胸科術(shù)后疼痛及鎮(zhèn)痛治療

胸科術(shù)后急慢性疼痛及

鎮(zhèn)痛治療胸科術(shù)后疼痛胸科術(shù)后急性疼痛胸科術(shù)后慢性疼痛鎮(zhèn)痛方法硬膜外鎮(zhèn)痛椎旁鎮(zhèn)痛

胸科術(shù)后疼痛胸科術(shù)后急性疼痛胸科術(shù)后慢性疼痛鎮(zhèn)痛方法硬膜外鎮(zhèn)痛椎旁鎮(zhèn)痛胸科手術(shù)是最疼痛手術(shù)之一AcuteandchronicpainsyndromesafterthoracicsurgerySurgClinNAm82(2002)849-865患者痛苦降低肺功能肺不張低氧血癥呼吸衰竭循環(huán)系統(tǒng)呼吸系統(tǒng)內(nèi)分泌系統(tǒng)消化系統(tǒng)神經(jīng)系統(tǒng)心理影響社會影響引流管呼吸運(yùn)動排痰急性疼痛急性疼痛發(fā)生率（100%）急性疼痛相關(guān)性因素急性中重度痛壓痛閾值Spearmancoefficient-0.241P-value0.011瑞芬太尼用量Spearmancoefficient0.271P-value0.004慢性疼痛慢性疼痛胸科術(shù)后慢性疼痛，即胸科術(shù)后疼痛綜合征

（chronicpost-thoracotomypain,CPTP）

（post-thoracotomypainsyndrom,PTPS）被定義為肋間皮區(qū)持續(xù)或反復(fù)疼痛，持續(xù)至少2個(gè)月PTPS的癥狀、性質(zhì)被描述為沿著傷口周肋間皮區(qū)持續(xù)的感覺遲鈍性燒灼感。異常性疼痛是其特征近一半的病人描述為酸痛或觸痛，也有持續(xù)性灼痛、刺痛或所有這些交織在一起的感覺，疼痛可持續(xù)或間斷性發(fā)生疼痛可因咳嗽、溫度改變、肩部移動而加重，或因情緒緊張、陰天或天氣的快速變化、攜重物、手術(shù)側(cè)胸部著床及用手術(shù)側(cè)手工作而加重，坐位是最常加重的體位因素PTPS起因多數(shù)認(rèn)為肋間神經(jīng)損害是最重要的病理因素①損傷后的肋間神經(jīng)瘤②正在愈合的肋骨骨折③凍肩④局部感染與胸膜炎⑤肋軟骨炎與肋軟骨脫位⑥局部腫瘤復(fù)發(fā)⑦心理原因（焦慮、抑郁）Acuteandchronicpainsyndromesafterthoracicsurgery.SurgClinNorthAm.2002PTPS發(fā)病率術(shù)后慢性疼痛的發(fā)生率為52%（mild32%、moderate16%、severe4%）術(shù)后慢性疼痛的發(fā)生率為41%（mild19%、moderate-severe22%）慢性術(shù)后疼痛的發(fā)生變化術(shù)后3m（89%）；6m（75%）；1y（61%）0.5-1.5y（58%）；1.5-2.5y（55%）慢性疼痛相關(guān)因素切口大小

手術(shù)范圍手術(shù)時(shí)間患者年齡放、化療糖尿病

（pneumonectomy>wedgeexcision）（age<6054%：39%p=0.07）術(shù)后慢性疼痛的相關(guān)性分析慢性疼痛心理焦慮Contingencycoefficient0.199P-value0.032文化程度Contingencycoefficient-0.297P-value0.030糖尿病史Contingencycoefficient0.200P-value0.030回顧性研究67%61%急性疼痛慢性疼痛醫(yī)生能夠做些什么？觀念手術(shù)方式鎮(zhèn)痛方法RCT66patientswithearly-stageNSClungcancerVATS

lobectomyOpenresectionVATS

groupshowedahigherproportionofpatientswithverylowpostop

pain

andwithout

pain

胸腔鏡手術(shù)降低術(shù)后疼痛甚至無痛慢性疼痛？外科技術(shù)的改善在過去的十年沒有降低CPTP的發(fā)生率研究546人，開胸63%手術(shù)區(qū)域感覺改變，腔鏡手術(shù)發(fā)生率相同

胸科術(shù)后疼痛胸科術(shù)后急性疼痛胸科術(shù)后慢性疼痛鎮(zhèn)痛方法硬膜外鎮(zhèn)痛椎旁鎮(zhèn)痛硬膜外鎮(zhèn)痛(TEA)椎旁阻滯鎮(zhèn)痛(PVB)胸膜間鎮(zhèn)痛(interpleuralanalgesia)肋間神經(jīng)阻滯(intercostalblock)冷凍鎮(zhèn)痛(cryoanalgesia)鞘內(nèi)鎮(zhèn)痛(intrathecalanalgesia)傷口置管持續(xù)鎮(zhèn)痛(CWCA)經(jīng)皮電神經(jīng)刺激(TENS)RCT48patientsundergoingthoracotomyTEB（24）(fentanyl+bupivicaine)PVB（24）(naropine)TheJournalofThoracicandCardiovascularSurgery2016低血壓、尿潴留、惡心、嘔吐、皮膚瘙癢椎旁阻滯可以減少副作用TocomparePVBvsTEBFEV1(P=0.023)VAS(P=0.002)(restandcoughing)Airsaturation(P=0.023)Cortisolblood(P=0.08)Conclusion:drugsasministeredthroughaparavertebralcatheterareveryeffective.Moreover,itdoesnotpresentcontraindicationstoitspositioningorcollateraleffects.Morestudiesarenecessarytoconfirmdatawecollected.效果好、無禁忌Meta-analysis14RCTs,698participantsundergoingthoracotomyTocomparePVBvsTEBinadultsundergoingthoracotomy30-daymortalitySimilarbetweenPVBandTEB(RR1.28,95%CI0.39-4.24,P=0.68)Majorcomplications:Cardiovascularcomplicationshypotensionrequiringinotropes(RR0.30,95%CI0.01to6.62,Pvalue=0.45),arrhythmias(RR0.36,95%CI0.04to3.29,Pvalue=0.36)myocardialinfarction(RR3.19,95%CI0.13to76.42,Pvalue=0.47)Majorcomplications:RespiratorycomplicationsPostoperativeventilatorysupport(P=0.54)Acutecarborndioxideretention(P=0.71)Pneumonia(P=0.16)Acutepain:PVBvsTEB

(restandcoughing)At2-6hoursSMD0.35,95%CI-0.09to0.78,P=0.12At24hoursSMD0.02,95%CI-0.24to0.28,P=0.90At48hoursSMD0.02,95%CI-0.26to0.30,P=0.90FailureoftechniquePVB1.98%<TEB11.22%（P=0.03）RR0.27,95%CI0.09-0.86MinorcomplicationsHypotensionPVB<TEB(RR0.16,95%CI0.07-0.38,P<0.0001)PONVPVB<TEB(RR0.48,95%CI0.30-0.75,P=0.001)PruritisPVB<TEB(RR0.29,95%CI0.14-0.59,P=0.0005)UrinaryretentionPVB<TEB(RR0.22,95%CI0.11-0.46,P<0.0001)DurationofhospitalstayandcostSimilarbetweenPVBandTEB(MD-0.41days,95%CI-1.54~0.72,P=0.48)PVBvsTEB30天病死率，大的并發(fā)癥，住院時(shí)間無差異控制急性疼痛作用相同減少小的并發(fā)癥

TPVB并發(fā)癥包括刺破胸膜，氣