疼痛的诊断和治疗英文.ppt

Diagnosis and treatment of Pain,Liu Hui Anesthesiology Department, West China Hospital, Sichuan University.,疼痛学 【目的要求】： 1. 掌握术后镇痛重要性及病人自控镇痛应用 2. 掌握慢性疼痛治疗的基本方法及治疗原则 3掌握癌痛药物治疗的三阶梯原则 4. 熟悉疼痛的恶性循环及传导通路，神经阻滞治疗疼痛的机理； 5. 了解疼痛的简史、分类、机理和测量评估 【讲授内容】： 疼痛基本知识（概念、发展简史、疼痛的测定与评估、发生机理及传导通路） 慢性疼痛的治疗方法及原则，神经阻滞治疗疼痛的机理及适应症、禁忌症 癌痛治疗方法 术后镇痛：定义、术后疼痛对机体的影响、术后镇痛的意义及方法； 病人自控镇痛：定义、方法、分类及适应症、基本术语及意义。 【重点难点】： 难点：疼痛的发病机理及传导通路； 重点：1.疼痛的恶性循环及神经阻滞治疗疼痛的机理； 2.慢性疼痛的治疗方法及癌痛的三阶梯药物治疗； 3.术后疼痛对机体的影响及术后镇痛的意义。 四、【讲授时数】：2 3学时 五、【参考书】：疼痛诊疗学 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,每一个人生命过程中会由于不同原因在不同时期不同程度受到疼痛的折磨，严重时会影响生理机能和生命质量，甚至危及生命安全。有的时候疼痛本身就是一种病（如三叉神经痛），或者引起疼痛的原发疾病已不那么重要（如晚期癌痛），使疼痛治疗成为唯一的选择,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,国际疼痛研究会和WHO提出：,疼痛是人体第五大生命体征; 慢性疼痛是一种疾病； 解除疼痛是患者的基本权利。,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对伤害性刺激敏感性增强和反应阈值降低 allogesia非痛刺激引起。 自发痛-损伤区域 Bad pain坏痛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,从病程分 acute pain chronic pain 从人体的部位分 headache cervical-shouder pain thoracico-abdominal pain low back pain,从疼痛的来源分 皮肤痛 muscles pain、tendons pain、ligaments pain arthralgia bone pain visceral pain neuropathic pain（central pain）,pathogenic classfication,无菌性炎症(inflammation pain)椎管内外或关节内外软组织因急性损伤后遗或慢性劳损而引起的损害性疼痛。 神经病理性疼痛neuropathic pain_机械性压迫(mechanic pressure)机体生物力学失去平衡，解剖位置改变，肌应力异常引起的神经血管受压性疼痛。（neuropathic pain神经病理性疼痛） 癌痛(cancer pain ),部位分类position classfication,浅表痛(superficial pain)由机械性、化学性、物理性的不良刺激引起皮肤、黏膜部位的疼痛。程度剧烈、定位精确多呈局限性如刀割、针刺。Adelta神经传递。 深部痛(deep pain)内脏、关节、胸膜、腹部受刺激而产生的疼痛，常为灼痛，无明显疼痛部位，不呈局限性。C神经传递 中枢痛(central pain)-疼痛强烈、持久、难忍,疼痛的性质分类,刺痛(pricking pain) 灼痛(burning pain) 胀痛(distending pain) 酸痛(aching pain) 绞痛(colicky pain),Treatment of pain,Significance of pain treatment,Control pain and facilitate rehabilitation（消除疼痛，促进恢复） Improve body function and life quality（改善机体功能和生活质量） Treat original disease（治疗原 发病）,疼痛治疗的原则,明确诊断 除痛与病因治疗相结合 综合治疗 确保安全有效,常用治疗方法,药物疗法 物理疗法 心理疗法 手术疗法 介入疗法、 神经阻滞疗法 其他疗法,疼痛治疗可以在疼痛产生过程的各个环节进行 采用多模式的综合疗法 目前，大多数疼痛是可以得到治疗或控制的；而且新的技术不断发展,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.,什麽是神经阻滞(nerve block) 是指在末梢的脑脊髓神经节，脑脊髓神经，交感神经节等神经内或附近注入药物或用物理方法使针触到神经给予刺激，阻断神经传导功能。,疼痛临床是指以神经阻滞为主的麻醉学方法诊疗疼痛性疾病的一门学科。 既要找出病因，又要使患者达到治疗的目的。,脑,脊髓,压迫血管,感觉神经,血管收缩,组织缺血、缺氧,致痛物质,肌肉收缩,交感神经,运动N,疼痛的恶性循环,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,神经阻滞奏效的机理： 阻断疼痛的传导通路 阻断疼痛的恶性循环 改善血行状态 抗炎症作用,神经阻滞疗法的位置 1 药物疗法 2手术疗法 3神经阻滞疗法：又称为第三疗法 神经阻滞疗法 药物疗法 手术疗法,Surgery,Nerve block (Micro-invasive therapy),Pharmacotherapy,Therapies of chronic pain,Quantization of pain intensity,疼痛测定和评估的意义,准确判定疼痛特征,指导用药和治疗方法. 