治療 Chronic Pain Management 慢性疼痛的概念 一種急性疾病或一次損傷所引起的疼痛持續(xù)超過正常所需的治愈時間，或疼痛緩解后間隔數(shù)月或數(shù)年復發(fā)或反復發(fā)作者成為慢性疼痛。 慢性疼痛是一種疾病。Definition of Chronic PainHistorically defined as pain extending 3 or 6 months beyond onset or expected period of heal

36、ingNow considered as pain thatExtends beyond the healing periodHas low levels of identified pathology that inadequately explain the presence and / or extent of painDisrupts sleep or normal activitiesContains:Neuralgias: PHNMusculoskeletal Pain: back painCancer painOthers:headache vascular disease (R

37、aynaud syndrome, Buerger disease) CRPS Unidentified clinical syndrome慢性疼痛的治療原則明確診斷，查明疼痛的病因和部位。疼痛評估，包括治療前和治療過程中評估。綜合治療措施。安全有效。合理用藥。三慢性疼痛的治療方法藥物治療。神經(jīng)組滯療法。物理療法。其它。常見的慢性疼痛性疾病頭面部痛頸肩及上肢痛胸背部痛腰背部痛下肢痛全身性疾病Cancer pain(癌性疼痛)惡性腫瘤在其發(fā)展過程中出現(xiàn)的疼痛.癌癥致痛機制或原因 1. 癌癥發(fā)展所致的疼痛 2. 癌癥診斷和治療后的疼痛 3. 合并慢性疼痛性疾病 4. 癌痛綜合征持續(xù)性疼痛定時用藥突發(fā)性疼痛時間中至重度慢性疼痛的組成癌性疼痛的治療病因治療1.手術治療2.放射治療3.化學治療4.抗癌止痛治療癌痛的對癥治療藥物治療癌痛三階梯治療方案遵循的原則1.階梯給藥2.口服給藥3.按時給藥4.用藥劑量個體化5.輔助用藥癌痛三階梯治療第一階梯：非阿片類鎮(zhèn)痛藥阿司匹林第二階梯：弱阿片類可待因、曲馬多；可并用第一階梯的鎮(zhèn)痛藥或輔助藥第三階梯：強阿片類鎮(zhèn)