2022年医学专题—癌性疼痛的处理.ppt

癌性疼痛的处理EPECWHO3-阶梯(jiētī)镇痛疗法ManagementofCancerPainWHO3–StepAnalgesicLadderTerenceL.Gutgsell,MDHospiceoftheBluegrassLexington,KY第一页，共三十二页。目标比较，对比感受伤害性的和神经病性的疼痛了解癌痛镇痛处理的阶梯了解阿片类镇痛剂给药的其他途径(tújìng)讲解维持镇痛时阿片类药物间互相转换的技巧ObjectivesCompare,contrastnociceptive,neuropathicpainKnowstepsofanalgesicmanagementofcancerpainKnowalternativeroutesfordeliveryofopioidanalgesicsDemonstrateabilitytoconvertbetweenopioidswhilemaintaininganalgesia第二页，共三十二页。病痛=总体的疼痛Suffering=TotalPain躯体(qūtǐ)情感(qínggǎ的疼痛n)的Physical疼痛PainEmotional社交(shèjiPaināo)宗教的困扰障碍SocialSpiritualDistressDiscord第三页，共三十二页。总的原则多因素(yīnsù)对患者反应的影响环境心理/社会状态年龄性别多系统疾病和障碍复合用药GeneralPrinciplesInfluencesonpatient’sresponsetoRxEnvironmentPsycho/socialstatusAgeSexMulti-systemdiseaseanddisordersPolypharmacy第四页，共三十二页。普遍原则“拇指原则”诊断可能的机制(jīzhì),个体化治疗ATC和PRN用药,保持简单反复评价,注意细节GeneralPrinciples“RulesofThumb”DiagnoseunderlyingmechanismIndividualizetreatmentATCandPRNmedicationsKeepitsimple,ReassessAttentiontoDetail第五页，共三十二页。疼痛的病理生理学急性疼痛已明确的原因，缓解时间(shíjiān)：数日到数周通常是感受伤害性的慢性疼痛原因常不易确定，多因素的持续时间不确定感受伤害性的和/或神经病理性的PainpathophysiologyAcutepainIdentifiedevent,resolvesdays–weeksUsuallynociceptiveChronicpainCauseoftennoteasilyidentified,multifactorialIndeterminatedurationNociceptiveand/orneuropathic第六页，共三十二页。感受伤害性的疼痛对健全的伤害感受器的直接刺激沿正常(zhèngcháng)神经传递锐痛，酸痛，搏动性疼痛本体性的-易于描述和定位内脏性的-难以描述和定位NociceptivepainDirectstimulationofintactnociceptorsTransmissionalongnormalnervesSharp,aching,throbbingSomatic-Easytodescribe,localizeVisceral-Difficulttodescribe,localize第七页，共三十二页。(gǎnshòu)感受伤害性疼痛组织损伤明显治疗阿片类药物辅助药物/联合镇痛剂NociceptivepainTissueinjuryapparentManagementOpioidsAdjuvant/coanalgesics第八页，共三十二页。神经病性疼痛外周或中枢神经的功能障碍压迫，横断，浸润，缺血，代谢性损伤不同类型外周的传入神经阻滞(zǔzhì)交感神经介导的NeuropathicpainDisorderedperipheralorcentralnervesCompression,transection,infiltration,ischemia,metabolicinjuryVariedtypesPeripheraldeafferentationsympatheticallymediated第九页，共三十二页。神经病性疼痛(téngtòng)疼痛可能不仅只由可见的损伤引起描述为烧灼感，麻刺感，射痛，刺痛，电击样疼痛治疗阿片类药物常需要辅助药物/联合镇痛剂NeuropathicpainPainmayexceedobservableinjuryDescribedasburning,tingling,shooting,stabbing,electricalManagementOpioidsAdjuvant/coanalgesicsoftenrequired第十页，共三十二页。WHO3-阶梯(jiētī)疗法3severe(7-10/10)WHO3-stepLadder2moderate(4–6/10)Morphine吗啡(m1mild(1–3/10)A/Codeine可待因afēi)ASAA/Hydrocodone氢可酮HydromorphoneAcetaminophen扑热息痛A/Oxycodone羟考酮氢吗啡酮Tramadol曲马多NSAIDsOxycodone羟考酮±Adjuvants±AdjuvantsFentanyl芬太尼Methadone美沙酮±Adjuvants第十一页，共三十二页。WHO3-阶梯(jiētī)3重度(7-10/10)疗法吗啡2中度(4–6/10)氢吗啡酮A/可待因羟考酮A/氢可酮芬太尼1轻度(qīnɡdù)(1–3/10A)/羟考酮美沙酮阿斯匹林曲马多±辅助药物扑热息痛±辅助药物NSAIDs±辅助(fǔzhù)药物第...