海外讲者：术后疼痛管理ppt

3-56 %

Inguinal hernia
12 %
Chronic postsurgical pain
Surgical Genetic predisposition
• Severity of postopertaive pain • Surgical factors - site and extent of surgery - damage to nerves - reoperations - bleeding, infection
•Some evidence of reduced risk of cancer recurrence (?)
299 RCT’s
Epidural analgesia in every combination superior to i.v. PCA upto 3-days (exception epidural morphine alone) Continuous infusion superior to PCEA for pain at rest and activity (but more PONV and motor block, less pruritus) Epidural l.a. opioid better than epidural opioid alone ”In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared with intravenous patient-controlled analgesia”
control or perioperative outcomes. (Level Ia evidence from 3 metaanalyses and 2 systematic
* Current literature only on ”bimodal” therapy. (i.v. PCA+paracetamol or NSAID
•Reduced risk of pulmonary complications (Ballantyne 1998)
•Reduced risk of postoperative myocardial infarction (Beattie 2001)
•Reduced risk of persistent postoperative pain
* The following only stand by personal opinion. Naropin prescription should follow product instruction.
Postoperative Pain Continues To Be Undertreated
* analgesia”** No reduction of opioid adverse effects, ** in 54 % studies
Anesth Analg 2004;99:482-95
37 RCT’s, n= 2385, 5 subgroups: i.v. ketamine single dose, cont. Infusion, PCA, epidural, pediatric I.v. morphine + ketamine not better than i.v. Morphine I.v. ketamine infusion decreased i.v. and epidural opioid requirements in 6/11 studies* Single bolus ketamine decreased opioid requirements in 7/11 studies* Epidural ketamine beneficial in 5/8 trials Adverse effects not increased with small dose (0.15-1 mg/kg bolus, 0.12-0.6 mg/kg/h infusion ”…small dose ketamine is a safe and useful adjuvant to standard practice opioid analgesia”**
• Other routes of opioid PCA (intranasal, transdermal)
Non-opioid analgesic techniques
Analgesic drugs Paracetamol NSAID’s (including COX-2-inhibitors) NMDA antagonists (ketamine, dextromethorphan) 2 receptor agonists (clonidine, dexmedetomidine) others (gabapentin, corticosteroids, capsaicin, nicotine, neostigmine etc.) Regional techniques (including catheter techniques) Central blocks (EDA, spinal, CSE) Peripheral blocks Incisional Intraarticular
8%
20032
Extreme Miቤተ መጻሕፍቲ ባይዱd Severe
18%
13% 21%
Mild
19%
23%
49%
47%
Moderate
1Warfield 2Apfelbaum
Moderate
CA, Kahn CH. Anesthesiology. 1995;83(5):1090-1094. JL, et al. Anesth Analg. 2003;97(2):534-540.

Thoracotomy
50 %
Bertrand 1996 Katz 1996
Jung 2003 Tasmuth 1996 Stiff 1994 Ure 1995 de Povourville 1997 Aasvang 2005

Breast surgery
11-57 %

Lap cholecystectomy
Despite nearly a decade of progress in pain research, 39% of patients reported severe-to-extreme postoperative pain in 2003 versus 31% in 1995
19951
Extreme Severe
May prevent central sensitization and chronic neuropathic pain * No reduction of opioid adverse effects, ** in 54 % studies
Buvanendran A, Kroin J S Best Practice and Reasearch Clin Anaesthesiology 2007;21:31-49
• Younger age • Pain before surgery • Analgesic use
PCA techniques for postoperative pain
• Epidural PCA (PCEA) • Perineural PCA
• Incisional and intraarticular (PCRA)
Wu CL et al Anesthesiology 2000;96:994-
Persistent postsurgical pain – the incidence
Craniotomy 6-12 % Kaur 2000 Harner 1993 Finch 1980 Fisher 1998 Sherman 1984 Leg amputation 50-80 %
Symptoms at home after ambulatory surgery – literature review
1966-2000, 156 articles, (33 included)
50 45 40 35 30 25 20 15 10 5 0
Pain Nausea Vomiting Sedation Dizziness Fatigue
Reg Anesth Pain Med 2006;31:1-42
Despite much rhetoric about combining multiple analgesic techniques to provide multimodal* analgesia, only limited
evidence suggests that this approach will improve pain
Postoperative Pain Management
Professor Narinder Rawal, MD, PhD, FRCA (Hon) Department of Clinical Medicine Division of Anaesthesiology and Intensive Care University Hospital Örebro, Sweden
reviews)
Perioperative EDA and outcome after major surgery