开颅手术后镇痛的研究进展

正对于开颅手术后镇痛长期存在认识误区,认为由于脑实质没有痛觉神经分布,开颅手术后的疼痛轻,而且部分患者开颅术后神志、意识欠清醒,有的存在严重失语、意识模糊、认知功能损害,不能确切表达疼痛的部位和程度;加上外科医师对开颅术后疼痛的重视度不够,恐怕药物影响瞳孔观察或导致意识改变,以及患者家属对疼痛的认知不足等因素,开颅术后的镇痛不是普遍存在。实际上,开颅术后疼痛不仅存在使患者遭受着痛苦,影响其术后情绪,使其对手术     

成人开颅手术术后疼痛现状及治疗进展

<正>近年来大量临床研究显示,开颅手术术后疼痛的发生率和疼痛程度常被低估。另外,由于神经外科疾病的特殊性以及神经外科医师对患者病情评估的需要,常规术后镇痛方法不能直接应用于开颅手术患者。本文就目前成人开颅手术术后疼痛的现状及治疗方法做一简要综述。     

罗哌卡因切口浸润对神经外科术后疼痛的影响

<正>长期以来,关于神经外科患者术后是否需要镇痛存在很大争议,多数学者认为患者在神经外科术后对疼痛反应不敏感,可以不需要镇痛[1]。然而,近年来大量研究表明神经外科术后疼痛比预期的严重,如Thibault等[2]对299例行开颅手术患者的术后疼痛进行研究,发现76%患者术后出现中度至重度疼痛。而严重的疼痛反应对于神经外科术后患者的康复是不利的,它通过兴奋交感神经引起患者出现烦躁、     

曲马多用于硬膜外麻醉下中小型手术后镇痛的观察

中小手术和门诊手术患者术后同样产生疼痛和不适，但因创伤较小而容易被人们忽视。笔者认为对于中小型手术后的疼痛，同样需要给予术后镇痛治疗。为此，本文采用曲马多预先镇痛方法进行术后止痛。今总结和评价其镇痛效果，为临床选用提供参考资料。     

硬膜外自控镇痛泵在腹部手术中的应用及护理

术后疼痛是影响患者术后康复过程的重要因素。为减轻患者术后疼痛，提高术后生活质量，术后镇痛已成为医疗护理过程中的一个重要环节。我院自2006年10月至2007年10月应用硬膜外自控镇痛泵（PCEA）为158例腹部手术患者进行术后镇痛，效果满意。现报告如下：     

曲马多应用于术后镇痛的观察

术后疼痛是人体受到手术伤害刺激后的一种反应。疼痛本身可以产生一系列的病理生理改变，例如机体自主神经系统、精神方面及内分泌、激素的改变，从而影响到手术的预后。而术后镇痛可以最大程度地减轻手术后切口的疼痛，避免疼痛引起的围术期并发症，使患者尽早下床活动，尽快恢复正常的生理功能。因此术后镇痛势在必行。本文对曲马多在术后镇痛中的效果进行临床观察。     

全膝关节置换术围手术期疼痛综合控制的临床研究

目的探讨采用围手术期疼痛综合控制方法进行全膝关节置换术术后镇痛的临床疗效。方法2006年3月至2007年6月期间对60例单侧全膝关节置换术的患者采用围手术期疼痛综合控制方法进行术后疼痛的治疗。围手术期疼痛综合控制包括：术前患者教育和应用COX-2抑制剂超前镇痛；术中手术技术改进和减少手术创伤，并行关节周围多模式药物镇痛注射；术后常规应用COX-2抑制剂、医患沟通、冰敷和主动功能锻炼。术中关节周围注射随机分成多模式药物注射（MI）组和非多模式药物周围注射（NMI）组。观察患者术后疼痛情况（VAS）包括静息痛、运动疼痛。监测术后阿片类药物使用量和并发症。结果MI组术后静息疼痛评分均比NMI组低，术后阿片类镇痛药物使用量比NMI组少，两者之间的差异有统计学意义。MI组术后运动疼痛评分均比NMI组低，两者之间的差异无统计学意义。结论采用围手术期疼痛综合控制和关节周围多模式药物注射，能有效地控制全膝关节置换手术后的疼痛，且术后并发症少，有利于关节功能的恢复。     

