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1、 Diagnosis and treatment of PainLiu HuiAnesthesiology Department, West China Hospital, Sichuan University. l 疼痛学 l 【目的要求】： l 1. 掌握术后镇痛重要性及病人自控镇痛应用 l 2. 掌握慢性疼痛治疗的基本方法及治疗原则 l 3掌握癌痛药物治疗的三阶梯原则 l 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； l 5. 了解疼痛的简史、分类、机理和测量评估 l 【讲授内容】： l 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） l 慢性疼痛
2、的治疗方法及原则，神经阻滞治疗疼痛的机理及适应症、禁忌症 l 癌痛治疗方法 l 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； l 病人自控镇痛：定义、方法、分类及适应症、基本术语及意义。 l 【重点难点】： l 难点：疼痛的发病机理及传导通路； l 重点：1.疼痛的恶性循环及神经阻滞治疗疼痛的机理； l 2.慢性疼痛的治疗方法及癌痛的三阶梯药物治疗； l 3.术后疼痛对机体的影响及术后镇痛的意义。 l 四、【讲授时数】：2 3学时 l 五、【参考书】：疼痛诊疗学 第一版 l Introduction Come as you be bornIntroduction Accompa
3、ny with you all your lifePain: a fashionable topica fashionable topicIntruduction 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
4、injuries/risks. Pain also cause us unpleasant feeling, influence 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. Intruductionl 每一个人生命过
5、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 management3500 DC Egyptian used opioidHistory of pain History of pain =history of medicine=history of medicineAdvance in the field of painlBasic researchlMore target
6、ing,less toxic drugslPCA lMicroinvasive techniques国际疼痛研究会和WHO提出：l疼痛是人体第五大生命体征; l慢性疼痛是一种疾病； l解除疼痛是患者的基本权利。The history of pain managementDefinition of Painlpain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.“T
7、eaching Outlinel Basic aspect lAnatomylInjury and painlProcessing of painPain in generalPain in generall Clinical aspectlEffect on bodylClassificationlPain assessment and diagnosislPain treatmentlAdvancement in pain management13Basic aspect of PainInjury and painTRAUMAPOTENTIAL INJURYINTOXICATIONSUR
8、GERYINFECTIONTUMORDEGENERATIONASIC/BNCThe Model of Pain by DescartesClinical aspect of painClinical aspect of painTeaching Outlinel Basic aspect lAnatomylInjury and painlProcessing of painPain in generalPain in generall Clinical aspectlClassification lEffect on bodylPain assessment and diagnosislPai
9、n treatmentlAdvancement in pain management22classificationl Good gain pain：physiological pain（good pain）l“good pain”alarmingprotectionl No good gain pain：pathophysiological pain（bad pain）l bad pain except alariming，pain is of no goodWe would like with no pain system if we had other alarming systemsh
10、yperalgesia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SensitizationGottschalk A, Smith DS. Am Fam Physician. 2001;1979-84.Injury InjuryPain Intensity1086420Stimulus IntensityNormal Pain ResponseAllodyniaHyperalgesiaclassficationl 从病程分lacute painlchronic painl 从人体的部位分lheadachel
11、cervical-shouder painlthoracico-abdominal painllow back painl从疼痛的来源分l皮肤痛lmuscles pain、tendons pain、ligaments pain larthralgialbone painlvisceral painlneuropathic pain（central pain）pathogenic classficationl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。 l神经病理性疼痛neuropathic pain_机械性压 迫(me
12、chanic 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） l癌痛(cancer pain )部位分类position classficationl浅表痛(superficial pain)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。 l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 l中枢痛(central pain)-疼痛强烈、持
13、久、难 忍疼痛的性质分类l刺痛(pricking pain) l灼痛(burning pain) l胀痛(distending pain) l酸痛(aching pain) l绞痛(colicky pain)Treatment of painSignificance of pain treatmentl Control pain and facilitate rehabilitation（消除疼痛，促进恢复）l Improve body function and life quality（改善机体功能和生活质量）l Treat original disease（治疗原 发病）疼痛治疗 的原则l
14、 明确诊断l 除痛与病因治疗相结合l 综合治疗l 确保安全有效常用治疗方法l 药物疗法l 物理疗法l 心理疗法l 手术疗法l 介入疗法、l 神经阻滞疗法l 其他疗法l 疼痛治疗可以在疼痛产生过程的各个环节进行 l 采用多模式的综合疗法 l 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 for PainCategories of analgesic drugslOpioid analgesicslNonopioid analgesicslAdjuvant analgesicslDrugs for headacheThe first ladder a
15、nalgesics: Nonopioid AnalgesicslAcetaminophen (paracetamol)lNonsteroidal anti-inflammatory drugsNonopioid AnalgesicslAcetaminophen (paracetamol) lMinimal anti-inflammatory effects lFewer adverse effects than other nonopioid analgesics lAdverse effects lRenal toxicity lRisk for hepatotoxicity at high
16、 doses lIncreased risk with liver disease or chronic alcoholism lNo effect on platelet functionNSAIDslMechanismlInhibit both peripheral and central cyclo-oxygenase(COX), reducing prostaglandin formationl2 isoforms of COXlCOX-1: Constitutive, physiologiclCOX-2: Inducible, inflammatoryCOX Pathway and NSAIDs, COX-2Arachidonic acid (an fatty acid)COX-1COX-2Normal constituentlbrainlkidneylovary luteru
