術(shù)后鎮(zhèn)痛課件

術(shù)后鎮(zhèn)痛

--理念的共識(shí)與方法的爭(zhēng)議理念的共識(shí)：

“疼痛-第五生命體征”疼痛管理新標(biāo)準(zhǔn)：疼痛評(píng)價(jià)、治療在臨床具有優(yōu)先地位；疼痛作為第5生命體征，與體溫、呼吸、脈搏、血壓具有同樣重要意義；病人具有足夠的權(quán)利要求重視其疼痛的診治。

美國醫(yī)療機(jī)構(gòu)評(píng)審聯(lián)合委員會(huì)

JamesCampell,美國疼痛協(xié)會(huì)主席

消除疼痛是基本的人權(quán)！

Painreliefisabasichumanright！

疼痛是第五生命體征！

Painisthefifthvitalsign!

“Byanyreasonablecode,freedomfrompainshouldbeabasichumanright,limitedonlybyourknowledgetoachieveit...”

LiebeskindJC&MelzackR1987

鎮(zhèn)痛用藥階梯（Analgesicladder）術(shù)后疼痛的演變：惡性循環(huán)手術(shù)急性疼痛慢性疼痛行為變化神經(jīng)學(xué)改變Neuronalchanges脊髓興奮性增高Spinalcordhyperexcitability上揚(yáng)術(shù)后鎮(zhèn)痛方法與選擇

Post-OpModalitiesPainpump(localanesthesiainfiltration)IndwellingepiduralcatheterPCAIV/IManalgesics(NSAIDs,opioids)OralanalgesicsTopical(cryotherapy,heat)PT/OT靜脈

PCA程序化機(jī)械泵Programmablemechanicalpump自行給藥

Self-administered按壓鈕給予設(shè)定的藥物Pressbuttontogiveasetdoseofmorphineiv鎖定時(shí)間避免藥物過量Lock-outperiodtominimizeoverdose經(jīng)導(dǎo)管連續(xù)輸注給藥ContinuousInfusionviaacatheter

硬膜外腔（Inepiduralspace）:局麻藥-阻斷運(yùn)動(dòng)/感覺/交感神經(jīng)阿片類藥物阻斷脊髓阿片受體硬膜外鎮(zhèn)痛病人自控鎮(zhèn)痛（PCA）術(shù)后鎮(zhèn)痛常用方法PCA：我國臨床應(yīng)用十年（1994-2004）靜脈PCA的優(yōu)點(diǎn)

（與傳統(tǒng)肌肉注射/皮下注射相比）藥物吸收更加可靠

用藥靈活/起效快維持更為穩(wěn)定的鎮(zhèn)痛水平個(gè)體對(duì)鎮(zhèn)痛藥物的敏感性2-5倍的差異PCA是克服個(gè)體差異較為理想的鎮(zhèn)痛方法PCA治療的藥理學(xué)依據(jù)PCA流行的原因間斷肌注阿片類藥物不能有效緩解疼痛；安全、精細(xì)的給藥技術(shù)深受患者喜愛；患者滿意度高；是性能價(jià)格比理想的一種鎮(zhèn)痛方法。與傳統(tǒng)給藥方法相比，病人自主給藥方式更好；在鎮(zhèn)痛藥用量方面，病人之間個(gè)體差異性很大；鎮(zhèn)痛泵設(shè)計(jì)合理，使用時(shí)不會(huì)造成用藥過量；多數(shù)病人用藥安全、有效，滿意度高?？s短住院時(shí)間,節(jié)省護(hù)理時(shí)間,副作用少PCA（病人自控鎮(zhèn)痛）PCA的臨床意義PCA-不能改變病人的預(yù)后，但是能夠提供良好的鎮(zhèn)痛！PCA-doesnotalteroutcome,butgoodqualityofpainrelief10thWorldCongressonPain,Aug.17-22,2002,SanDiego,USAPCA術(shù)后鎮(zhèn)痛用藥新動(dòng)向增強(qiáng)嗎啡鎮(zhèn)痛作用；減少副作用；撲熱息痛&NSAIDs氯胺酮1mg+嗎啡1mgforPCAor氯胺酮at1-2ug/kg/min氯胺酮與嗎啡合用；減輕痛覺過敏；hyperalgesia/allodynia撲熱息痛1g/4-6h;雙氯芬酸50mg/8h;酮洛酸10-30mg/8h布洛芬400mg/8h.靜脈PCA仍是術(shù)后鎮(zhèn)痛最常用的方法病例n=1793PCA=1478,

