疼痛的診斷和治療英文.ppt

Diagnosis and treatment of Pain,Liu Hui Anesthesiology Department, West China Hospital, Sichuan University.,疼痛學(xué) 【目的要求】： 1. 掌握術(shù)后鎮(zhèn)痛重要性及病人自控鎮(zhèn)痛應(yīng)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(dǎo)通路，神經(jīng)阻滯治療疼痛的機(jī)理； 5. 了解疼痛的簡史、分類、機(jī)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(jī)理及傳導(dǎo)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(jī)理及適應(yīng)癥、禁忌癥 癌痛治療方法 術(shù)后鎮(zhèn)痛：定義、術(shù)后疼痛對機(jī)體的影響、術(shù)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(yīng)癥、基本術(shù)語及意義。 【重點(diǎn)難點(diǎn)】： 難點(diǎn)：疼痛的發(fā)病機(jī)理及傳導(dǎo)通路； 重點(diǎn)：1.疼痛的惡性循環(huán)及神經(jīng)阻滯治療疼痛的機(jī)理； 2.慢性疼痛的治療方法及癌痛的三階梯藥物治療； 3.術(shù)后疼痛對機(jī)體的影響及術(shù)后鎮(zhèn)痛的意義。 四、【講授時數(shù)】：2 3學(xué)時 五、【參考書】：疼痛診療學(xué) 第一版,Introduction,Come as you be born,Introduction,Accompany with you all your life,Pain: a fashionable topic,Intruduction, 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 physiological 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(yán)重時會影響生理機(jī)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)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 management,3500 DC Egyptian used opioid,History of pain =history of medicine,Advance in the field of pain,Basic research More targeting,less toxic drugs PCA 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(quán)利。,The history of pain management,Definition of Pain,pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.“,13,Teaching Outline,Basic aspect Anatomy Injury and pain Processing of pain,Pain in general,Clinical aspect Effect on body Classification Pain assessment and diagnosis Pain treatment Advancement in pain management,Basic aspect of Pain,Injury and pain,TRAUMA,POTENTIAL INJURY,INTOXICATION,SURGERY,INFECTION,TUMOR,DEGENERATION,ASIC/BNC,The Model of Pain by Descartes,Clinical aspect of pain,22,Teaching Outline,Basic aspect Anatomy Injury and pain Processing of pain,Pain in general,Clinical aspect Classification Effect on body Pain assessment and diagnosis Pain treatment Advancement in pain management,classification,Good gain pain：physiological pain（good pain） “good pain”alarmingprotection No good gain pain：pathophysiological pain（bad pain） bad pain except alariming，pain is of no good We would like with no pain system if we had other alarming systems,hyperalgesia對傷害性刺激敏感性增強(qiáng)和反應(yīng)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,Sensitization,Gottschalk A, Smith DS. Am Fam Physician. 2001;1979-84.,Injury,Pain Intensity,10 8 6 4 2 0,Stimulus Intensity,Normal Pain Response,Hyperalgesia,classfication,從病程分 acute pain chronic pain 從人體的部位分 headache cervical-shouder pain thoracico-abdominal pain low back pain,從疼痛的來源分 皮膚痛 muscles pain、tendons pain、ligaments pain arthralgia bone pain visceral pain neuropathic pain（central pain）,pathogenic classfication,無菌性炎癥(inflammation pain)椎管內(nèi)外或關(guān)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(jī)械性壓迫(mechanic pressure)機(jī)體生物力學(xué)失去平衡，解剖位置改變，肌應(yīng)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(jī)械性、化學(xué)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(guān)節(jié)、胸膜、腹部受刺激而產(chǎn)生的疼痛，常為灼痛，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(qiáng)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 pain,Significance of pain treatment,Control pain and facilitate rehabilitation（消除疼痛，促進(jìn)恢復(fù)） Improve body function and life quality（改善機(jī)體功能和生活質(zhì)量） Treat original disease（治療原 發(fā)?。?