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,neuropathicpainKnowstepsofanalgesicmanagementofcancerpainKnowalternativeroutesfordeliveryofopioidanalgesicsDemonstrateabilitytoconvertbetweenopioidswhilemaintaininganalgesia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”DiagnoseunderlyingmechanismIndividualizetreatmentATCandPRNmedicationsKeepitsimple,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PainpathophysiologyAcutepain：Identifiedevent,resolvesdays–weeksUsuallynociceptiveChronicpain：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,throbbingSomatic-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NociceptivepainTissueinjuryapparentManagement：OpioidsAdjuvant/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NeuropathicpainDisorderedperipheralorcentralnervesCompression,transection,infiltration,ischemia,metabolicinjuryVariedtypes:Peripheraldeafferentationsympatheticallymediated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NeuropathicpainPainmayexceedobservableinjuryDescribedasburning,tingling,shooting,stabbing,electricalManagement:OpioidsAdjuvant/coanalgesicsoftenrequiredWHO3-阶梯疗法WHO3-stepLadder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Opioidpharmacology:ConjugatedinliverExcretedviakidney(90%–95%)First-orderkinetics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OpioidpharmacologySteadystateafter4–5half-livesSteadystateafter1day(24hours)Durationofeffectof“immediate-release”formulations~4hoursPO/PRShorterwithparenteralbolus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Q4H，每天调整剂量25%–50%-轻度/中度疼痛-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Routineoraldosingimmediate-releasepreparationsMorphine,hydrocodone,oxycodonehydromorphone,(fentanyl)Doseq4hAdjustdosedaily25%–50%-mild/moderatepain-severe/uncontrolled50%–100%painAdjustmorequicklyforsevereuncontrolledpain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extended-releasepreparationsImprovecompliance,adherenceDoseq8,12,or24hDon’tcrushorchewt...
