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1、癌性疼痛的处理WHO3-阶梯镇痛疗法ManagementofCancerPainWHO3–StepAnalgesicLadderTerenceL.Gutgsell,MDHospiceoftheBluegrassLexington,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ObjectivesCompare,contrastnociceptive,neuropathicpainKnowstepsofanalge
2、sicmanagementofcancerpainKnowalternativeroutesfordeliveryofopioidanalgesicsDemonstrateabilitytoconvertbetweenopioidswhilemaintaininganalgesia躯体的疼痛PhysicalPain情感的疼痛EmotionalPain社交障碍SocialDiscord宗教的困扰SpiritualDistress病痛=总体的疼痛Suffering=TotalPain总的原则多因素对患者反应
3、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GeneralPrinciplesInfluencesonpatient’sresponsetoRxEnvironmentPsycho/socialstatusAgeSexMulti-systemdiseaseanddisordersPolypharmacy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GeneralPrinciples“RulesofThumb”Diagnoseunderlyingme
4、chanismIndividualizetreatmentATCandPRNmedicationsKeepitsimple,ReassessAttentiontoDetail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PainpathophysiologyAcutepainIdentifiedevent,resolvesdays–weeksUsuallynociceptiveChronicpain
5、Causeoftennoteasilyidentified,multifactorialIndeterminatedurationNociceptiveand/orneuropathic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NociceptivepainDirectstimulationofintactnociceptorsTransmissionalongnormalnervesSharp,aching,thro
6、bbingSomatic-Easytodescribe,localizeVisceral-Difficulttodescribe,localize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NociceptivepainTissueinjuryapparentManagementOpioidsAdjuvant/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NeuropathicpainDisorder
7、edperipheralorcentralnervesCompression,transection,infiltration,ischemia,metabolicinjuryVariedtypesPeripheraldeafferentationsympatheticallymediated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NeuropathicpainPainmayexceedobservableinjury
8、Describedasburning,tingling,shooting,stabbing,electricalManagementOpioidsAdjuvant/coanalgesicsoftenrequiredWHO3-阶梯疗法WHO3-stepLadder1mild(1–3/10)2moderate(4–6/10)3severe(7-10/10)Morphine吗啡Hydromorphone氢吗啡酮Oxycodone羟考酮Fentan