疼痛治療的原則,明確診斷 除痛與病因治療相結(jié)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(shù)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(jìn)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(shù)不斷發(fā)展,Pharmacotherapy for Pain,Categories of analgesic drugs Opioid analgesics Nonopioid analgesics Adjuvant analgesics Drugs for headache,The first ladder analgesics: Nonopioid Analgesics,Acetaminophen (paracetamol) Nonsteroidal anti-inflammatory drugs,Nonopioid Analgesics,Acetaminophen (paracetamol) Minimal anti-inflammatory effects Fewer adverse effects than other nonopioid analgesics Adverse effects Renal toxicity Risk for hepatotoxicity at high doses Increased risk with liver disease or chronic alcoholism No effect on platelet function,NSAIDs,Mechanism Inhibit both peripheral and central cyclo-oxygenase(COX), reducing prostaglandin formation 2 isoforms of COX COX-1: Constitutive, physiologic COX-2: Inducible, inflammatory,COX Pathway and NSAIDs, COX-2,Arachidonic acid (an fatty acid),COX-1,COX-2,Normal constituent,brain kidney ovary uterus,Inducible,inflammation pain fever,Coxibs,NSAIDs,(-),(-),gastric cytoprotection renal sodium / water balance platelet aggregation,Glucocorticoids (block mRNA expression),(-),Normal constituent,And MI / stroke risk factors,NSAIDs - Safety Concerns,Opioid Therapy in Pain Related to Medical Illness,Opioid therapy is the mainstay approach for Acute pain Cancer pain AIDS pain Pain in advanced illnesses But undertreatment is a major problem,Opioids-Routes of Administration,Oral (pills, liquid) Rectal Transdermal Transmucosal SubQ (IM) IV Epidural Intrathecal =modalities (PCA),Opioids Side Effects,Common Constipation Nausea Pruritis Sedation,Less common Respiratory depression Urinary retention Myoclonic jerks Delirium Seizures,其他,Local anesthetic Neurolytic drugs Glucocorticoid hormone Adjuvant analgesics,Nerve block,What is a nerve block? Nerve block is a general term, but it basically means the injection 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(dǎo)功能。,疼痛臨床是指以神經(jīng)阻滯為主的麻醉學(xué)方法診療疼痛性疾病的一門學(xué)科。 既要找出病因，又要使患者達(dá)到治療的目的。,腦,脊髓,壓迫血管,感覺神經(jīng),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(yùn)動N,疼痛的惡性循環(huán),cortex,Spinal cord,sensory nerve,vasoconstriction,ischemia hypoxia (tissue),pain substance,muscular contraction,sympathetic nerve,motor nerve,Mechanisms:： interrupting pain sensory pathways Interrupting vicious circle of pain Improving vascular/ nutrition supply Anti-inflammatory effect,trauma injury herpes zoster,pain,Blood vessel compressed,Vicious Cycle of Pain,神經(jīng)阻滯奏效的機(jī)理： 阻斷疼痛的傳導(dǎo)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(shù)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(shù)療法,Surgery,Nerve block (Micro-invasive therapy),Pharmacotherapy,Therapies of chronic pain,Quantization of pain intensity,疼痛測定和評估的意義,準(zhǔn)確判定疼痛特征,指導(dǎo)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(yù)后,If you dont measure it, you cant improve it,Single dimension of pain assessment,visual analogue scale, VAS numeric rating scale, NRS verbal rating scale, VRS faces pain rating scale,Multi-dimension tools,McGill Pain Questionnaire, MPQ Brief pain inventory, BPI,Visual analogue scale(VAS),Numeric pain intensity scale,Verbal descriptive rating scale（VRS）,0 no pain 1 slight pain 2 moderate pain 3 severe pain,Verbal 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 scale,McGill pain questionnaire,Objective pain assessment, Pain threshold Thermal radiation,TR Electrical stimulation,ES cold stimulation drug stimulation Physiological parameters tidal volume heart rate and blood pressure hormone examination Evoked potential,EP Image examination Psychological examination,行為測定法,6點(diǎn)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(biāo)和生化指標(biāo),Objective of life？