疼痛的診斷和治療(英文)課件

疼痛的診斷和治療（英文）疼痛的診斷和治療（英文）1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(jiǎn)史、分類、機(jī)理和測(cè)量評(píng)估【講授內(nèi)容】：疼痛基本知識(shí)（概念、發(fā)展簡(jiǎn)史、疼痛的測(cè)定與評(píng)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(duì)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(yǔ)及意義?！局攸c(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(duì)機(jī)體的影響及術(shù)后鎮(zhèn)痛的意義。四、【講授時(shí)數(shù)】：2~3學(xué)時(shí)五、【參考書】：疼痛診療學(xué)第一版

疼痛學(xué)2疼痛的診斷和治療(英文)課件3疼痛的診斷和治療(英文)課件4Pain:afashionabletopic…Pain:afashionabletopic…5Intruduction◆Everypersonmayexperiencepainatsometime,insomeextent,forsomereason.◆Painisoneofthemostimportantpartofoursensation,whichwarnusofkindsofinjuries/riskssothatwecanavoidordealwiththeseinjuries/risks.◆Painalsocauseusunpleasantfeeling,influenceonourphysiologicalfunctionandlifequality,eventhreatonourlives.Thismakepainanimportantproblemtobetreatedclinically.◆Itisnecessaryforusmedicalstudentstohaveagoodunderstandingofpain.Intruduction◆Everypersonmay6Intruduction每一個(gè)人生命過(guò)程中會(huì)由于不同原因在不同時(shí)期不同程度受到疼痛的折磨，嚴(yán)重時(shí)會(huì)影響生理機(jī)能和生命質(zhì)量，甚至危及生命安全。有的時(shí)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

Intruduction每一個(gè)人生命過(guò)程中會(huì)由于不同原因在不7Thedevelopmentofpainmanagement3500DCEgyptianusedopioidHistoryofpain=historyofmedicineThedevelopmentofpainmanage8AdvanceinthefieldofpainBasicresearchMoretargeting,lesstoxicdrugsPCAMicroinvasivetechniquesAdvanceinthefieldofpainBa9國(guó)際疼痛研究會(huì)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。國(guó)際疼痛研究會(huì)和WHO提出：疼痛是人體第五大生命體征;10ThehistoryofpainmanagementThehistoryofpainmanagement11DefinitionofPainpainas"anunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,ordescribedintermsofsuchdamage."DefinitionofPainpainas12TeachingOutlineBasicaspectAnatomyInjuryandpainProcessingofpainPainingeneralClinicalaspectEffectonbodyClassificationPainassessmentanddiagnosisPaintreatmentAdvancementinpainmanagement13TeachingOutlineBasicaspectPBasicaspectofPainBasicaspectofPain14InjuryandpainTRAUMAPOTENTIALINJURYINTOXICATIONSURGERYINFECTIONTUMORDEGENERATIONInjuryandpainTRAUMAPOTENTIAL15ASIC/BNCASIC/BNC16TheModelofPainbyDescartesTheModelofPainbyDescartes17

Clinicalaspectofpain

Clinicalaspectofpain18疼痛的診斷和治療(英文)課件19疼痛的診斷和治療(英文)課件20疼痛的診斷和治療(英文)課件21TeachingOutlineBasicaspectAnatomyInjuryandpainProcessingofpainPainingeneralClinicalaspectClassificationEffectonbodyPainassessmentanddiagnosisPaintreatmentAdvancementinpainmanagement22TeachingOutlineBasicaspectPclassificationGoodgainpain：physiologicalpain（‘goodpain’）“goodpain”——alarming——protectionNogoodgainpain：pathophysiologicalpain（badpain）

