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1、术后镇痛-理念的共识与方法的争议,北京协和医院 黄宇光,理念的共识：“疼痛-第五生命体征”,疼痛管理新标准：疼痛评价、治疗在临床具有优先地位；疼痛作为第5生命体征，与体温、呼吸、脉搏、血压具有同样重要意义；病人具有足够的权利要求重视其疼痛的诊治。美国医疗机构评审联合委员会 James Campell,美国疼痛协会主席,消除疼痛是基本的人权！Pain relief is a basic human right！疼痛是第五生命体征！Pain is the fifth vital sign!,“By any reasonable code,freedom from pain should be a
2、basic human right,limited only by our knowledge to achieve it.”Liebeskind JC&Melzack R 1987,镇痛用药阶梯（Analgesic ladder）,术后疼痛的演变：恶性循环,手术,急性疼痛,慢性疼痛,行为变化,神经学改变Neuronal changes,脊髓兴奋性增高Spinal cord hyperexcitability,上扬,术后镇痛方法与选择Post-Op Modalities,Pain pump(local anesthesia infiltration)Indwelling epidural ca
3、theterPCA IV/IM analgesics(NSAIDs,opioids)Oral analgesicsTopical(cryotherapy,heat)PT/OT,静脉 PCA,程序化机械泵Programmable mechanical pump自行给药 Self-administered按压钮给予设定的药物Press button to give a set dose of morphine iv锁定时间避免药物过量Lock-out period to minimize overdose,经导管连续输注给药Continuous Infusion via a catheter,硬膜
4、外腔（In epidural space）:局麻药-阻断运动/感觉/交感神经阿片类药物阻断脊髓阿片受体,硬膜外镇痛,病人自控镇痛（PCA）术后镇痛常用方法,PCA：我国临床应用十年（1994-2004）,静脉PCA的优点（与传统肌肉注射/皮下注射相比）,药物吸收更加可靠 用药灵活/起效快维持更为稳定的镇痛水平,个体对镇痛药物的敏感性2-5倍的差异,PCA是克服个体差异较为理想的镇痛方法,PCA治疗的药理学依据,PCA 流行的原因,间断肌注阿片类药物不能有效缓解疼痛；安全、精细的给药技术深受患者喜爱；患者满意度高；是性能价格比理想的一种镇痛方法。,与传统给药方法相比，病人自主给药方式更好；在镇痛
5、药用量方面，病人之间个体差异性很大；镇痛泵设计合理，使用时不会造成用药过量；多数病人用药安全、有效，满意度高。缩短住院时间,节省护理时间,副作用少,PCA（病人自控镇痛）,PCA的临床意义,PCA-不能改变病人的预后，但是能够提供良好的镇痛！PCA-does not alter outcome,but good quality of pain relief,10th World Congress on Pain,Aug.17-22,2002,San Diego,USA,PCA术后镇痛用药新动向,增强吗啡镇痛作用；减少副作用；扑热息痛&NSAIDs,氯胺酮 1 mg+吗啡 1 mg for PC
6、A or 氯胺酮 at 1-2 ug/kg/min,氯胺酮与吗啡合用；减轻痛觉过敏；hyperalgesia/allodynia,扑热息痛 1 g/4-6 h;双氯芬酸 50 mg/8 h;酮洛酸 10-30 mg/8 h布洛芬 400 mg/8h.,静脉PCA仍是术后镇痛最常用的方法,病例 n=1793PCA=1478,80.5%CEI=261,14.3%Others=54,5.2%,Josephine PY Chen,Acute Pain Service Data PWH1/2003 12/2003,镇痛效果(VAS评分的结果)PCAVAS 8-10=3.2%CEI:VAS 8-10=3.
