2022年医学专题—癌性疼痛的处理.ppt

癌性疼痛的处理WHO 3-阶梯(jit)镇痛疗法Management of Cancer PainWHO 3 Step Analgesic Ladder,Terence L.Gutgsell,MDHospice of the BluegrassLexington,KY,第一页，共三十二页。,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(tjng)讲解维持镇痛时阿片类药物间互相转换的技巧ObjectivesCompare,contrast nociceptive,neuropathic painKnow steps of analgesic management of cancer painKnow alternative routes for delivery of opioid analgesicsDemonstrate ability to convert between opioids while maintaining analgesia,第二页，共三十二页。,躯体(qt)的疼痛PhysicalPain,情感(qnggn)的疼痛EmotionalPain,社交(shjio)障碍Social Discord,宗教的困扰SpiritualDistress,病痛=总体的疼痛Suffering=Total Pain,第三页，共三十二页。,总的原则多因素(yn s)对患者反应的影响 环境 心理/社会状态 年龄 性别 多系统疾病和障碍 复合用药 General PrinciplesInfluences on patients response to Rx Environment Psycho/social status Age Sex Multi-system disease and disorders Polypharmacy,第四页，共三十二页。,普遍原则“拇指原则”诊断可能的机制(jzh),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 mechanism Individualize treatment ATC and PRN medications Keep it simple,Reassess Attention to Detail,第五页，共三十二页。,疼痛的病理生理学急性疼痛 已明确的原因，缓解时间(shjin)：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 pathophysiologyAcute pain Identified event,resolves daysweeks Usually nociceptiveChronic pain Cause often not easily identified,multifactorial Indeterminate duration Nociceptive and/or neuropathic,第六页，共三十二页。,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(zhngchng)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 painDirect stimulation of intact nociceptorsTransmission along normal nervesSharp,aching,throbbing Somatic-Easy to describe,localize Visceral-Difficult to describe,localize,第七页，共三十二页。,感受(gnshu)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 painTissue injury apparentManagement Opioids Adjuvant/coanalgesics,第八页，共三十二页。,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(z zh)交感神经介导的Neuropathic painDisordered peripheral or central nervesCompression,transection,infiltration,ischemia,metabolic injuryVaried types Peripheral deafferentation sympathetically mediated,第九页，共三十二页。,神经病性疼痛(tngtng)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 painPain may exceed observable injury Described as burning,tingling,shooting,stabbing,electrical Management Opioids Adjuvant/coanalgesics often required,第十页，共三十二页。,WHO 3-阶梯(jit)疗法WHO 3-step Ladder,1 mild(1 3/10),2 moderate(4 6/10),3 severe(7-10/10),Morphine吗啡(ma fi)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,ASAAcetaminophen扑热息痛NSAIDs Adjuvants,第十一页，共三十二页。,WHO 3-阶梯(jit)疗法,1 轻度(qn d)(1 3/10),阿斯匹林扑热息痛NSAIDs 辅助(fzh)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,第十二页，共三十二页。,阿片类的药理学在肝脏结合(jih)通过肾脏排泄（90%-95%）一级动力学Opioid pharmacologyConjugated in liverExcreted via kidney(90%95%)First-order kinetics,第十三页，共三十二页。,Plasma Concentration,0,Half-life(t1/2),Time,IV,po/pr,SC,Cmax,第十四页，共三十二页。,阿片类的药理学4-5个半衰期后呈稳定状态 1天（24小时）后呈稳定状态“即释”剂型(jxng)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 pharmacologySteady state after 4 5 half-lives Steady state after 1 day(24 hours)Duration of effect of“immediate-release”formulations 4 hours PO/PR Shorter with parenteral bolus,第十五页，共三十二页。,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/中度疼痛 25%50%-重度/难以控制的疼痛 50%100%对于(duy)严重的难以控制的疼痛需要较快地调整剂量Routine oral dosingimmediate-release preparationsMorphine,hydrocodone,oxycodone hydromorphone,(fentanyl)Dose q 4 h Adjust dose daily-mild/moderate pain 25%50%-severe/uncontrolled pain 50%100%Adjust more quickly for severe uncontrolled pain,第十六页，共三十二页。,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(yow)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 dosingextended-release preparationsImprove compliance,adherenceDose q 8,12,or 24 h Dont crush or chew tablets May flush time-release granules down feeding tubesAdjust dose q 2 3 days,第十七页，共三十二页。,突破性剂量使用(shyng)即释阿片类 应用24小时总量的10%-15%在达最高浓度后使用 PO q 1 h SC q 30 min IV q 1015 min不要使用缓（控）释阿片类Breakthrough dosingUse immediate-release opioids 10%15%of 24-h dose Offer after Cmax reached PO q 1 h SC q 30 min IV q 1015 minDO NOT use extended-release opioids,第十八页，共三十二页。,对阿片类反应欠佳的疼痛如果剂量增加不良反应 需要(xyo)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 poorly responsive to opioidsIf dose escalation adverse effects More sophisticated therapy to counteract adverse effect Alternative-route of administration-opioid rotation Coanalgesic Use a non-pharmacologic approach,第十九页，共三十二页。,给药的替代(tdi)途径Alternative routes of administration,Enteral feeding tubes 置管喂饲Transmucosal 经粘膜(zhn m)Rectal经直肠,Transdermal 经皮Parenteral 胃肠外Intraspinal 脊柱(jzh)内 Epidural 硬膜外 Intrathecal 鞘内,第二十页，共三十二页。,更换阿片类药物交叉耐受(nai shu)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 opioidsCross-tolerance Start with 50%75%of published equianalgesic doseMore if pain not controlled less if adverse effects prominent,第二十一页，共三十二页。,阿片类镇痛剂的等效(dn xio)剂量Equianalgesic doses of opioid analgesics,po/pr(mg)AnalgesicSC/IV(mg)30Morphine吗啡(ma fi)1030Hydrocodone氢可酮-20Oxycodone羟考酮-7.5 Hydromorphone氢吗啡酮1.5(300Meperidine度冷丁75)(200Codeine可待因120),第二十二页，共三十