badpain——exceptalariming，painisofnogoodWewouldlikewithnopainsystemifwehadotheralarmingsystemsclassificationGoodgainpain：p23hyperalgesia——對(duì)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Badpain壞痛——elimination消除hyperalgesia——對(duì)傷害性刺激敏感性增強(qiáng)和反應(yīng)閾值24SensitizationGottschalkA,SmithDS.AmFamPhysician.2001;1979-84.InjuryPainIntensity1086420StimulusIntensityNormalPainResponseAllodyniaHyperalgesiaSensitizationGottschalkA,Smi25classfication從病程分acutepainchronicpain從人體的部位分headachecervical-shouderpainthoracico-abdominalpainlowbackpain從疼痛的來(lái)源分皮膚痛musclespain、tendonspain、ligamentspainarthralgiabonepainvisceralpainneuropathicpain（centralpain）classfication從病程分從疼痛的來(lái)源分26pathogenicclassfication無(wú)菌性炎癥(inflammationpain)——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neuropathicpain__機(jī)械性壓迫(mechanicpressure)——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。（neuropathicpain神經(jīng)病理性疼痛）癌痛(cancerpain)pathogenicclassfication無(wú)菌性炎癥(27部位分類positionclassfication淺表痛(superficialpain)——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(deeppain)——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(wú)明顯疼痛部位，不呈局限性。C神經(jīng)傳遞中樞痛(centralpain)---疼痛強(qiáng)烈、持久、難忍部位分類positionclassfication淺表痛(28疼痛的性質(zhì)分類刺痛(prickingpain)灼痛(burningpain)脹痛(distendingpain)酸痛(achingpain)絞痛(colickypain)疼痛的性質(zhì)分類刺痛(prickingpain)29TreatmentofpainTreatmentofpain30SignificanceofpaintreatmentControlpainandfacilitaterehabilitation（消除疼痛，促進(jìn)恢復(fù)）Improvebodyfunctionandlifequality（改善機(jī)體功能和生活質(zhì)量）Treatoriginaldisease（治療原發(fā)?。㏒ignificanceofpaintreatment31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的原則明確診斷常用治療方法藥物療法32疼痛治療可以在疼痛產(chǎn)生過(guò)程的各個(gè)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)展疼痛治療可以在疼痛產(chǎn)生過(guò)程的各個(gè)環(huán)節(jié)進(jìn)行33PharmacotherapyforPainCategoriesofanalgesicdrugsOpioidanalgesicsNonopioidanalgesicsAdjuvantanalgesicsDrugsforheadachePharmacotherapyforPainCatego34Thefirstladderanalgesics:

NonopioidAnalgesicsAcetaminophen(paracetamol)Nonsteroidalanti-inflammatorydrugsThefirstladderanalgesics:

N35NonopioidAnalgesicsAcetaminophen(paracetamol)Minimalanti-inflammatoryeffectsFeweradverseeffectsthanothernonopioidanalgesics

AdverseeffectsRenaltoxicityRiskforhepatotoxicityathighdosesIncreasedriskwithliverdiseaseorchronicalcoholismNoeffectonplateletfunctionNonopioidAnalgesicsAcetaminop36NSAIDsMechanismInhibitbothperipheralandcentralcyclo-oxygenase(COX),reducingprostaglandinformation2isoformsofCOXCOX-1:Constitutive,physiologicCOX-2:Inducible,inflammatoryNSAIDsMechanism37COXPathwayandNSAIDs,COX-2Arachidonicacid(anfattyacid)COX-1COX-2Normal

constituentbrainkidneyovaryuterusInducibleinflammationpainfeverCoxibsNSAIDs(-)(-)gastriccytoprotectionrenalsodium/waterbalanceplateletaggregationGlucocorticoids(blockmRNAexpression)(-)Normal

constituentAndMI/strokeriskfactorsCOXPathwayandNSAIDs,COX-2A38Dose-dependenttoxicityIntolerability,dyspepsiaGIbleedingUlcers–bleeds/perforationsUpper-GIRenalFluidretention,oedema,hypertensionRenaldysfunction/failure

–acute/chronicHeartfailureAnti-plateleteffectsAngioedema,bronchospasmContributestobloodlossHypersensitivityNSAIDs-SafetyConcernsDose-dependenttoxicityUpper-G39OpioidTherapyinPainRelatedto

MedicalIllness

OpioidtherapyisthemainstayapproachforAcutepainCancerpainAIDSpainPaininadvancedillnessesButundertreatmentisamajorproblem

OpioidTherapyinPainRelated40Opioids-RoutesofAdministrationOral(pills,liquid)RectalTransdermalTransmucosalSubQ(IM)IVEpiduralIntrathecal=modalities(PCA)Opioids-RoutesofAdministrati41OpioidsSideEffectsCommonConstipationNauseaPruritisSedationLesscommonRespiratorydepressionUrinaryretentionMyoclonicjerksDeliriumSeizuresOpioidsSideEffectsCommonLess42其他LocalanestheticNeurolyticdrugsGlucocorticoidhormoneAdjuvantanalgesics其他43NerveblockNerveblock44Whatisanerveblock?

Nerveblockisageneralterm,butitbasicallymeanstheinjectionofalocalanestheticoraneurolyticagentintoornearaperipheralnerve,asympatheticnerveplexus,oralocalpain-sensitivetriggerpoint.Whatisanerveblock?

