海外讲者：术后疼痛管理课件

,Professor Narinder Rawal,MD,PhD,FRCA(Hon),Department of Clinical Medicine,Division of Anaesthesiology and Intensive Care,University Hospital,rebro,Sweden,Postoperative Pain Management,*The following only stand by personal opinion.Naropin prescription should follow product instruction.,Professor Narinder Rawal,MD,Postoperative Pain Continues To Be Undertreated,Despite nearly a decade of progress in pain research,39%of patients reported severe-to-extreme postoperative pain in 2003 versus 31%in 1995,1,Warfield CA,Kahn CH.,Anesthesiology.,1995;83(5):1090-1094.,2,Apfelbaum JL,et al.,Anesth Analg.,2003;97(2):534-540,.,Severe,Extreme,Moderate,Mild,1995,1,2003,2,Severe,Extreme,Moderate,Mild,19%,49%,23%,8%,47%,21%,18%,13%,Postoperative Pain Continues,Symptoms at home after ambulatory surgery,literature review,1966-2000,156 articles,(33 included),Wu CL et alAnesthesiology 2000;96:994-1003,Symptoms at home after ambulat,Persistent postsurgical pain the incidence,Craniotomy 6-12%Kaur 2000Harner 1993,Leg amputation 50-80%Finch 1980Fisher 1998Sherman 1984,Thoracotomy50%Bertrand 1996Katz 1996,Breast surgery11-57%Jung 2003Tasmuth 1996,Lap cholecystectomy3-56%Stiff 1994Ure 1995de Povourville 1997,Inguinal hernia12%Aasvang 2005,Persistent postsurgical pain,Chronic postsurgical pain,Psychological,Patient attiudes,Preop anxiety,Expectation of chronicity,Environmental,Poor education,Low income,Poor self-rated health,Surgical,Severity of postopertaive pain,Surgical factors-site and extent of surgery-damage to nerves-reoperations-bleeding,infection,Preoperative,Female gender,Younger age,Pain before surgery,Analgesic use,Genetic predisposition,Chronic postsurgical painPsych,PCA techniques for postoperative pain,Epidural PCA(PCEA),Perineural PCA,Incisional and intraarticular(PCRA),Other routes of opioid PCA (intranasal,transdermal),PCA techniques for postoperati,海外讲者：术后疼痛管理课件,Non-opioid analgesic techniques,Analgesic drugsParacetamolNSAIDs(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 blocksIncisionalIntraarticular,Non-pharmacological techniques,Non-opioid analgesic technique,37 RCTs,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”*,Anesth Analg 2004;99:482-95,May prevent central sensitization and chronic neuropathic pain,*No reduction of opioid adverse effects,*in 54%studies,37 RCTs,n=2385,5 subgroup,37 RCTs,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”*,Anesth Analg 2004;99:482-95,May prevent central sensitization and chronic neuropathic pain,*No reduction of opioid adverse effects,*in 54%studies,37 RCTs,n=2385,5 subgroup,Buvanendran A,Kroin J SBest Practice and Reasearch Clin Anaesthesiology 2007;21:31-49,Buvanendran A,Kroin J SBest,Despite much rhetoric about combining multiple analgesic techniques to provide multimodal*analgesia,only limited evidence suggests that this approach will improve pain control or perioperative outcomes.(Level Ia evidence from 3 metaanalyses and 2 systematic reviews),Reg Anesth Pain Med 2006;31:1-42,*Current literature only on”bimodal”therapy.(i.v.PCA+paracetamol or NSAID,Despite much rhetoric about co,Perioperative EDA and outcome after major surgery,Advantages of EDA,Excellent analgesia-the best technique,Shorter duration of postoperative ilieus,Reduced risk of pulmonary complications(Ballantyne 1998),Reduced risk of postoperative myocardial infarction(Beattie 2001),Reduced risk of persistent postoperative pain,Some evidence of reduced risk of cancer recurrence(?),Perioperative EDA and outcome,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,epidu