疼痛的诊断和治疗(英文).ppt
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1、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
2、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 fashion
3、able 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, in
4、fluence 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
5、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
6、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
7、,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
8、,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”alarmingprotectio
9、n 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 Physicia
10、n. 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
11、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 p
12、ain)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
13、,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 fo
14、r 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-inflamma
15、tory 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), re
16、ducing 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 cyt
17、oprotection 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
18、 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 d
19、epression 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 nea
20、r 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 cor
21、d,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,p
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