及时调整治疗方案 判断治疗效果 判断预后,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(口述描绘评分法) 无痛 轻微痛 中度痛 重度痛 极重度痛,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,行为测定法,6点行为评分法(behavioral rating scale,BRS-6) 疼痛日记评分法(pain diary scale,PDS) 生理指标和生化指标,Objective of life？,Painless，无痛 Happiness，快乐,术后镇痛(post-operative analgesia),术后疼痛是一种急性疼痛，指机体对疾病本身和手术造成的组织损伤的一种复杂的生理反应，它表现为心理和行为上一种不愉快的经历。,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,术后镇痛的意义：,减轻患者手术后痛苦 提高防止围术期并发症能力 提高围术期安全性 缩短住院日，提高出院率，节省住院费用 促进早日康复,术后镇痛的原则,明确病因 镇痛药物和方法选择：安全、有效、简便易性行、对机体干扰小。 根据疼痛强度选用药物和方法 镇痛药物从最低有效量开始，定时评估和调整方案，个体化用药,术后镇痛的方法,口服给药 椎管内给药 蛛网膜下隙镇痛 硬膜外胫镇痛 胃肠外给 肌肉注射 静脉注射 PCA 其它,术后镇痛的治疗目的,解除术后病人疼痛的同时，没有更多的副反应并降低术后并发症的发生率。,传统的术后镇痛方法肌注镇痛药,缺点：（1）不灵活 （2）依赖性 （3）不及时 不灵活病人之间对药物的需要量可能相差十倍以上 依赖性必须叫护士，护士确信病人需要镇痛 不及时必须由两名护士准备、核对药物，并肌注，药物吸收入血管还需一定的时间扩散至大脑的作用位置才能产生镇痛效果。最终导致镇痛不够。,病人自控镇痛技术（patient-controlled analgeria ，PCA）,病人根据自己的镇痛需要自己控制给药，在方便快捷、反应迅速的同时，对镇痛药用量的个体差异性降低到最小的程度。术后镇痛的主要方法,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既为一种新型镇痛给药法 PCA特点：1. 病人不必打扰医护人员，可以自行控制给药 2镇痛效果迅速，镇静程度轻 3利于病情恢复 4能克服药效学和药动学的个体差异 5镇痛效果好、简便、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的专用术语,负荷剂量（loading dose） 给予负荷剂量旨在迅速达到镇痛所需 的血药浓度，称之为“最小有效镇痛浓度”（MEAC）使病人迅速达到无痛状态。,单次给药剂量（bolus）,PCA装置有病人控制间断给药。这种给药方式也称PCA给药或维持给药。病人通过PCA装置上的特殊按钮给药。PCA所采用的小剂量多次给药的目的在于维持一定的血浆镇痛药浓度，但又不产生过度镇静作用。,锁定时间（lockout time，LT）,指的是该时间内PCA装置对病人再次给药的指令不作反应。 锁定时间可防止病人在前次给药完全生效之前再次给药，是一种自我保护措施。,最大用药量（maximal dose）,是PCA装置的另一自我保护措施：有1小时限制和4小时限制量。,连续背景输注给药（basal infusion 或background infusion）,（1）持续给药 （2）连续给药+PCA （3）PCA给药基础上的连续给药,PCA分类：根据给药途径不同,静脉PCA（PCIA），硬膜外PCA（RCEA），皮下PCA（PCSA），外周神经阻滞PCA（PCNA）,PCA临床应用范围：,术后急性疼痛的治疗 肿瘤疼痛病人的治疗 内科疼痛病人 分娩镇痛 儿童病人镇痛 烧伤和创伤疼痛治疗 将PCA作为一种研究手段或工具,PCA的优点,避免反复肌肉注射给病人带来的痛苦 可使病人积极参与疼痛治疗，减少焦虑，并使镇痛所需的药量减少 能容易和精确地满足病人的镇痛需要，及时有效的镇痛 尽快恢复病人生理机能,分娩镇痛（labor pain ）,自学,慢性疼痛的治疗,Chronic Pain Management,慢性疼痛的概念,一种急性疾病或一次损伤所引起的疼痛持续超过正常所需的治愈时间，或疼痛缓解后间隔数月或数年复发或反复发作者成为慢性疼痛。 慢性疼痛是一种疾病。,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,慢性疼痛的治疗原则,明确诊断，查明疼痛的病因和部位。 疼痛评估，包括治疗前和治疗过程中评估。 综合治疗措施。 安全有效。 合理用药。,三慢性疼痛的治疗方法,药物治疗。 神经组滞疗法。 物理疗法。 其它。,常见的慢性疼痛性疾病,头面部痛 颈肩及上肢痛 胸背部痛 腰背部痛 下肢痛 全身性疾病,Cancer pain(癌性疼痛),恶性肿瘤在其发展过程中出现的疼痛. 癌症致痛机制或原因 1. 癌症发展所致的疼痛 2. 癌症诊断和治疗后的疼痛 3. 合并慢性疼痛性疾病 4. 癌痛综合征,持续性疼痛,定时用药,突发性疼痛,时间,中至重度慢性疼痛的组成,癌性疼痛的治疗,病因治疗 1.手术治疗 2.放射治疗 3.化学治疗 4.抗癌止痛治疗,癌痛的对症治疗,药物治疗 癌痛三阶梯治疗方案遵循的原则 1.阶梯给药 2.口服给药 3.按时给药 4.用药剂量个体化 5.辅助用药,癌痛三阶梯治疗,第一阶梯：非阿片类镇痛药阿司匹林 第二阶梯：弱阿片类可待因、曲马多；可并用第一阶梯的镇痛药或辅助药 第三阶梯：强阿片类镇痛药吗啡； 可并用第一阶梯、第二阶梯的镇痛药或辅助药,癌痛的对症治疗,神经阻滞 经皮电