低龄儿童颅脑手术术后疼痛情况的评估

目的 观察低龄儿童(1岁～6岁)开颅术后的疼痛现状,并探讨影响其术后疼痛的相关因素. 方法 应用前瞻性队列研究,入选择期开颅肿瘤切除术1岁～6岁患儿135例,其中15例因为术后不能即刻拔除气管导管被排除,11例因为术后1h内未清醒不能配合术后评分也被排除,另有1例因术后2日血肿行二次手术也被排除.最终共108例能够配合术后疼痛评分的患儿纳入研究.美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级.测量和记录每名患儿的人口统计学资料、手术的变量及术后疼痛及相关变量,术后分别采用Face、Legs、Activity、Cry and Consolability(FLACC)评分和Wong-Baker Faces Scale (WBFS)评分两种方法进行疼痛评分. 结果 108名患儿中大部分的患儿(FLACC法62％、WBFS法82％)在术后1h的疼痛评分超过4分.开颅部位(PFLACC=0.035;PWBS=0.039)、手术结束前末次镇痛药的使用(PFLACC=0.026,PWBFS=0.015)、手术结束后患儿的去向(PW肝S=0.022)及术后是否使用静脉镇痛泵(PFLACC=0.000,PWBFS=0.002)均为术后疼痛的相关因素. 结论 大部分低龄儿童在行开颅肿瘤切除术后48 h内经历了中到重度的疼痛,尤其是某些1岁～2岁小儿.在可以控制的因素中手术,手术结束前镇痛药的使用,术后及时得到父母的安抚与关怀,术后使用静脉镇痛泵等可以明显减轻患儿的术后疼痛.     

氟比洛芬酯超前镇痛在整形外科中的应用

目的探讨氟比洛芬酯的超前镇痛效果以及超前镇痛在整形美容手术中的临床作用。方法40例吸脂手术患者随机分为氟比洛芬脂组（Ⅰ组，n=20）和对照组（Ⅱ组，n=20）。麻醉前30minⅠ组静脉注射氟比洛芬酯100mg，Ⅱ组静脉注射生理盐水10ml，采用疼痛程度视觉模拟评分（Visual analogue scale，VAS）法观测手术开始、手术结束时患者的疼痛程度并记录分析。结果手术开始时Ⅰ组与Ⅱ组两组样本t检验、结束时Ⅰ组与Ⅱ组两组样本t检验，p〈0．05，说明Ⅰ组与Ⅱ组比较，氟比洛芬酯在术中、术后具有明显减轻疼痛的效果。结论氟比洛芬酯具有良好的超前镇痛效果：在整形美容手术中应用超前镇痛的作用，能使患者在术中或术后减轻疼痛和恐惧感，提高患者对手术效果的满意度。     

自控静脉镇痛加括约肌侧切用于痔术后镇痛的效果探讨

为探讨自控静脉镇痛加括约肌侧切用于痔术后的镇痛效果，将拟接受手术治疗的80例痔患者随机分为A组和B组，各40例，A组术中给予括约肌侧切，并在术后给予自控静脉镇痛，B组给予亚甲蓝局部注射镇痛，对比两组患者术后疼痛程度、换药及排便时疼痛情况，同时观察A组的不良反应。结果显示，A组术后6h、24h、48h及术后首次换药和排便时VAS评分均明显低于B组，P〈O．05。A组自控静脉镇痛期间无明显不良反应。结果表明，自控静脉镇痛加括约肌侧切可有效减轻痔术后疼痛，而且无不良反应。     

Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study

OBJECTIVE: This retrospective study was designed to assess the intensity of postoperative pain in relation to the location of craniotomy. METHODS: After Research Ethics Board approval, data were collected from the charts of all patients who underwent a craniotomy at our institution between January 2004 and December 2005. The severity of post-craniotomy pain was assessed by collecting scores obtained using an 11-point verbal rating scale and calculating the cumulative analgesic requirements for the first 48 hr postoperatively. Data were compared according to the craniotomy location. RESULTS: Data from 299 patients was available for analysis. On average, 76% of patients experienced moderate to severe postoperative pain. Frontal craniotomy was associated with lower pain scores than four of six craniotomy sites analyzed, with 49% of patients reporting mild pain, a significant difference (P < 0.05) compared with all other groups except for parietal craniotomies. Frontal craniotomy patients also had lower opioid analgesic requirements compared to patients who underwent posterior fossa craniotomy (P < 0.05). Logistic regression analysis showed that craniotomy location (P < 0.0001) and age (P = 0.004) were both independent predictors of the intensity of postoperative pain, with lower pain scores as age increased. Postoperative use of steroids, gender and presence of preoperative pain were not statistically linked to postoperative pain intensity. The prevalence of postoperative nausea and vomiting was 56% and it did not vary according to the location of craniotomy. CONCLUSION: This study shows that the intensity of postoperative pain in neurosurgery is affected by the site of craniotomy. Frontal craniotomy patients experienced the lowest pain scores, and required significantly less opioid than patients undergoing posterior fossa interventions.     

