外科学教学课件：Pain-Management

1PainManagementVitalsigns1.Bodytemperature,2.Pulse(orheartrate),3.Bloodpressure,4.Respiratoryrate5.PAIN2PainManagementisabranchofmedicineemployinganinterdisciplinaryapproachforeasingthesufferingandimprovingthequalityoflifeofthoselivingwithpain.Notincludingallkindsofpains:aftermakingadefinitediagnosis.3

PainAssessmentOnsetanddurationLocationQualityIntensityrating(usingnumeric,VASorverbalratingscale,VRS)AggravatingandalleviatingfactorsPasteffectivetreatmentQUESTIONSWhatisthedefinitionofpain?WhatisPCA?WhatisVAS?WhatisWHO’sThree-stepladderforcancerpainrelief?56ThedefinitionofpainUnpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,ordescribedintermsofsuchdamage.疼痛是与实际发生的或潜在组织损伤相联系的不愉快的感官和情感体验，或者是用某种伤害来形容的一种感觉。TheInternationalAssociationfortheStudyofPain(IASP)TypesofPain

accordingtothedegreeofpain:1.mild2.moderate3.severepain①轻微疼痛②中度疼痛;③剧烈疼痛。TypesofPainAccordingtodurationofPain1.Acutepain(trauma、operation、Acuteinflammation、Myocardialinfarction)2.Chronicpain

(backpain、cancerpain)9AcuteversusChronicpainAcutepain:thenormalbodyrespondstonoxiousstimuliwiththeexperienceofpain.（是疾病的一种症状）Chronicpain:thesensitizednervoussystemrespondsmorereadilytobothnoxiousandinnocuousstimuli.本身就是一种疾病。TypesofPainaccordingtothelocationofpain:1.Superficialpain：Superficialpainismostlysharppain,usuallylimited,andcleartolocation.TheyareconductedbyAδmyelinatednervefiber.Suchascornea、dentalpulp、oralmucosa2.Deep-Seated

Pain:

Deep-Seated

Painismostlydullpain,diffuse,anddifficulttolocaion.TheyareconductedbyunmyelinatedC-fibers.Suchasviscera、joint、ligament、periosteumTypesofPain

NociceptivePainExample:SurgicalPainNeuropathicPainExample:Diabeticneuropathy

PathogenesisofthepainPathogenesisisunclear.1213MechanismsofPaingenerationPainmaybegeneratedinanumberofways:TISSUESSPINALCORDBRAINExperienceandExpressionofpainSimplestimulationTissueinjuryOtherstimuliPeripheralnervedamageDenervationCentralpainHigherpainPainpassagewayNociceptor-Aδ/C-DRG(dorsalrootganglion)-Lissauer

-dorsalhornspinalcord-excitatorytransmitter-CNS（thalamusopticus、pallium）algesthesiaintegration。characteristic：1.neuronalexcitabilityenhanced2.Wind-up3.

areaofpainreception

enlarge，（Aβnervefiber）。15PeripheralsensitizationStructuralelementsbeingdamagedandinflammatoryresponseoccursManychemicalsarereleased,includingHistamine,Bradykinin,5-hydroxytriptamine,Hydrogenandpotassiumions,ProstaglandinsThesesensitizenerveendingstoreactmoreintenselytofurtherstimulation.CentralsensitizationPlasticityinCNS（可塑性变化）Wind-upofneuronsindorsalhornofspinalcord.（上扬效应）Reacttobothnoxiousandinnocuousstimuli.1617MeasurementofpainImpossibletomeasurepaindirectlyRelyonwrittenorverbalself-report,facialexpression,bodylanguageandbehaviourtoassesspain.Measurementofpain1.视觉模拟评分法VAS(visualanaloguescales):

Ona10cmlongline,onesiderespectivelymarkedwith"0"andtheotherwith"10"."0"representsnopain,"10"representsthemostseverepain.Patientsbasedontheirpastexperience,markthecurrentfeelingofthepaindegreeonthescaleinthecorrespondingposition.Thestartingpointtomarkpointdistanceisthescore.