7、5%,静脉PCA与硬膜外镇痛的比较,病人满意度评分:PCA=49.2%8-10CEI=68.1%8-10,静脉PCA与硬膜外镇痛的比较,但是有报道：静脉PCA使病人更多参与，满意度更高！,硬膜外镇痛-副作用,就技术而言穿破硬脊膜硬膜外血肿硬膜外脓肿神经根损伤,就LA而言低血压感觉麻木运动阻滞就opioid而言延迟性呼吸抑制尿潴留皮肤瘙痒,硬膜外镇痛的缺点,硬膜外穿刺相关的风险Dural puncture with post spinal headacheNerve root/cord damageHaematomaInfection 低血压-交感神经阻断Dehydration,on-going
8、 blood lossOverdose硬膜外置管的相关问题Dislodgement;infection;haematoma;coagulopathyMigration to blood vessel/subarachnoid space镇痛失败需更多的人力More monitoring:Inappropriate increase level of block,lower limb weakness,静脉PCA与硬膜外镇痛的临床资料,提前终止治疗:CEI=11%原因:无效；血流动力学不稳定;导管脱出;出现感染征象等一些医院硬膜外给药量偏小：如 2 ml/h 连续输注 效差！,硬膜外镇痛的麻烦：
9、可能的低血压,Epidural需排除手术并发症;低血容量;降压治疗;导管置入蛛网膜下腔其他问题：,PCA很少发生,防止导管脱出或打折相对制动注意是否出现运动阻滞/麻木感觉,静脉PCA与硬膜外镇痛的比较,术后恶心呕吐、早期行走和尽早出院：硬膜外 与 IV PCA 谁更好？尚难定论！,注意事项:局部/全身感染持续/波动 T38C导管部位发红,静脉通路副作用,结束镇痛时的注意事项 Epidural PCA,导管尖端是否完整皮肤完整性有无感染征象肝素/LMWH在2hrs后再使用,没有过多注意事项,硬膜外镇痛好于PCA的证据何在？,38 篇关于 IV PCA vs epidural的研究腹部、胸部、骨科
10、和妇科手术病人观察指标如下：Pain reliefOpioid sparing effects:less N&V,less sedativeMobilizationRespiratory functionCardiovascular complicationsHospital Stay,Steinberg RB,Liu SS,Wu CL,Mackey DC,Grass JA,Ahlen K,Jeppsson L.Comparison of ropivacaine-fentanyl patient-controlled epidural analgesia with morphine intra
11、venous patient-controlled analgesia for perioperative analgesia and recovery after open colon surgery.J Clin Anesth.2002 Dec;14(8):571-7.2.Mann C,Pouzeratte Y,Boccara G,Peccoux C,Vergne C,Brunat G,Domergue J,Millat B,Colson P.Comparison of intravenous or epidural patient-controlled analgesia in the
12、elderly after major abdominal surgery.Anesthesiology.2000 Feb;92(2):433-41.3.Wulf H,Biscoping J,Beland B,Bachmann-Mennenga B,Motsch J.Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of
13、hip replacement.Ropivacaine Hip Replacement Multicenter Study Group.Anesth Analg.1999 Jul;89(1):111-6.4.Jayr C,Beaussier M,Gustafsson U,Leteurnier Y,Nathan N,Plaud B,Tran G,Varlet C,Marty J.Continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery:comparat
14、ive study with i.v.PCA morphine.Br J Anaesth.1998 Dec;81(6):887-92.5.Tsui SL,Lee DK,Ng KF,Chan TY,Chan WS,Lo JW.Epidural infusion of bupivacaine 0.0625%plus fentanyl 3.3 micrograms/ml provides better postoperative analgesia than patient-controlled analgesia with intravenous morphine after gynaecolog
15、ical laparotomy.Anaesth Intensive Care.1997 Oct;25(5):476-81.,硬膜外镇痛与静脉PCA的比较,6.Kampe S,Randebrock G,Kiencke P,Hunseler U,Cranfield K,Konig DP,Diefenbach C.Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient-controlled analgesia after total hip replacemen
16、t.Anaesthesia.2001 Dec;56(12):1189-93.7.Ngan Kee WD,Lam KK,Chen PP,Gin T.Comparison of patient-controlled epidural analgesia with patient-controlled intravenous analgesia using pethidine or fentanyl.Anaesth Intensive Care.1997 Apr;25(2):126-32.8.Bois S,Couture P,Boudreault D,Lacombe P,Fugere F,Girar
17、d D,Nadeau N.Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery.Anesth Analg.1997 Dec;85(6):1233-9.9.Silvasti M,Pitkanen M.Continuous epidural analgesia with bupivacaine-fentanyl versus patient-controlled
18、analgesia with i.v.morphine for postoperative pain relief after knee ligament surgery.Acta Anaesthesiol Scand.2000 Jan;44(1):37-4210.Benzon HT,Wong HY,Belavic AM Jr,Goodman I,Mitchell D,Lefheit T,Locicero J A randomized double-blind comparison of epidural fentanyl infusion versus patient-controlled
