疼痛的诊断和治疗(英文)课件

1、 Diagnosis and treatment of PainLiu 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

2、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 IntroductionCome as you be bornIntroductionAccompany with you all your lifePain: a fashionable topicIntruductio

3、n 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 physiolo

4、gical 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

5、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 management3500 DC Egyptian used opioidHistory of pain =history of medicineAdvance in the field of painBasic researchMore targeting,less toxic drugsPCA 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 ma

6、nagementDefinition of Painpain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.Teaching OutlineBasic aspect AnatomyInjury and painProcessing of painPain in generalClinical aspectEffect on bodyClassificationPain

7、 assessment and diagnosisPain treatmentAdvancement in pain management13Basic aspect of PainInjury and painTRAUMAPOTENTIAL INJURYINTOXICATIONSURGERYINFECTIONTUMORDEGENERATIONASIC/BNCThe Model of Pain by DescartesClinical aspect of painTeaching OutlineBasic aspect AnatomyInjury and painProcessing of p

8、ainPain in generalClinical aspectClassification Effect on bodyPain assessment and diagnosisPain treatmentAdvancement in pain management22classificationGood gain pain：physiological pain（good pain）“good pain”alarmingprotectionNo good gain pain：pathophysiological pain（bad pain） bad pain except alarimin

9、g，pain is of no goodWe would like with no pain system if we had other alarming systemshyperalgesia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SensitizationGottschalk A, Smith DS. Am Fam Physician. 2019;1979-84. InjuryPain Intensity10 8 6 4 2 0Stimulus IntensityNormalPainResponse

10、AllodyniaHyperalgesiaclassfication从病程分acute painchronic pain从人体的部位分headachecervical-shouder painthoracico-abdominal painlow back pain从疼痛的来源分皮肤痛muscles pain、tendons pain、ligaments pain arthralgiabone painvisceral painneuropathic pain（central pain）pathogenic classfication无菌性炎症(inflammation pain)椎管内外或关

11、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

12、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 painSignificance of pain treatmentControl 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 orig

13、inal 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 PainCategories of analgesic drugsOpioid analgesicsNonopioid analgesicsAdjuvant analgesicsDrugs for headacheThe first ladder analgesi

14、cs:Nonopioid AnalgesicsAcetaminophen (paracetamol)Nonsteroidal anti-inflammatory drugsNonopioid AnalgesicsAcetaminophen (paracetamol)Minimal anti-inflammatory effectsFewer adverse effects than other nonopioid analgesics Adverse effects Renal toxicity Risk for hepatotoxicity at high doses Increased r

15、isk with liver disease or chronic alcoholismNo effect on platelet functionNSAIDsMechanismInhibit both peripheral and central cyclo-oxygenase(COX), reducing prostaglandin formation2 isoforms of COXCOX-1: Constitutive, physiologicCOX-2: Inducible, inflammatoryCOX Pathway and NSAIDs, COX-2Arachidonic a

16、cid (an fatty acid)COX-1COX-2Normalconstituentbrainkidneyovary uterusInducibleinflammationpainfeverCoxibsNSAIDs(-)(-)gastric cytoprotectionrenal sodium / water balanceplatelet aggregationGlucocorticoids(block mRNA expression)(-)NormalconstituentAnd MI / stroke risk factorsDose-dependent toxicityInto

17、lerability, dyspepsiaGI bleedingUlcers bleeds / perforationsUpper-GIRenalFluid retention, oedema, hypertensionRenal dysfunction / failure acute / chronicHeart failureAnti-platelet effectsAngioedema, bronchospasmContributes to blood lossHypersensitivityNSAIDs - Safety ConcernsOpioid Therapy in Pain R

18、elated to Medical Illness Opioid therapy is the mainstay approach for Acute painCancer painAIDS painPain in advanced illnessesBut undertreatment is a major problemOpioids-Routes of AdministrationOral (pills, liquid)RectalTransdermalTransmucosalSubQ(IM)IVEpiduralIntrathecal=modalities (PCA)Opioids Si

19、de EffectsCommonConstipationNauseaPruritisSedationLess commonRespiratory depressionUrinary retentionMyoclonic jerksDeliriumSeizures其他Local anestheticNeurolytic drugsGlucocorticoid hormoneAdjuvant analgesicsNerve blockWhat is a nerve block?Nerve block is a general term, but it basically means the inj

20、ection 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

21、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 cortexSpinal cord sensory nerve vasoconstrictionischemia hypoxia(tissue) pain substance muscular contractionsympathetic nerve motor nerve Mechanisms:：interrupting pain sensory pathways Interrupting vicious circle of pain Improving vascular/ nutrition supply Anti

22、-inflammatory effect trauma injury herpes zoster painBlood vessel compressedVicious 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 SurgeryNerve block(Micro-invasive therapy)PharmacotherapyTherapies of chronic painQuantization of pain inte

23、nsity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 itSingle dimension of pain assessment visual analogue scale, VASnumeric rating scale, NRSverbal rating scale, VRS faces pain rating scaleMulti-dimension tools McGill Pain Questionnaire, MPQBrief pain invento

24、ry, BPIVisual analogue scale(VAS)Numeric pain intensity scaleVerbal descriptive rating scale（VRS）0 no pain1 slight pain2 moderate pain3 severe painVerbal 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 scaleMcGill pain questionnaireObjective pain assessment Pain thresholdTherma

25、l radiation,TRElectrical stimulation,EScold stimulation drug stimulation Physiological parameterstidal 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

26、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 surgeryOne kind of acute painIt

27、 is a complex process influenced by both physiological and psychological factors Management of postoperative pain has generally been shown to be inadequate Acute painSignals of diseasesFor insult of tissue intactAdaptive,of goodAlarm for early treatmentOne symptom of disease traumasurgeryAcute phase

28、 of infectionAcute pain（Post-Operation Pain）Psychological status：exciting, agitation,sc-reaming, depression if at pain state for a long timeNeuroendocrine system：increased secretion of catecholamineCirculation system：rapid or slow P related to intensity of pain,even cardiac arrest. BP increase or de

29、crease, collapse, shock or cardiac vascular accidentRespiratory system：rapid with small VTDigestive system：nausea and vomiting, malfunctioningImmuno system ：Delayed healingGenitourinary - 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

30、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-

31、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 intr

32、avenous (other routes) line.What is PCAPatient-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 acc

33、idental overdose Terms in PCAPCA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

34、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

35、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 PainHistorically defined as pain extending 3 or 6 months beyond onset or expected period of heal

36、ingNow considered as pain thatExtends beyond the healing periodHas low levels of identified pathology that inadequately explain the presence and / or extent of painDisrupts sleep or normal activitiesContains:Neuralgias: PHNMusculoskeletal Pain: back painCancer painOthers:headache vascular disease (R

37、aynaud 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