【原】急慢性术后痛的管理（一）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Ishida Y, Okada T, Kobayashi T, Funatsu K, Uchino H. Pain Management of Acute and Chronic Postoperative Pain. Cureus. 2022 Apr 9;14(4):e23999.本次学习由赵学军主任医师主讲。

Abstract

Inadequate management of acute postoperative pain is associated with effects related to both physiological and psychological function. Postoperative pain increases the risk of perioperative complications, so postoperative pain should be prevented. Postoperative pain management by sufficient analgesia is important while considering the use of various kinds of analgesics. Insufficient management of postoperative pain may lead to chronic postsurgical pain (CPSP). It is suggested that CPSP is dependent not only upon biological factors but also upon psychological factors, including the type of surgery, age, physical health, mental health, and preoperative pain. As CPSP is a severe complication that may prolong hospitalization and interferes with activities of daily living (ADL) and quality of life (QoL), its prevention of development is paramount. Therefore, in order to prevent the onset of CPSP, it is necessary to craft analgesic management to prevent CPSP during the perioperative period.

Keywords: multimodal analgesia, postsurgical analgesia, biological factors, psychological factors, chronic postsurgical pain

摘要

急性术后痛处理不当会导致患者躯体和心理功能出现障碍。术后痛会增加围手术期并发症的风险，因此预防术后痛显得尤为重要。使用各种止痛药充分镇痛来控制术后痛是很重要的。术后疼痛管理不当可能会导致慢性术后痛（chronic postsurgical pain，CPSP）。CPSP不仅可以由生物学因素所致，也可以由心理因素引起，包括手术类型、年龄、身体状况、心理状况和术前疼痛等等。由于CPSP是一种严重的并发症，它可能会延长患者住院时间并干扰其日常生活能力（activities of daily living，ADL）和生活质量（quality of life，QOL），因此预防其发生就显得至关重要了。因此，为了预防CPSP的发生，有必要在围手术期进行镇痛管理以预防CPSP。

关键词 多模式镇痛，术后镇痛，生物因素，心理因素，术后慢性疼痛

Introduction and background

The prevention of postsurgical pain is one of the major key points of anesthetic management. Depending on the case, the use of intravenous patient-controlled analgesia (IV-PCA) and the combined administration of epidural anesthesia are considered for postsurgical analgesia. Recently, the combined use of regional anesthesia for neural blockade (such as brachial plexus block and transversus abdominis plane block) is also performed for postsurgical analgesia. Typical postsurgical analgesia methods are using opioids such as fentanyl from the time of operation and considering the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen after surgery. In certain situations, direct local anesthesia for the wound is also carried out. In this way, we are examining postoperative analgesia using various methods and will consider its importance.

引言和背景知识

预防术后痛是临床麻醉的主要任务之一。视情况而定，静脉PCA联合硬膜外麻醉常用于术后镇痛。最近，联合区域麻醉用于神经阻滞（如臂丛神经阻滞和腹横肌平面阻滞）也用于术后镇痛。典型的术后镇痛方法是从手术开始使用芬太尼等阿片类药物，并考虑术后使用非甾体抗炎药（NSAIDs）和醋氨酚。在某些情况下，也会对伤口进行直接局部麻醉。这样，我们正在检查使用各种方法术后镇痛的结果。

Review

Pain mechanism and harmful effects of pain

It is known that the mechanism of inducing pain, especially pain during and after surgery, involves the activation and sensitization of the nociceptor due to surgical stress. Furthermore, it is suggested that humoral factors, such as prostaglandin and cytokines that function locally (at the surgery site) and systemically, decrease tissue pH and partial pressure of oxygen (pO2), enhance the reaction of nociceptive neurons of the central nervous system (CNS), and facilitate the spontaneous excitation of neurons due to peripheral nerve injury; they are associated with the mechanism to induce pain during and after an operation. Inadequate management of acute postoperative pain is associated with effects related to both physiological and psychological function. The effects of postsurgical pain on the respiratory system include a decrease in lung capacity, functional residual capacity (FRC), tidal volume, hypertonia of the abdominal muscles, and a decrease in diaphragm function. Furthermore, the fear of pain may restrain the patient from coughing and taking deep breaths, which, in turn, may induce atelectasis and accumulation of secreted products. These factors can become a cause of hypoxemia. The effects on the circulatory system include tachycardia and an increase in blood pressure due to excitation of the sympathetic nervous system. This causes an increase in oxygen consumption, which consequently causes a disruption of the balance between oxygen supply and demand. These effects raise the possibility of complications such as myocardial ischemia and myocardial infarction to occur. Prolonged bed rest due to persistent postsurgical pain may also cause the development of deep-vein thrombosis (DVT). The development of blood clots increases the risk of pulmonary thrombosis, which can become fatal. Effects on the digestive system include the suppression of intestinal movement, which can cause postsurgical ileus. Voiding dysfunction may also occur. Effects on the endocrine system include the excitation of the sympathetic nervous system, which prompts the discharge of catecholamine and catabolic hormones. This causes an increase in metabolism and oxygen consumption. Effects on the mental aspect of the patient include the overuse of analgesic drugs due to anxiety and fear of postsurgical pain. Prolonged pain may also cause a sense of distrust toward medicine. It is known that the risk of the above-mentioned complications increases as postsurgical pain becomes stronger. The development of these complications can also cause prolonged hospitalization and an increase in medical expenses. Therefore, sufficient analgesic management of postsurgical pain is important to prevent the delay of postsurgical recovery.

文献综述

疼痛机制和疼痛的有害影响

众所周知，诱发疼痛的机制，尤其是手术期间和手术后的疼痛，涉及到手术应激引起的痛觉感受器的激活和致敏。此外，有研究表明，体液因子，如在局部（手术部位）和全身发挥作用的前列腺素和细胞因子，可降低组织pH值和氧分压（pO2），增强中枢神经系统（CNS）伤害性神经元的反应，并促进外周神经损伤引起的神经元自发兴奋；它们与手术期间和手术后诱发疼痛的机制有关。急性术后疼痛处理不当会影响患者的生理和心理功能。术后痛对呼吸系统的影响包括肺容量、功能残气量（FRC）、潮气量、腹肌张力增加和膈肌功能下降。此外，对疼痛的恐惧可能会抑制患者咳嗽和深呼吸，进而可能导致肺不张和呼吸道分泌物的聚累。这些因素可能成为低氧血症的原因。对循环系统的影响包括心动过速和交感神经系统兴奋引起的血压升高。这会导致耗氧量增加，从而破坏氧气供应和需求之间的平衡关系。这些影响增加了发生心肌缺血和心肌梗死等并发症的可能性。手术后持续疼痛导致的卧床休息时间延长也可能导致深静脉血栓形成（DVT）。血块的形成增加了肺血栓形成的风险，这可能会致命。对消化系统的影响包括抑制肠道运动，这可能导致术后肠梗阻。也可能出现排尿功能障碍。对内分泌系统的影响包括交感神经系统的兴奋，这促使儿茶酚胺和分解代谢激素的释放。这导致新陈代谢和氧气消耗增加。对患者心理方面的影响包括由于焦虑和对术后疼痛的恐惧而过度使用止痛药。长期的疼痛也可能导致对药物的不信任感。众所周知，随着术后疼痛加剧，上述并发症的风险增加。这些并发症的发展也会导致住院时间延长和医疗费用增加。因此，充分的术后痛的管理对于防止术后恢复的延迟非常重要。