19、analgesia with morphine for postthoracotomy pain.Anesth Analg.1993 Feb;76(2):316-22,硬膜外镇痛更好（Better with Epidural）de Leon-Casasola OA,Lema MJ,Karabella D,Harrison P.Postoperative myocardial ischemia:epidural versus intravenous patient-controlled analgesia.A pilot project.Reg Anesth.1995 Mar-Apr;20(2)
20、:105-12.Garnett RL,MacIntyre A,Lindsay P,Barber GG,Cole CW,Hajjar G,McPhail NV,Ruddy TD,Stark R,Boisvert D.Perioperative ischaemia in aortic surgery:combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and i.v.analgesia.Can J Anaesth.1996 Aug;43(8):769-77.两种方法没有区别（No d
21、ifference）Bois S,Couture P,Boudreault D,Lacombe P,Fugere F,Girard D,Nadeau N.Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery.Anesth Analg.1997 Dec;85(6):1233-9.,心血管并发症:硬膜外与 IV PCA比较,对血管搭桥手术效果的影响:硬膜外与 IV
22、 PCA的比较,硬膜外镇痛更好（Better with epidural）Perler BA,Christopherson R,Rosenfeld BA,Norris EJ,Frank S,Beattie C,Williams GM.The influence of anesthetic method on infrainguinal bypass graft patency:a closer look.Am Surg.1995 Sep;61(9):784-9.Tuman KJ,McCarthy RJ,March RJ,DeLaria GA,Patel RV,Ivankovich AD.Eff
23、ects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery.Anesth Analg.1991 Dec;73(6):696-704.一些研究表明麻醉方法(PCA vs EA)并非重要的影响因子Pierce ET,Pomposelli FB Jr,Stanley GD,Lewis KP,Cass JL,LoGerfo FW,Gibbons GW,Campbell DR,Freeman DV,Halpern EF,Bode RH Jr.Anesthesia typ
24、e does not influence early graft patency or limb salvage rates of lower extremity arterial bypass.J Vasc Surg.1997 Feb;25(2):226-32Schunn CD,Hertzer NR,OHara PJ,Krajewski LP,Sullivan TM,Beven EG.Epidural versus general anesthesia:does anesthetic management influence early infrainguinal graft thrombo
25、sis?Ann Vasc Surg.1998 Jan;12(1):65-9.,硬膜外麻醉的风险,尽管硬膜外镇痛的价值超过其罕见但十分严重并发症的风险。The advantages of epidural analgesia are widely believed to outweigh rare but important morbidity risks.Lancet 2002 但是，我国每年硬膜外镇痛相关并发症时有耳闻，触目惊心！,硬膜外镇痛的潜在问题,患者不同意硬膜外血肿和脓肿技术失败需要更多的APS服务医疗资源花费大,肝素与硬膜外镇痛,标准化肝素 5,000u使用后 4-6 hours之
26、内不能进行硬膜外穿刺硬膜外穿刺结束2 hr以后才能再次使用标准肝素,低分子量肝素使用后12 hours之内不能进行硬膜外穿刺硬膜外穿刺结束 2 hr以后才能再次使用低分子量肝素,术后镇痛发展趋势,用药个体化采用多模式镇痛方法（multimodal fashion）平衡镇痛：使用阿片类药物；减少外周刺激(NSAIDs）；阻断疼痛传导通路（如神经阻滞）；情感行为治疗。对术后患者加强心血管系统及呼吸系统监测,区域麻醉的演变(1784-2004),神经刺激器定位：外周神经阻滞腰丛坐骨神经阻滞,外周神经阻滞(NB)对术后并发症的影响,PCA在我国临床应用十年,1994年,2004年,如何进一步提高PCA
27、镇痛疗效？如何进一步防治PCA相关副作用？如何建立和普及APS规范化治疗？,麻醉医师,护理人员,病人,外科医师,目的：-选择个体化镇痛方案-使副作用减到最少-预防术后并发症-使病人满意,APS查房MD ANDERSON CANCER CENTER 2004年3月见闻,不论何种镇痛方法，都迫切需要规范化的镇痛服务！,术后镇痛服务机构（Acute Pain Service，APS）,麻醉医师和护士为基础；任务和作用：建立临床镇痛规范和指南指导术后镇痛的实施（如 PCA）教育和培训相关人员每日查房制度-daily round监测镇痛治疗效果及相关副作用-Anaesthesiologist or nu
28、rse based,Assess site,nature,and intensity of pain,Is pain 5,Is respiratory rate and sedation normal?,Yes,Correct,No,Yes,Is pain appropriate to pathology,No,Encourage use of PCA and reassess in 1 hr.,No,术后镇痛呼唤规范化流程！,评价镇痛疗效的四个“A”Four As for Pain Treatment Outcome Assessment,Analgesia（镇痛效果）Activities
29、of daily living（日常活动）Adverse events（不良反应）Aberrant drug-taking behavior（觅药行为）,疼痛治疗的团队Multidisciplinary Approach,急性疼痛团队Acute Pain Team,药剂师,护士,麻醉医师,理疗师,心理医师,外科医师,有效术后镇痛的基本原则Certain basic principles of effective postop pain management,正确的疼痛评估（ASSESSMENT）；尽早的疼痛治疗（THE EARLIER THE BETTER）；更多的病人参与（PATIENT INVOLVED）；个体化治疗方案（INDIVIDUALIZED METHODS）。,术后镇痛服务的良性循环,患者,General Practice,告知,选择,同意,APT,满意,质量,交流,无法回避的临床现实：术后疼痛的困扰,疼痛的困扰,我们的思考,非常感谢！,Questions?,