,Painless，無痛 Happiness，快樂,術(shù)后鎮(zhèn)痛(post-operative analgesia),術(shù)后疼痛是一種急性疼痛，指機(jī)體對疾病本身和手術(shù)造成的組織損傷的一種復(fù)雜的生理反應(yīng)，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 surgery One kind of acute pain It is a complex process influenced by both physiological and psychological factors Management of postoperative pain has generally been shown to be inadequate,Acute pain,Signals of diseases For insult of tissue intact Adaptive,of good Alarm for early treatment,One symptom of disease,trauma surgery Acute phase of infection,Acute pain（Post-Operation Pain）,Psychological status：exciting, agitation,sc-reaming, depression if at pain state for a long time Neuroendocrine system：increased secretion of catecholamine Circulation system：rapid or slow P related to intensity of pain,even cardiac arrest. BP increase or decrease, collapse, shock or cardiac vascular accident Respiratory system：rapid with small VT Digestive system：nausea and vomiting, malfunctioning Immuno system ：Delayed healing Genitourinary - urinary retention 凝血功能,術(shù)后鎮(zhèn)痛的意義：,減輕患者手術(shù)后痛苦 提高防止圍術(shù)期并發(fā)癥能力 提高圍術(shù)期安全性 縮短住院日，提高出院率，節(jié)省住院費(fèi)用 促進(jìn)早日康復(fù),術(shù)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、簡便易性行、對機(jī)體干擾小。 根據(jù)疼痛強(qiáng)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(shù)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(shù)后鎮(zhèn)痛的治療目的,解除術(shù)后病人疼痛的同時，沒有更多的副反應(yīng)并降低術(shù)后并發(fā)癥的發(fā)生率。,傳統(tǒng)的術(shù)后鎮(zhèn)痛方法肌注鎮(zhèn)痛藥,缺點(diǎn)：（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(hù)士，護(hù)士確信病人需要鎮(zhèn)痛 不及時必須由兩名護(hù)士準(zhǔn)備、核對藥物，并肌注，藥物吸收入血管還需一定的時間擴(kuò)散至大腦的作用位置才能產(chǎn)生鎮(zhèn)痛效果。最終導(dǎo)致鎮(zhèn)痛不夠。,病人自控鎮(zhèn)痛技術(shù)（patient-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(yīng)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(shù)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 intravenous (other routes) line.,What is PCA,Patient-controlled analgesia(PCA),PCA既為一種新型鎮(zhèn)痛給藥法 PCA特點(diǎn)：1. 病人不必打擾醫(yī)護(hù)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(fù) 4能克服藥效學(xué)和藥動學(xué)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 accidental overdose,Terms in PCA,PCA的專用術(shù)語,負(fù)荷劑量（loading dose） 給予負(fù)荷劑量旨在迅速達(dá)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(dá)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(yīng)。 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(hù)措施。,最大用藥量（maximal dose）,是PCA裝置的另一自我保護(hù)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(chǔ)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(yīng)用范圍：,術(shù)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(diǎn),避免反復(fù)肌肉注射給病人帶來的痛苦 可使病人積極參與疼痛治療，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(fù)病人生理機(jī)能,分娩鎮(zhèn)痛（labor pain ）,自學(xué),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(fù)發(fā)或反復(fù)發(fā)作者成為慢性疼痛。 慢性疼痛是一種疾病。,Definition of Chronic Pain,Historically defined as pain extending 3 or 6 months beyond onset or expected period of healing Now considered as pain that Extends beyond the healing period Has low levels of identified pathology that inadequately explain the presence and / or extent of pain Disrupts sleep or normal activities,Contains:,Neuralgias: PHN Musculoskeletal Pain: back pain Cancer pain Others:headache vascular disease (Raynaud 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(jī)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(shù)治療 2.放射治療 3.化學(xué)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(qiáng)阿片類鎮(zhèn)痛藥嗎啡； 可并用第一階梯、第二階梯的鎮(zhèn)痛藥或輔助藥,癌痛的對癥治療,神經(jīng)阻滯 經(jīng)皮電