Nerveb45什麼是神經(jīng)阻滯(nerveblock)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。什麼是神經(jīng)阻滯(nerveblock)46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。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)47

腦脊髓

壓迫血管

感覺(jué)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(dòng)N

疼痛的惡性循環(huán)腦脊髓壓迫血管感覺(jué)神經(jīng)血管收縮組織缺血、缺氧致48cortexSpinalcordsensorynerve

vasoconstriction

ischemiahypoxia

(tissue)painsubstancemuscularcontractionsympatheticnervemotornerve

Mechanisms:：◆interruptingpainsensorypathways◆Interruptingviciouscircleofpain

◆

Improvingvascular/nutritionsupply◆Anti-inflammatoryeffect

traumainjuryherpeszosterpain×××BloodvesselcompressedViciousCycleofPaincortexSpinalcordsensoryne49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)阻滯奏效的機(jī)理：50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)療法神經(jīng)阻滯療法的位置51SurgeryNerveblock(Micro-invasivetherapy)PharmacotherapyTherapiesofchronicpainSurgeryNerveblockPharmaco52QuantizationofpainintensityQuantizationofpainintensity53疼痛測(cè)定和評(píng)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(shí)調(diào)整治療方案判斷治療效果判斷預(yù)后疼痛測(cè)定和評(píng)估的意義準(zhǔn)確判定疼痛特征,指導(dǎo)用藥和治療方法.54Ifyoudon’tmeasureit,you

can’timproveitIfyoudon’tmeasureit,you

55Singledimensionofpainassessment

visualanaloguescale,VASnumericratingscale,NRSverbalratingscale,VRSfacespainratingscaleSingledimensionofpainasses56Multi-dimensiontools

McGillPainQuestionnaire,MPQBriefpaininventory,BPIMulti-dimensiontoolsMcGillP57Visualanaloguescale(VAS)Visualanaloguescale(VAS)58NumericpainintensityscaleNumericpainintensityscale59疼痛的診斷和治療(英文)課件60Verbaldescriptiveratingscale（VRS）0nopain1slightpain2moderatepain3severepainVerbaldescriptiveratingscal61Verbalratingscales,VRS(口述描繪評(píng)分法)無(wú)痛輕微痛中度痛重度痛極重度痛Verbalratingscales,VRS(口述描繪評(píng)62Wong-BakerfacespainratingscaleWong-Bakerfacespainratings63McGillpainquestionnaireMcGillpainquestionnaire64Objectivepainassessment◆Painthreshold Thermalradiation,TR Electricalstimulation,ES coldstimulation drugstimulation◆Physiologicalparameters tidalvolume heartrateandbloodpressurehormoneexamination Evokedpotential,EP◆Imageexamination◆Psychologicalexamination Objectivepainassessment◆Pai65行為測(cè)定法6點(diǎn)行為評(píng)分法(behavioralratingscale,BRS-6)疼痛日記評(píng)分法(paindiaryscale,PDS)生理指標(biāo)和生化指標(biāo)行為測(cè)定法6點(diǎn)行為評(píng)分法(behavioralrating66疼痛的診斷和治療(英文)課件67疼痛的診斷和治療(英文)課件68Objectiveoflife？Painless，無(wú)痛Happiness，快樂(lè)Objectiveoflife？Painless，無(wú)痛69疼痛的診斷和治療(英文)課件70術(shù)后鎮(zhèn)痛(post-operativeanalgesia)術(shù)后疼痛是一種急性疼痛，指機(jī)體對(duì)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。術(shù)后鎮(zhèn)痛(post-operativeanalgesia)71post-operativepainanunpleasantsensoryandemotionalexperienceassociatedwiththediseaseitselfortissuedamagecausedbythesurgeryOnekindofacutepainItisacomplexprocessinfluencedbybothphysiologicalandpsychologicalfactorsManagementofpostoperativepainhasgenerallybeenshowntobeinadequate