Measurementofpain2.语言描述评分法VRS(verbalratingscale)

fourlevels:1.painless,2.mild,3.moderate,4.severepain①无痛;②轻微疼痛;③中度疼痛;④剧烈疼痛。

每级1分，如为“剧烈疼痛”，其评分为4分。此法很简单，病人容易理解，但不够精确。

TheeffectofpainonphysiologyMentalandemotionalchangesAcutepain:mentalexcitement,anxiety,irritability,andevencrying.Chronicpain:depression,indifference,lagsinresponse.TheeffectofpainonphysiologyEndocrineSystemPaincancausestress,topromotethereleaseofavarietyofhormones.

suchascatecholamines,corticosteroids,angiotensinII,antidiuretichormone,aldosterone,glucagonandothersincrease→correspondingsymptomscausedbytheincrease→hyperglycemiaandnegativenitrogenbalanceTheeffectofpainonphysiologyCardiovascularsystemsharppain→sympatheticnerveexciting→catecholamineandangiotensinIIlevelsinblood,antidiuretichormonelevelincrease→BPelevated,tachycardiaandarrhythmiaButdeeppain→parasympatheticnervousexciting→BPdeclined,HRslowdown,evencollapse,shock.22TheeffectofpainonphysiologyRespiratorysystempain→muscletensionincreases,lungcompliancedecrease→rapidshallowbreathing,vitalcapacity、tidalvolume、residualvolume、functionalresidualcapacity、V/Qratiodecreased→hypoxemiaAtthesametimepainmakesthepatientcannotbreatheandcough→secretionsaccumulatedinthesmallbronchialcannotbedischarged→pneumoniaandatelectasis(morecommoninolderpatients)23TheeffectofpainonphysiologyAlimentarysystemchronicpain→digestivedisorders→lostofappetiteIntensedeeppain→causenausea,vomit24TheeffectofpainonphysiologyUrinarySystempain→angiotensinIIlevelsincreased,antidiuretichormonelevelsincreased→hypourocriniaPain→causesdysuresia,urinationdifficulty,urinaryretention→Urinarysysteminfection25TheeffectofpainonphysiologySkeletal

andMascularsystempain→Musclespasmpain→sympatheticnerveexciting→hyperalgesia、allodynia26TheeffectofpainonphysiologyImmunesystemPain→immunesystemdysfunction→infectionandtumorspread27TheeffectofpainonphysiologyCoagulationsystemAcutepain→Stressreaction→bodyinahypercoagulablestate→thrombosis,suchasacutepulmonaryembolismcancausedeathofthepatientimmediately28chronicpainManagementChronicpain:thepainlastsmorethanonegeneralcourseoftheacutediseaseormorethanthenormaltimerequiredfortheinjuryhealing,orpainrelapselastsmorethanonemonth.疼痛持续超过一种急性疾病的一般病程或超过损伤愈合所需的一般时间，或疼痛复发持续超过1个月。Range①Headache(头痛);②Theneckpainandlowbackpain(颈肩痛和腰腿痛);③Thechronicinjurydisease(四肢慢性损伤性疾病);④Theneuralgia(神经痛);⑤Theperipheralvasculardisease(周围血管疾病);⑥Thecancerpain(癌症疼痛);⑦Thepsychologicalpain(心理性疼痛)31SpecificchronicpainproblemsNeuropathicpain:Postherpeticneuralgia(PHN)PhantomlimbpainComplexregionalpainsyndromeTrigeminalneuralgiaArthritisCancerpain32ClinicalassessmentofchronicpainThebasicprinciplesare:TakingafullhistoryPerformingaphysicalexaminationPerformingapsychologicalassessmentOrderinginvestigationsInitiatingtreatment33TreatmentofchronicpainVeryfeweffective‘cures’forchronicpainproblems.Interventionisonlyappropriateifthereisarealisticchanceofsuccess.Treatmentofpainmayhavetoproceedalongsidetreatmentofthecondition.treatmentmethod(一)Pharmacologicaltreatments药物治疗(二)Nerveblocktherapy神经阻滞(三)Intrathecalinjection椎管内注药(四)