80.5%CEI=261,

14.3%Others=54,

5.2%JosephinePYChen,AcutePainServiceDataPWH

1/2003–12/2003鎮(zhèn)痛效果(VAS評(píng)分的結(jié)果)PCAVAS8-10

=3.2%CEI:VAS8-10

=3.5%靜脈PCA與硬膜外鎮(zhèn)痛的比較病人滿意度評(píng)分:PCA

=

49.2%

>8-10CEI

=

68.1%

>8-10靜脈PCA與硬膜外鎮(zhèn)痛的比較但是有報(bào)道：靜脈PCA使病人更多參與，滿意度更高！硬膜外鎮(zhèn)痛--副作用就技術(shù)而言穿破硬脊膜硬膜外血腫硬膜外膿腫神經(jīng)根損傷就LA而言低血壓感覺麻木運(yùn)動(dòng)阻滯就opioid而言延遲性呼吸抑制尿潴留皮膚瘙癢硬膜外鎮(zhèn)痛的缺點(diǎn)硬膜外穿刺相關(guān)的風(fēng)險(xiǎn)DuralpuncturewithpostspinalheadacheNerveroot/corddamageHaematomaInfection

低血壓-交感神經(jīng)阻斷Dehydration,on-goingbloodlossOverdose硬膜外置管的相關(guān)問題Dislodgement;infection;haematoma;coagulopathyMigrationtobloodvessel/subarachnoidspace鎮(zhèn)痛失敗需更多的人力Moremonitoring:Inappropriateincreaselevelofblock,lowerlimbweakness

靜脈PCA與硬膜外鎮(zhèn)痛的臨床資料

提前終止治療:CEI=11%原因

:無效；血流動(dòng)力學(xué)不穩(wěn)定;

導(dǎo)管脫出;

出現(xiàn)感染征象等一些醫(yī)院硬膜外給藥量偏?。喝?ml/h連續(xù)輸注

效差！硬膜外鎮(zhèn)痛的麻煩：可能的低血壓

Epidural需排除手術(shù)并發(fā)癥;低血容量;降壓治療;導(dǎo)管置入蛛網(wǎng)膜下腔其他問題：PCA很少發(fā)生防止導(dǎo)管脫出或打折相對(duì)制動(dòng)注意是否出現(xiàn)運(yùn)動(dòng)阻滯/麻木感覺靜脈PCA與硬膜外鎮(zhèn)痛的比較

術(shù)后惡心嘔吐、早期行走和盡早出院：

硬膜外與IVPCA

誰更好？

尚難定論！注意事項(xiàng):局部/全身感染持續(xù)/波動(dòng)

T↑38°C導(dǎo)管部位發(fā)紅靜脈通路副作用

結(jié)束鎮(zhèn)痛時(shí)的注意事項(xiàng)

Epidural PCA導(dǎo)管尖端是否完整皮膚完整性有無感染征象肝素/LMWH

在2hrs后再使用沒有過多注意事項(xiàng)硬膜外鎮(zhèn)痛好于PCA的證據(jù)何在？38篇關(guān)于

IVPCAvsepidural的研究腹部、胸部、骨科和婦科手術(shù)病人觀察指標(biāo)如下：PainreliefOpioidsparingeffects:lessN&V,lesssedativeMobilizationRespiratoryfunctionCardiovascularcomplicationsHospitalStay

SteinbergRB,LiuSS,WuCL,MackeyDC,GrassJA,AhlenK,JeppssonL.Comparisonofropivacaine-fentanylpatient-controlledepiduralanalgesiawithmorphineintravenouspatient-controlledanalgesiaforperioperativeanalgesiaandrecoveryafteropencolonsurgery.JClinAnesth.2002Dec;14(8):571-7.2.

MannC,PouzeratteY,BoccaraG,PeccouxC,VergneC,BrunatG,DomergueJ,MillatB,ColsonP.Comparisonofintravenousorepiduralpatient-controlledanalgesiaintheelderlyaftermajorabdominalsurgery.Anesthesiology.2000Feb;92(2):433-41.3.

WulfH,BiscopingJ,BelandB,Bachmann-MennengaB,MotschJ.Ropivacaineepiduralanesthesiaandanalgesiaversusgeneralanesthesiaandintravenouspatient-controlledanalgesiawithmorphineintheperioperativemanagementofhipreplacement.RopivacaineHipReplacementMulticenterStudyGroup.AnesthAnalg.1999Jul;89(1):111-6.4.