post-operativepainanunpleas72AcutepainSignalsofdiseasesForinsultoftissueintactAdaptive,ofgoodAlarmforearlytreatmentOnesymptomofdiseasetraumasurgeryAcutephaseofinfectionAcutepainSignalsofdiseasesO73Acutepain（Post-OperationPain）Psychologicalstatus：exciting,agitation,sc-reaming,depressionifatpainstateforalongtimeNeuroendocrinesystem：increasedsecretionofcatecholamineCirculationsystem：rapidorslowPrelatedtointensityofpain,evencardiacarrest.BPincreaseordecrease,collapse,shockorcardiacvascularaccidentRespiratorysystem：rapidwithsmallVTDigestivesystem：nauseaandvomiting,malfunctioningImmunosystem：DelayedhealingGenitourinary-urinaryretention凝血功能Acutepain（Post-OperationPain74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)痛的意義：75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(jiǎn)便易性行、對(duì)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(kāi)始，定時(shí)評(píng)估和調(diào)整方案，個(gè)體化用藥術(shù)后鎮(zhèn)痛的原則明確病因76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)痛的方法77術(shù)后鎮(zhèn)痛的治療目的解除術(shù)后病人疼痛的同時(shí)，沒(méi)有更多的副反應(yīng)并降低術(shù)后并發(fā)癥的發(fā)生率。術(shù)后鎮(zhèn)痛的治療目的解除術(shù)后病人疼痛的78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(shí)不靈活——病人之間對(duì)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(shí)——必須由兩名護(hù)士準(zhǔn)備、核對(duì)藥物，并肌注，藥物吸收入血管還需一定的時(shí)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。傳統(tǒng)的術(shù)后鎮(zhèn)痛方法——肌注鎮(zhèn)痛藥79病人自控鎮(zhèn)痛技術(shù)（patient-controlledanalgeria，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(shí)，對(duì)鎮(zhèn)痛藥用量的個(gè)體差異性降低到最小的程度。術(shù)后鎮(zhèn)痛的主要方法病人自控鎮(zhèn)痛技術(shù)（patient-controlledan80Patient?controlledanalgesia(PCA)isameansforthepatienttoself?administeranalgesics(painmedications)intravenously(otherroutes)byusingacomputerizedpump,whichintroducesspecificdosesintoanintravenous(otherroutes)line.WhatisPCAPatient-controlledanalgesia(PCA)Patient?controlledanalgesia(81PCA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(dòng)學(xué)的個(gè)體差異5．鎮(zhèn)痛效果好、簡(jiǎn)便、安全PCA既為一種新型鎮(zhèn)痛給藥法82疼痛的診斷和治療(英文)課件83PCA:combinationofsingledoseandcontinuingdrugadministration（1）loaddose:（2）backgrounddose:（3）bolus:（4）locktime:preventsaccidentaloverdoseTermsinPCAPCA:combinationofsingledos84PCA的專用術(shù)語(yǔ)負(fù)荷劑量（loadingdose）——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(wú)痛狀態(tài)。PCA的專用術(shù)語(yǔ)85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(guò)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(guò)度鎮(zhèn)靜作用。單次給藥劑量（bolus）86鎖定時(shí)間（lockouttime，LT）

指的是該時(shí)間內(nèi)PCA裝置對(duì)病人再次給藥的指令不作反應(yīng)。鎖定時(shí)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。鎖定時(shí)間（lockouttime，LT）

87最大用藥量（maximaldose）是PCA裝置的另一自我保護(hù)措施：有1小時(shí)限制和4小時(shí)限制量。最大用藥量（maximaldose）88連續(xù)背景輸注給藥（basalinfusion或backgroundinfusion）（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)給藥連續(xù)背景輸注給藥（basalinfusion或backg89PCA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分類：根據(jù)給藥途徑不同

靜脈PCA（PCIA），硬膜外90PCA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臨床應(yīng)用范圍：91PCA的優(yōu)點(diǎn)避免反復(fù)肌肉注射給病人帶來(lái)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(shí)有效的鎮(zhèn)痛盡快恢復(fù)病人生理機(jī)能PCA的優(yōu)點(diǎn)92分娩鎮(zhèn)痛（laborpain）自學(xué)分娩鎮(zhèn)痛（laborpain）自學(xué)93慢性疼痛的治療