Acupuncture针灸疗法针灸疗法(五)Massagetherapy推拿疗法(六)Physicaltherapy物理疗法(七)Transcutaneouselectricalnervestimulation,TENS经皮神经电刺激疗法(八)Psychotherapy心理疗法Pharmacologicaltreatmentsthemostbasicandmostcommonlyusedmethodinpaintreatment.Pharmacologicaltreatments（Medication）NSAIDs:aspirinandibuprofenNarcoticanalgesics:morphineandfentanylHypnoticsedatives:diazepam,midazolamAntiepilepticdrugs:carbamazepine,phenytoinsodiumAntidepressanst:amitriptyline,Dorset解热消炎镇痛药：阿司匹林、布洛芬麻醉性镇痛药：吗啡、芬太尼催眠镇静药：地西泮、咪达唑仑抗癫痫药：卡马西平、苯妥英钠抗抑郁药：阿米替林、多塞平37Non-steroidalanti-inflammatorydrugs（NSAIDs)Indication:

painwithinflammatoryorbonepain.Administration:oftenusedaloneorincombinationwithopioids.38Mechanismofaction:

workbyaffectingsomechemicalsinthebodywhichcauseinflammation,theprostaglandins.Reducethelevelofprostaglandinbyinhibitingthecombinationofprostaglandin,andincreasethesensitivityofperipheralreceptorstobradykininandotherpainfactors.通过抑制体内前列腺素的生物合成；降低前列腺素在末梢感受器对缓激肽等致痛因子增敏作用；并且降低前列腺素本身的致痛作用。Sideeffects:

gastric-ulceration/perforation,bleeding,Specificallergy，asthma,renalimpairment,hepatictoxicity/dysfunctionNon-steroidalanti-inflammatorydrugs（NSAIDs)41Antiepileptic

DrugsMechanismofaction:unknown.Drugnames:

carbamazepine,Pregabalin

,gabapentinIndications:treatpainassociatedwithnervedamage,painsyndromes(wheretheremaybesensitizationoftheCNS.)suchasTrigeminalneuralgiaNerveblocktherapyPrimarytreatmentinChronicpaintreatment（神经阻滞治疗是慢性疼痛的主要治疗手段）43NerveblocksMaybeperformed

onanynervesthoughttobepartofthepainpathway.Sometimesnerveblockswithlocalanestheticgiveprolongedreliefbyreducingcentralsensitization.Indwellingepiduralorintrathecalcathetersdeliveringlocalanestheticoropioidcanprovidesustainedanalgesiainsevereanduncontrollablecancerpain.Stellateganglionblock；(看视频)Lumbarsympatheticnerveblock（星状神经节阻滞；腰交感神经阻滞）StellateganglionblockThestellateganglioniscomposedoftheinferiorcervicalsympatheticgangliaandthefirstthoracicsympatheticganglia,whichislocatedbetweentheseventhcervicalvertebraandthefirstthoracicvertebra,andthehead,neckandupperlimb.StellateganglionblockEffectivesigns：霍纳综合征，手指温度增高Complication：Unexpectedtoxicreactionoflocalanesthetics;drugaccidentallyinjectedintothespinalcanal,causinglowbloodpressure,respiratoryarrest;pneumothorax;diaphragmaticparalysis;recurrentlaryngealnerveparalysis)（局麻药的毒性反应；药物意外注入椎管内、引起血压下降、呼吸停止；气胸；膈神经麻痹；喉返神经麻痹）Lumbarsympatheticnerveblock腰交感神经节位于腰椎椎体的前侧面，左右有4-5对神经节，支配下肢，其中L2交感神经节尤为重要。Thelumbarsympatheticganglionislocatedinthefrontsideofthelumbarvertebra,leftandrightsidesofthe4-5totheganglion,whichgovernsthelowerlimbs,L2isparticularlyimportant.并发症:①药液意外注入蛛网膜下腔;②局麻药毒性反应;③损伤引起局部血肿。lumbarsympatheticganglionblockIntrathecalinjection1.