JayrC,BeaussierM,GustafssonU,LeteurnierY,NathanN,PlaudB,TranG,VarletC,MartyJ.Continuousepiduralinfusionofropivacaineforpostoperativeanalgesiaaftermajorabdominalsurgery:comparativestudywithi.v.PCAmorphine.BrJAnaesth.1998Dec;81(6):887-92.5.

TsuiSL,LeeDK,NgKF,ChanTY,ChanWS,LoJW.Epiduralinfusionofbupivacaine0.0625%plusfentanyl3.3micrograms/mlprovidesbetterpostoperativeanalgesiathanpatient-controlledanalgesiawithintravenousmorphineaftergynaecologicallaparotomy.AnaesthIntensiveCare.1997Oct;25(5):476-81.硬膜外鎮(zhèn)痛與靜脈PCA的比較疼痛腸功能恢復(fù)呼吸功能鎮(zhèn)靜早期活動(dòng)N&V盡早出院Epiduralbetter1,2,3,4,5,6,7,8,9,10,12,13,14,15,16,17,18,19,20,21,22,26,29,31,34,37(26)2,3,11,14,17,24,28(7)16,18,26,27(4)2,10,12,18,19,20,28(7)(0)3,6,16,20,31(5)11,26,31(3)Epidural=PCA23,24,26,28,30,32,33,35,36,38(10)13,34(2)10,28(2)38(1)13,23,33(3)5,12,13,25,28,38(6)17,23,33,34(4)Epiduralworse(0)(0)(0)(0)(0)(0)(0)6.KampeS,RandebrockG,KienckeP,HunselerU,CranfieldK,KonigDP,DiefenbachC.Comparisonofcontinuousepiduralinfusionofropivacaineandsufentanilwithintravenouspatient-controlledanalgesiaaftertotalhipreplacement.Anaesthesia.2001Dec;56(12):1189-93.7.

NganKeeWD,LamKK,ChenPP,GinT.Comparisonofpatient-controlledepiduralanalgesiawithpatient-controlledintravenousanalgesiausingpethidineorfentanyl.AnaesthIntensiveCare.1997Apr;25(2):126-32.8.

BoisS,CoutureP,BoudreaultD,LacombeP,FugereF,GirardD,NadeauN.Epiduralanalgesiaandintravenouspatient-controlledanalgesiaresultinsimilarratesofpostoperativemyocardialischemiaafteraorticsurgery.AnesthAnalg.1997Dec;85(6):1233-9.9.

SilvastiM,PitkanenM.Continuousepiduralanalgesiawithbupivacaine-fentanylversuspatient-controlledanalgesiawithi.v.morphineforpostoperativepainreliefafterkneeligamentsurgery.ActaAnaesthesiolScand.2000Jan;44(1):37-4210.

BenzonHT,WongHY,BelavicAMJr,GoodmanI,MitchellD,LefheitT,LociceroJArandomizeddouble-blindcomparisonofepiduralfentanylinfusionversuspatient-controlledanalgesiawithmorphineforpostthoracotomypain.AnesthAnalg.1993Feb;76(2):316-22硬膜外鎮(zhèn)痛更好（BetterwithEpidural）deLeon-CasasolaOA,LemaMJ,KarabellaD,HarrisonP.Postoperativemyocardialischemia:epiduralversusintravenouspatient-controlledanalgesia.Apilotproject.RegAnesth.1995Mar-Apr;20(2):105-12.

GarnettRL,MacIntyreA,LindsayP,BarberGG,ColeCW,HajjarG,McPhailNV,RuddyTD,StarkR,BoisvertD.Perioperativeischaemiainaorticsurgery:combinedepidural/generalanaesthesiaandepiduralanalgesiavsgeneralanaesthesiaandi.v.analgesia.CanJAnaesth.1996Aug;43(8):769-77.