慢性疼痛的治療94ChronicPain

Management

ChronicPain

Management95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(guò)正常所需的治愈時(shí)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。慢性疼痛的概念96DefinitionofChronicPainHistoricallydefinedaspainextending3or6monthsbeyondonsetorexpectedperiodofhealingNowconsideredaspainthatExtendsbeyondthehealingperiodHaslowlevelsofidentifiedpathologythatinadequatelyexplainthepresenceand/orextentofpainDisruptssleepornormalactivitiesDefinitionofChronicPainHist97Contains:Neuralgias:PHNMusculoskeletalPain:backpainCancerpainOthers:headachevasculardisease(Raynaudsyndrome,Buergerdisease)CRPSUnidentifiedclinicalsyndromeContains:Neuralgias:PHN98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(píng)估，包括治療前和治療過(guò)程中評(píng)估。綜合治療措施。安全有效。合理用藥。慢性疼痛的治療原則99三．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。三．慢性疼痛的治療方法100常見(jiàn)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常見(jiàn)的慢性疼痛性疾病頭面部痛101Cancerpain(癌性疼痛)惡性腫瘤在其發(fā)展過(guò)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Cancerpain(癌性疼痛)惡性腫瘤在其發(fā)展過(guò)程中出現(xiàn)102持續(xù)性疼痛定時(shí)用藥突發(fā)性疼痛時(shí)間中至重度慢性疼痛的組成持續(xù)性疼痛定時(shí)用藥突發(fā)性疼痛時(shí)間中至重度慢性疼痛的組成103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.抗癌止痛治療癌性疼痛的治療病因治療104癌痛的對(duì)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(shí)給藥4.用藥劑量個(gè)體化5.輔助用藥癌痛的對(duì)癥治療藥物治療105疼痛的診斷和治療(英文)課件106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)痛藥或輔助藥癌痛三階梯治療第一階梯：非阿片類鎮(zhèn)痛藥—阿司匹林107癌痛的對(duì)癥治療神經(jīng)阻滯經(jīng)皮電刺激神經(jīng)外科手術(shù)PCA激素療法其他癌痛的對(duì)癥治療神經(jīng)阻滯108TeachingOutlineBasicaspectAnatomyInjuryandpainProcessingofpainPainingeneralClinicalaspectEpidemiologyClassificationEffectonbodyPainassessmentanddiagnosisPaintreatmentAdvancementinpainmanagement109TeachingOutlineBasicaspectPNewadvanceinclinicalpaincontrolNewadvanceinclinicalpainc110病人自控鎮(zhèn)痛介紹PCA（病人自控鎮(zhèn)痛）給藥是結(jié)合單次給藥和連續(xù)給藥的方法，通常需設(shè)定（1）負(fù)荷劑量：目的在于迅速達(dá)到藥物鎮(zhèn)痛的有效濃（2）背景劑量：維持穩(wěn)態(tài)有效的血藥濃度（3）沖擊劑量：為適應(yīng)個(gè)體差異以及術(shù)后生理需要(如理療等)，病人可按需自控給予已經(jīng)預(yù)定好的沖擊劑量覆蓋爆發(fā)痛（4）鎖定時(shí)間：由于止痛藥?kù)o注達(dá)到最大作用時(shí)間有一過(guò)程，為防止病人在此期間反復(fù)按壓沖擊鍵導(dǎo)致藥物中毒而設(shè)定的每次用藥后不反應(yīng)時(shí)間病人自控鎮(zhèn)痛介紹PCA（病人自控鎮(zhèn)痛）給藥是結(jié)合單次給藥和連111經(jīng)硬膜外腔膠原酶化學(xué)溶盤術(shù)CT下操作，準(zhǔn)確性高細(xì)針穿刺，創(chuàng)傷極小膠原酶能選擇性的溶解突（膨）出的椎間盤經(jīng)硬膜外腔膠原酶化學(xué)溶盤術(shù)CT下操作，準(zhǔn)確性高112EpiduralcollagenaseInLDHEpiduralcollagenase113植入性蛛網(wǎng)膜下腔電腦微量緩釋泵連續(xù)輸注嗎啡等至蛛網(wǎng)膜下腔，作用于中樞阿片受體，藥量相當(dāng)于口服的1/300?？筛鶕?jù)疼痛類型調(diào)節(jié)輸注模式。長(zhǎng)期有效控制疼痛，提高生活質(zhì)量癌痛、骨質(zhì)疏松性疼痛、軸性軀干痛、蛛網(wǎng)膜炎植入性蛛網(wǎng)膜下腔電腦微量緩釋泵連續(xù)輸注嗎啡等至蛛網(wǎng)膜下腔，作114ImplantedsubarachnoidpumpImplantedsubarachnoidpump115經(jīng)硬膜外腔脊髓電刺激技術(shù)精確定位脊髓節(jié)段，阻斷疼痛信號(hào)傳遞，從而有效緩解疼痛腰背部手術(shù)后疼痛、身體局部頑固性疼痛、患肢痛、殘肢痛、神經(jīng)根性疼痛、外周缺血性疼痛、頑固性心絞痛經(jīng)硬膜外腔脊髓電刺激技術(shù)精確定位脊髓節(jié)段，阻斷疼痛信號(hào)傳遞，116TransepiduralspinalelectricstimulationTransepiduralspinalelectric117射頻感覺(jué)神經(jīng)熱凝術(shù)選擇性感覺(jué)神經(jīng)熱凝，不破壞運(yùn)動(dòng)神經(jīng)，還能保留觸覺(jué)微創(chuàng)可反復(fù)使用脈沖模式機(jī)理更復(fù)雜射頻感覺(jué)神經(jīng)熱凝術(shù)選擇性感覺(jué)神經(jīng)熱凝，不破壞運(yùn)動(dòng)神經(jīng)，還能保118radiofrequencythermocoagulation/lesion,RFTLSensorynerveselectivemicroinvasiverepeatableradiofrequencythermocoagulati119RF:SelectivespinalnerveblockRF:Selectivespinalnerve120Heatintradiscalelectrothermaltherapy,IDETHeatintradiscalelectrothermal121FacetjointlysisFacetjointlysis122疼痛的診斷和治療(英文)課件123疼痛的診斷和治療(英文)課件124疼痛的診斷和治療(英文)課件125疼痛的診斷和治療(英文)課件126疼痛的診斷和治療(英文)課件127疼痛的診斷和治療(英文)課件128疼痛的診斷和治療(英文)課件129疼痛的診斷和治療(英文)課件130關(guān)于疼痛治療的一些錯(cuò)誤認(rèn)識(shí)忍痛疼痛治療只治標(biāo)不治本痛的時(shí)候才用藥副作用成癮關(guān)于疼痛治療的一些錯(cuò)誤認(rèn)識(shí)忍痛131BeautifulWorldBeautifulWorld132PainlesslifePainlesslife133疼痛的診斷和治療(英文)課件134Posttest疼痛的惡性循環(huán)與神經(jīng)阻滯的機(jī)理疼痛評(píng)估的意義與方法VAS術(shù)后疼痛對(duì)機(jī)體的影響（PCA）WHOAnalgesicLadder藥物與用藥原則疼痛治療原則及方法Posttest135Anyquestion?Anyquestion?136疼痛的診斷和治療（英文）疼痛的診斷和治療（英文）137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(jiǎn)史、分類、機(jī)理和測(cè)量評(píng)估【講授內(nèi)容】：疼痛基本知識(shí)（概念、發(fā)展簡(jiǎn)史、疼痛的測(cè)定與評(píng)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(duì)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(yǔ)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(duì)機(jī)體的影響及術(shù)后鎮(zhèn)痛的意義。四、【講授時(shí)數(shù)】：2~3學(xué)時(shí)五、【參考書】：疼痛診療學(xué)第一版

