《癌性疼痛的处理》由会员分享，可在线阅读，更多相关《癌性疼痛的处理（31页珍藏版）》请在金锄头文库上搜索。
1、癌性疼痛的处理 WHO 3-阶梯镇痛疗法 Management of Cancer Pain WHO 3 Step Analgesic Ladder,Terence L. Gutgsell, MD Hospice of the Bluegrass Lexington, KY,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 讲解维持镇痛时阿片类药物间互相转换的技巧Objectives Compare, contrast nociceptive, neuropathic pain Know steps of analgesic manageme
2、nt of cancer pain Know alternative routes for delivery of opioid analgesics Demonstrate ability to convert between opioids while maintaining analgesia,躯体的疼痛Physical Pain,情感的 疼痛 Emotional Pain,社交 障碍 Social Discord,宗教的困扰Spiritual Distress,病痛=总体的疼痛 Suffering = Total Pain,总的原则 多因素对患者反应的影响环境 心理/社会状态 年龄性别
3、 多系统疾病和障碍 复合用药 General Principles Influences on patients response to RxEnvironmentPsycho/social statusAgeSexMulti-system disease and disordersPolypharmacy,普遍原则 “拇指原则”诊断可能的机制,个体化治疗 ATC和PRN用药,保持简单反复评价,注意细节General Principles “Rules of Thumb”Diagnose underlying mechanismIndividualize treatmentATC and PR
4、N medicationsKeep it simple, Reassess Attention to Detail,疼痛的病理生理学 急性疼痛已明确的原因，缓解时间：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Pain pathophysiology Acute painIdentified event, resolves daysweeksUsually nociceptive Chronic painCause often not easily identified, multifactorialIndeterminate du
5、rationNociceptive and / or neuropathic,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 Nociceptive pain Direct stimulation of intact nociceptors Transmission along normal nerves Sharp, aching, throbbingSomatic - Easy to describe, localizeVisceral - Difficult to describe, localize
6、,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Nociceptive pain Tissue injury apparent ManagementOpioidsAdjuvant / coanalgesics,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交感神经介导的Neuropathic pain Disordered peripheral or central nerves Compression, transection, infiltration, ischemia, metabolic injury Vari
7、ed typesPeripheraldeafferentationsympathetically mediated,神经病性疼痛 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 Neuropathic pain Pain may exceed observable injury Described as burning, tingling, shooting, stabbing, electrical ManagementOpioidsAdjuvant / coanalgesics often required,WHO 3
8、- 阶梯疗法 WHO 3-step Ladder,1 mild (1 3/10),2 moderate (4 6/10),3 severe (7 - 10/10),Morphine吗啡 Hydromorphone氢吗啡酮 Oxycodone羟考酮 Fentanyl芬太尼 Methadone美沙酮 Adjuvants,A/Codeine可待因 A/Hydrocodone氢可酮 A/Oxycodone羟考酮 Tramadol曲马多 Adjuvants,ASA Acetaminophen扑热息痛 NSAIDs Adjuvants,WHO 3-阶梯疗法,1 轻度 (1 3/10),阿斯匹林 扑热息痛
9、NSAIDs 辅助药物,2 中度 (4 6/10),A/可待因 A/氢可酮 A/羟考酮 曲马多 辅助药物,3 重度 (7 - 10/10),吗啡 氢吗啡酮 羟考酮 芬太尼 美沙酮 辅助药物,阿片类的药理学 在肝脏结合 通过肾脏排泄（90%-95%） 一级动力学Opioid pharmacology Conjugated in liver Excreted via kidney (90%95%) First-order kinetics,Plasma Concentration,0,Half-life (t1/2),Time,IV,po / pr,SC,Cmax,阿片类的药理学 4-5个半衰期后
10、呈稳定状态1天（24小时）后呈稳定状态 “即释”剂型作用的持续时间每4小时 PO/PR非肠道的冲击剂量持续时间更短 Opioid pharmacology Steady state after 4 5 half-livesSteady state after 1 day (24 hours) Duration of effect of “immediate-release” formulations 4 hours PO / PRShorter with parenteral bolus,常规口服剂量 即释剂型 吗啡，氢可酮，羟考酮，氢吗啡酮，（芬太尼）剂量 q 4 h每天调整剂量- 轻度/中
11、度疼痛 25%50%- 重度/难以控制的疼痛 50%100%对于严重的难以控制的疼痛需要较快地调整剂量 Routine oral dosing immediate-release preparations Morphine, hydrocodone, oxycodone hydromorphone, (fentanyl)Dose q 4 hAdjust dose daily - mild / moderate pain 25%50% - severe / uncontrolled pain 50%100%Adjust more quickly for severe uncontrolled p
12、ain,常规口服剂量 缓释剂型 增加依从性与合作性 按 q8,12,或24h给予药物不要压碎或咀嚼药片可以通过鼻饲管将缓释颗粒注入 每2-3天调整剂量Routine oral dosing extended-release preparations Improve compliance, adherence Dose q 8, 12, or 24 hDont crush or chew tabletsMay flush time-release granules down feeding tubes Adjust dose q 2 3 days,突破性剂量 使用即释阿片类应用24小时总量的10
13、%-15%在达最高浓度后使用 PO q 1 hSC q 30 minIV q 1015 min 不要使用缓（控）释阿片类 Breakthrough dosing Use immediate-release opioids10% 15% of 24-h doseOffer after Cmax reached PO q 1 hSC q 30 minIV q 1015 min DO NOT use extended-release opioids,对阿片类反应欠佳的疼痛 如果剂量增加不良反应需要更复杂的疗法来拮抗不良反应替代方法- 给药途径- 阿片类轮换联合镇痛剂使用非药物方法Pain poorl
14、y responsive to opioids If dose escalation adverse effectsMore sophisticated therapy to counteract adverse effectAlternative - route of administration - opioid rotationCoanalgesicUse a non-pharmacologic approach,给药的替代途径 Alternative routes of administration,Enteral feeding tubes 置管喂饲 Transmucosal经粘膜
15、Rectal经直肠,Transdermal 经皮 Parenteral 胃肠外 Intraspinal 脊柱内Epidural 硬膜外Intrathecal 鞘内,更换阿片类药物 交叉耐受按已公认的等效剂量原则，从相应剂量的50%-75%开始使用如果疼痛不能控制，追加剂量如果不良反应明显，减少剂量Changing opioids Cross-toleranceStart with 50%75% of published equianalgesic dose More if pain not controlled less if adverse effects prominent,阿片类镇痛剂的
16、等效剂量 Equianalgesic doses of opioid analgesics,po / pr (mg) Analgesic SC / IV (mg)30 Morphine吗啡 1030 Hydrocodone氢可酮 -20 Oxycodone羟考酮 -7.5 Hydromorphone氢吗啡酮 1.5( 300 Meperidine度冷丁 75 ) ( 200 Codeine可待因 120 ),阿片类镇痛剂的等效剂量 透皮芬太尼25 mg/张 50 mg PO 吗啡 / 24 h. 50 mg/张 100 mg PO 吗啡/24 h.Equianalgesic doses of opioid analgesics Transdermal fentanyl 25 mg patch 50 mg PO morphine / 24 h. 50 mg patch 100 mg PO morphine/24 h. etc . . .,