兩種方法沒有區(qū)別（Nodifference）BoisS,CoutureP,BoudreaultD,LacombeP,FugereF,GirardD,NadeauN.Epiduralanalgesiaandintravenouspatient-controlledanalgesiaresultinsimilarratesofpostoperativemyocardialischemiaafteraorticsurgery.AnesthAnalg.1997Dec;85(6):1233-9.心血管并發(fā)癥:

硬膜外與

IVPCA比較對(duì)血管搭橋手術(shù)效果的影響:

硬膜外與IVPCA的比較硬膜外鎮(zhèn)痛更好（Betterwithepidural）PerlerBA,ChristophersonR,RosenfeldBA,NorrisEJ,FrankS,BeattieC,WilliamsGM.Theinfluenceofanestheticmethodoninfrainguinalbypassgraftpatency:acloserlook.AmSurg.1995Sep;61(9):784-9.TumanKJ,McCarthyRJ,MarchRJ,DeLariaGA,PatelRV,IvankovichAD.Effectsofepiduralanesthesiaandanalgesiaoncoagulationandoutcomeaftermajorvascularsurgery.AnesthAnalg.1991Dec;73(6):696-704.一些研究表明麻醉方法

(PCAvsEA)

并非重要的影響因子PierceET,PomposelliFBJr,StanleyGD,LewisKP,CassJL,LoGerfoFW,GibbonsGW,CampbellDR,FreemanDV,HalpernEF,BodeRHJr.Anesthesiatypedoesnotinfluenceearlygraftpatencyorlimbsalvageratesoflowerextremityarterialbypass.JVascSurg.1997Feb;25(2):226-32SchunnCD,HertzerNR,O'HaraPJ,KrajewskiLP,SullivanTM,BevenEG.

Epiduralversusgeneralanesthesia:doesanestheticmanagementinfluenceearlyinfrainguinalgraftthrombosis?AnnVascSurg.1998Jan;12(1):65-9.硬膜外麻醉的風(fēng)險(xiǎn)

盡管硬膜外鎮(zhèn)痛的價(jià)值超過其罕見但十分嚴(yán)重并發(fā)癥的風(fēng)險(xiǎn)。Theadvantagesofepiduralanalgesiaarewidelybelievedtooutweighrarebutimportantmorbidityrisks. Lancet2002

但是，我國每年硬膜外鎮(zhèn)痛相關(guān)并發(fā)癥時(shí)有耳聞，觸目驚心?。。?/p>

硬膜外鎮(zhèn)痛的潛在問題患者不同意硬膜外血腫和膿腫技術(shù)失敗需要更多的APS服務(wù)醫(yī)療資源花費(fèi)大肝素與硬膜外鎮(zhèn)痛標(biāo)準(zhǔn)化肝素

5,000u使用后

4-6hours之內(nèi)不能進(jìn)行硬膜外穿刺硬膜外穿刺結(jié)束2hr以后才能再次使用標(biāo)準(zhǔn)肝素低分子量肝素使用后12hours之內(nèi)不能進(jìn)行硬膜外穿刺硬膜外穿刺結(jié)束

2hr以后才能再次使用低分子量肝素術(shù)后鎮(zhèn)痛發(fā)展趨勢(shì)用藥個(gè)體化采用多模式鎮(zhèn)痛方法（multimodalfashion）平衡鎮(zhèn)痛：使用阿片類藥物；減少外周刺激(NSAID’s）；阻斷疼痛傳導(dǎo)通路（如神經(jīng)阻滯）；情感行為治療。對(duì)術(shù)后患者加強(qiáng)心血管系統(tǒng)及呼吸系統(tǒng)監(jiān)測(cè)區(qū)域麻醉的演變(1784-2004)神經(jīng)刺激器定位：外周神經(jīng)阻滯

腰叢坐骨神經(jīng)阻滯

外周神經(jīng)阻滯(NB)對(duì)術(shù)后并發(fā)癥的影響PCA在我國臨床應(yīng)用十年1994年2004年如何進(jìn)一步提高PCA鎮(zhèn)痛療效？如何進(jìn)一步防治PCA相關(guān)副作用？如何建立和普及APS規(guī)范化治療？麻醉醫(yī)師護(hù)理人員病人外科醫(yī)師目的：-選擇個(gè)體化鎮(zhèn)痛方案-使副作用減到最少-預(yù)防術(shù)后并發(fā)癥-使病人滿意APS查房

MDANDERSONCANCERCENTER2004年3月見聞不論何種鎮(zhèn)痛方法，都迫切需要規(guī)范化的鎮(zhèn)痛服務(wù)！術(shù)后鎮(zhèn)痛服務(wù)機(jī)構(gòu)

（AcutePainService，APS）

麻醉醫(yī)師和護(hù)士為基礎(chǔ)；任務(wù)和作用：建立臨床鎮(zhèn)痛規(guī)范和指南指導(dǎo)術(shù)后鎮(zhèn)痛的實(shí)施（如PCA）教育和培訓(xùn)相關(guān)人員每日查房制度-dailyround監(jiān)測(cè)鎮(zhèn)痛治療效果及相關(guān)副作用-