疼痛學(xué)138疼痛的診斷和治療(英文)課件139疼痛的診斷和治療(英文)課件140Pain:afashionabletopic…Pain:afashionabletopic…141Intruduction◆Everypersonmayexperiencepainatsometime,insomeextent,forsomereason.◆Painisoneofthemostimportantpartofoursensation,whichwarnusofkindsofinjuries/riskssothatwecanavoidordealwiththeseinjuries/risks.◆Painalsocauseusunpleasantfeeling,influenceonourphysiologicalfunctionandlifequality,eventhreatonourlives.Thismakepainanimportantproblemtobetreatedclinically.◆Itisnecessaryforusmedicalstudentstohaveagoodunderstandingofpain.Intruduction◆Everypersonmay142Intruduction每一個(gè)人生命過(guò)程中會(huì)由于不同原因在不同時(shí)期不同程度受到疼痛的折磨，嚴(yán)重時(shí)會(huì)影響生理機(jī)能和生命質(zhì)量，甚至危及生命安全。有的時(shí)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

Intruduction每一個(gè)人生命過(guò)程中會(huì)由于不同原因在不143Thedevelopmentofpainmanagement3500DCEgyptianusedopioidHistoryofpain=historyofmedicineThedevelopmentofpainmanage144AdvanceinthefieldofpainBasicresearchMoretargeting,lesstoxicdrugsPCAMicroinvasivetechniquesAdvanceinthefieldofpainBa145國(guó)際疼痛研究會(huì)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。國(guó)際疼痛研究會(huì)和WHO提出：疼痛是人體第五大生命體征;146ThehistoryofpainmanagementThehistoryofpainmanagement147DefinitionofPainpainas"anunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,ordescribedintermsofsuchdamage."DefinitionofPainpainas148TeachingOutlineBasicaspectAnatomyInjuryandpainProcessingofpainPainingeneralClinicalaspectEffectonbodyClassificationPainassessmentanddiagnosisPaintreatmentAdvancementinpainmanagement149TeachingOutlineBasicaspectPBasicaspectofPainBasicaspectofPain150InjuryandpainTRAUMAPOTENTIALINJURYINTOXICATIONSURGERYINFECTIONTUMORDEGENERATIONInjuryandpainTRAUMAPOTENTIAL151ASIC/BNCASIC/BNC152TheModelofPainbyDescartesTheModelofPainbyDescartes153