subarachnoidspace蛛网膜下腔注药：Damagedrugs：ethylalcoholabsolute，Phenol用无水乙醇或5%-l0%酚甘油注人以治疗晚期癌痛。[ethylalcoholabsolute（Affectedsideup）or5%-l0%phenol（Affectedsidedown）]Intrathecalinjection2.Epiduralspace硬脊膜外间隙注药(1)glucocorticoid糖皮质激素:(2)Opioids阿片类药物:

常用吗啡。因其成瘾问题，多限于癌症疼痛治疗。(3)localanesthetic局麻药:可单独使用，但常与糖皮质激素或阿片类药物合用。51Physiotherapy52PsychologyDistressordepressionisusualforchronicpainpatients.Psychologistsareessentialinhelpingthem.Commonobstaclestocopingwithchronicbenignpainare:FearofnotbeingbelievedFearofdeteriorationanddependencyFailuretoacceptthatthepainispermanentAngerdirectedatthecauseofthepainGuiltatnotbeingabletofulfilperceivedroleSide-effectsofunhelpfulmedicaltreatments53CancerpainCause:cancersdestructtissuesCharacteristics:2/3ofpatientshavesignificantpain；

Modernchemotherapyradiotherapyreducethegrowthoftumour；

Surgeryevensuccessfultherapy,butpainpersist.Painmaybefearedmorethandeathitself.Cancerpaintreatmentprinciplesofthethreestepsanalgesicladderforcancerpainmanagement1.Choosedrugsaccordingtolevelofpain(ladder)2.oraladministrationispreferred(takeorally)3.takemedicineregularlyandontime(ontime)4.individualizetreatmentbasedonthespecificpatientanddrugs,preventionandcureadversereaction.(individualization)①根据疼痛程度选择镇痛药物;②口服给药，一般以口服药为主;③按时服药，根据药理特性有规律地按时给药;④个体化用药，应根据具体病人和疗效给药。Three-step"ladder"forcancerpainrelief(WHO)1.Mildpain

NSAIDs(aspirinandibuprofen)+/-adjuvant2.MildtoModeratePainweakopioidsmedications(Tramadol

,codeine,oxycodone)+/-NSAIDs+/-adjuvant3.ModeratetoSeverePain

opioidmedications(morphine,fentanyl,Oxycodone)+/-NSAIDs+/-adjuvant55CancerpaintreatmentAdjuvant(supplementarydrugs):Hypnoticsedatives:diazepam,midazolamAntiepilepticdrugs:carbamazepine,phenytoinsodiumAntidepressanst:amitriptyline,DorsetIntrathecalinjection-Cancerpaintreatment1.morphine2.Damagedrugs：ethylalcoholabsolute，Phenol毁损药物：苯酚（重比重）；无水乙醇（轻比重）苯酚：毁损部位在药物下方，椎管内毁损，背后倾斜45度乙醇：前倾斜45度PostoperativeanalgesiaAnalgesiaMedicationsFentanyl,Morphine,Tramadol,Sulfentanil,Dolantine,Bupivacaine,Ropivacaine,NSAIDs592.

Analgesicmethods

(1)intramuscularinjection(2)Nerveblock(3)Intrathecalinjection:常用吗啡(4)Patient-controlledanalgesia,PCA60PCA(patient-controlledanalgesia)61PCAPCA:PatientcanpressthePCAdevicewhentheyfeelpaintorelievepain.Doctorsmayadjustthebasalinfusionaccordingtofrequencyofbolus.Therearetwotypes,patient-controlledintravenousanalgesia(PCIA)andpatient-controlledepiduralanalgesia(PCEA).病人自控镇痛，即在患者感到疼痛时，可自行按压PCA装置的给药键，按设定的剂量注入镇痛药，从而达到止疼效果。PCA包括病人自控静脉镇痛（PCIA）和病人自控硬膜外镇痛（PCEA）PCA常用术语Loadingdose:ItisacomparativelylargedosegivenatthebeginningoftreatmenttogaintheleasteffectiveconcentrationofadrugBolus:Itistheadditionaldoseaddedwhenpainisnotwell-controll