Clinicalaspectofpain

Clinicalaspectofpain154疼痛的診斷和治療(英文)課件155疼痛的診斷和治療(英文)課件156疼痛的診斷和治療(英文)課件157TeachingOutlineBasicaspectAnatomyInjuryandpainProcessingofpainPainingeneralClinicalaspectClassificationEffectonbodyPainassessmentanddiagnosisPaintreatmentAdvancementinpainmanagement158TeachingOutlineBasicaspectPclassificationGoodgainpain：physiologicalpain（‘goodpain’）“goodpain”——alarming——protectionNogoodgainpain：pathophysiologicalpain（badpain）

badpain——exceptalariming，painisofnogoodWewouldlikewithnopainsystemifwehadotheralarmingsystemsclassificationGoodgainpain：p159hyperalgesia——對(duì)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Badpain壞痛——elimination消除hyperalgesia——對(duì)傷害性刺激敏感性增強(qiáng)和反應(yīng)閾值160SensitizationGottschalkA,SmithDS.AmFamPhysician.2001;1979-84.InjuryPainIntensity1086420StimulusIntensityNormalPainResponseAllodyniaHyperalgesiaSensitizationGottschalkA,Smi161classfication從病程分acutepainchronicpain從人體的部位分headachecervical-shouderpainthoracico-abdominalpainlowbackpain從疼痛的來(lái)源分皮膚痛musclespain、tendonspain、ligamentspainarthralgiabonepainvisceralpainneuropathicpain（centralpain）classfication從病程分從疼痛的來(lái)源分162pathogenicclassfication無(wú)菌性炎癥(inflammationpain)——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neuropathicpain__機(jī)械性壓迫(mechanicpressure)——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。（neuropathicpain神經(jīng)病理性疼痛）癌痛(cancerpain)pathogenicclassfication無(wú)菌性炎癥(163部位分類positionclassfication淺表痛(superficialpain)——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(deeppain)——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(wú)明顯疼痛部位，不呈局限性。C神經(jīng)傳遞中樞痛(centralpain)---疼痛強(qiáng)烈、持久、難忍部位分類positionclassfication淺表痛(164疼痛的性質(zhì)分類刺痛(prickingpain)灼痛(burningpain)脹痛(distendingpain)酸痛(achingpain)絞痛(colickypain)疼痛的性質(zhì)分類刺痛(prickingpain)165TreatmentofpainTreatmentofpain166SignificanceofpaintreatmentControlpainandfacilitaterehabilitation（消除疼痛，促進(jìn)恢復(fù)）Improvebodyfunctionandlifequality（改善機(jī)體功能和生活質(zhì)量）Treatoriginaldisease（治療原發(fā)病）Significanceofpaintreatment167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的原則明確診斷常用治療方法藥物療法168疼痛治療可以在疼痛產(chǎn)生過(guò)程的各個(gè)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)展疼痛治療可以在疼痛產(chǎn)生過(guò)程的各個(gè)環(huán)節(jié)進(jìn)行169PharmacotherapyforPainCategoriesofanalgesicdrugsOpioidanalgesicsNonopioidanalgesicsAdjuvantanalgesicsDrugsforheadachePharmacotherapyforPainCatego170Thefirstladderanalgesics:

NonopioidAnalgesicsAcetaminophen(paracetamol)Nonsteroidalanti-inflammatorydrugsThefirstladderanalgesics:

N171NonopioidAnalgesicsAcetaminophen(paracetamol)Minimalanti-inflammatoryeffectsFeweradverseeffectsthanothernonopioidanalgesics

AdverseeffectsRenaltoxicityRiskforhepatotoxicityathighdosesIncreasedriskwithliverdiseaseorchronicalcoholismNoeffectonplateletfunctionNonopioidAnalgesicsAcetaminop172NSAIDsMechanismInhibitbothperipheralandcentralcyclo-oxygenase(COX),reducingprostaglandinformation2isoformsofCOXCOX-1:Constitutive,physiologicCOX-2:Inducible,inflammatoryNSAIDsMechanism173COXPathwayandNSAIDs,COX-2Arachidonicacid(anfattyacid)COX-1COX-2Normal

constituentbrainkidneyovaryuterusInducibleinflammationpainfeverCoxibsNSAIDs(-)(-)gastriccytoprotectionrenalsodium/waterbalanceplateletaggregationGlucocorticoids(blockmRNAexpression)(-)Normal

constituentAndMI/strokeriskfactorsCOXPathwayandNSAIDs,COX-2A174Dose-dependenttoxicityIntolerability,dyspepsiaGIbleedingUlcers–bleeds/perforationsUpper-GIRenalFluidretention,oedema,hypertensionRenaldysfunction/failure

–acute/chronicHeartfailureAnti-plateleteffectsAngioedema,bronchospasmContributestobloodlossHypersensitivityNSAIDs-SafetyConcernsDose-dependenttoxicityUpper-G175OpioidTherapyinPainRelatedto

MedicalIllness

OpioidtherapyisthemainstayapproachforAcutepainCancerpainAIDSpainPaininadvancedillnessesButundertreatmentisamajorproblem

OpioidTherapyinPainRelated176Opioids-RoutesofAdministrationOral(pills,liquid)RectalTransdermalTransmucosalSubQ(IM)IVEpiduralIntrathecal=modalities(PCA)Opioids-RoutesofAdministrati177OpioidsSideEffectsCommonConstipationNauseaPruritisSedationLesscommonRespiratorydepressionUrinaryretentionMyoclonicjerksDeliriumSeizuresOpioidsSideEffectsCommonLess178其他LocalanestheticNeurolyticdrugsGlucocorticoidhormoneAdjuvantanalgesics其他179NerveblockNerveblock180Whatisanerveblock?

Nerveblockisageneralterm,butitbasicallymeanstheinjectionofalocalanestheticoraneurolyticagentintoornearaperipheralnerve,asympatheticnerveplexus,oralocalpain-sensitivetriggerpoint.Whatisanerveblock?

Nerveb181什麼是神經(jīng)阻滯(nerveblock)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。什麼是神經(jīng)阻滯(nerveblock)182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。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)183

腦脊髓

壓迫血管

感覺(jué)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(dòng)N

疼痛的惡性循環(huán)腦脊髓壓迫血管感覺(jué)神經(jīng)血管收縮組織缺血、缺氧致184cortexSpinalcordsensorynerve

vasoconstriction

ischemiahypoxia

(tissue)painsubstancemuscularcontractionsympatheticnervemotornerve

Mechanisms:：◆interruptingpainsensorypathways◆Interruptingviciouscircleofpain

◆

Improvingvascular/nutritionsupply◆Anti-inflammatoryeffect

traumainjuryherpeszosterpain×××BloodvesselcompressedViciousCycleofPaincortexSpinalcordsensoryne185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)阻滯奏效的機(jī)理：186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)療法神經(jīng)阻滯療法的位置187SurgeryNerveblock(Micro-invasivetherapy)PharmacotherapyTherapiesofchronicpainSurgeryNerveblockPharmaco188QuantizationofpainintensityQuantizationofpainintensity189疼痛測(cè)定和評(píng)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(shí)調(diào)整治療方案判斷治療效果判斷預(yù)后疼痛測(cè)定和評(píng)估的意義準(zhǔn)確判定疼痛特征,指導(dǎo)用藥和治療方法.190Ifyoudon’tmeasureit,you

can’timproveitIfyoudon’tmeasureit,you

191Singledimensionofpainassessment

visualanaloguescale,VASnumericratingscale,NRSverbalratingscale,VRSfacespainratingscaleSingledimensionofpainasses192Multi-dimensiontools

McGillPainQuestionnaire,MPQBriefpaininventory,BPIMulti-dimensiontoolsMcGillP193Visualanaloguescale(VAS)Visualanaloguescale(VAS)194NumericpainintensityscaleNumericpainintensityscale195疼痛的診斷和治療(英文)課件196Verbaldescriptiveratingscale（VRS）0nopain1slightpain2moderatepain3severepainVerbaldescriptiveratingscal197Verbalratingscales,VRS(口述描繪評(píng)分法)無(wú)痛輕微痛中度痛重度痛極重度痛Verbalratingscales,VRS(口述描繪評(píng)198Wong-BakerfacespainratingscaleWong-Bakerfacespainratings199McGillpainquestionnaireMcGillpainquestionnaire200Objectivepainassessment◆Painthreshold Thermalradiation,TR Electricalstimulation,ES coldstimulation drugstimulation◆Physiologicalparameters tidalvolume heartrateandbloodpressurehormoneexaminatio