Pain in neurosurgically treated patients: a prospective observational study

OBJECT: This is the first observational study to compare perioperative pain character and intensity in patients undergoing different types of elective neurosurgical procedures. METHODS: A structured questionnaire was used to inquire about pain intensity, character, and management during the perioperative course, and the anticipated visual analogue scale (VAS) score in 649 patients during a 1-year period. The anticipated maximal postoperative VAS score was lower than the actual postoperative maximal VAS score and was independent of operation type and preoperative VAS score. Patients undergoing craniotomy experienced less pain than those undergoing spinal surgery. A majority of patients did not receive analgesic medication after surgery. Patients undergoing spinal surgery experienced higher preoperative VAS scores than those undergoing other neurosurgical treatments, with a shift from preoperative referred pain to postoperative local pain. After lumbar flavectomy, referred pain was greater than local pain. Patients with preoperative pain suffered significantly more postoperative pain than those without preoperative pain. In patients with postoperative surgery-related complications, VAS scores were higher than in those without complications. CONCLUSIONS: Neurosurgical procedures cause more pain than anticipated. Anticipated pain intensity is independent of the operation type and preoperative pain intensity. Postcraniotomy on-demand analgesic medication is appropriate, if the nurses on the ward react quickly. Otherwise, patient-controlled analgesia might be an option. Other neurosurgical procedures require scheduled analgesic therapies. Spinal surgery requires intensive preoperative pain treatment; a shift in pain character from preoperative referred pain to postoperative local pain is expected. Patients with referred pain after lumbar flavectomy are prone to the most intense pain. Patients with preoperative pain experience more postoperative pain than those without preoperative pain and require more intensive pain management. Increased postoperative VAS scores are associated with surgery-related complications.     

Scalp nerve blocks decrease the severity of pain after craniotomy.

Up to 80% of patients report moderate to severe pain after craniotomy. In this study, we assessed the efficacy of scalp block for decreasing postoperative pain in brain surgery. Thirty patients scheduled for supratentorial craniotomy were enrolled. They were randomly divided into two groups: Ropivacaine (scalp block with 20 mL of ropivacaine 0.75%) and Saline (scalp block with 20 mL of saline 0.9%). Anesthesia was standardized. The scalp block was performed after skin closure and before awakening. Postoperative pain was assessed at 4, 8, 12, 16, 20, 24, and 48 h by using a 10-cm visual analog scale. Analgesia was provided with sub- cutaneous codeine as requested by the patient. Average visual analog scale scores were higher in the Saline group as compared with Ropivacaine (3.7 +/- 2.4 vs 2.0 +/- 1.6; P = 0.036). The total dose of codeine did not differ, nor did the duration of time before the first dose of codeine was required in the Ropivacaine (571 +/- 765 min) versus Saline (319 +/- 409 min; P = 0.17) group. In conclusion, we found that postoperative scalp block decreases the severity of pain after craniotomy and that this effect is long lasting, possibly through a preemptive mechanism. IMPLICATIONS: Up to 80% of patients report moderate to severe pain after craniotomy. This randomized double-blinded study demonstrated that ropivacaine scalp block decreases the severity of pain after supratentorial craniotomy.     

Postoperative pain management in a tertiary care hospital: initial situation prior to starting a quality assurance program

OBJECTIVE: To characterize the initial situation in postoperative pain management among the services General and Vascular surgery as the first step in developing a program to improve postoperative analgesia. METHODS: An anonymous questionnaire with 14 items covered the characteristics of postoperative pain, information received about analgesic treatments and requesting medication, and degree of satisfaction. The questionnaire was filled in during an early postoperative interview with all patients undergoing surgery in the aforementioned departments. RESULTS: A total of 158 patients were interviewed; 89% were from the general surgery department and 11% from vascular surgery. At 24 hours after surgery, 18% were free of pain, 35% had mild pain, and 47% had moderate or intense pain. Nonsteroidal anti-inflammatory drugs were the most frequently used postoperative analgesics, in 94% of patients, and the dosage and timing had been prescribed for 74%. Thirty-six percent of the patients asked for an analgesic to be administered. The correlation between degree of greatest pain and request for an analgesic was statistically significant (P < 0.001). CONCLUSIONS: Postoperative pain is an area in which improvements can be implemented to provide better care and treatment of surgical patients, particularly since there are efficacious analgesic treatments for pain control that are presently not being used. The custom of prescribing pain medication on demand should be avoided in all surgical procedures that are known to produce postoperative pain.     

Diclofenac and oxycodone in treatment of postoperative pain: a double-blind trial

The effects of a prostaglandin synthesis inhibitor (diclofenac, Voltaren) and an opiate (oxycodone, Oxanest) on postoperative pain were compared. Included in the study were 85 candidates for various operations. Patients requesting an analgesic were given either 75 mg of diclofenac or 10 mg of oxycodone as an intramuscular injection. The onset of analgesic effect occurred within 13 +/- 4 min with oxycodone and within 16 +/- 8 min with diclofenac. The analgesic effect of diclofenac was slightly weaker than that of oxycodone (on a pain scale of 1-4, 1.6/2.1 after 0.5 h and 1.5/1.8 after 1 h). The patients again asked for an analgesic after an average of 4.6 h in the oxycodone group and after an average of 6.1 h in the diclofenac group. The average number of injections required until the first postoperative morning was 2.5 in the oxycodone group and 1.8 in the diclofenac group. Side-effects: 21 patients in the oxycodone group reported a total of 39 side-effects and eight patients in the diclofenac group a total of 10 side-effects. Diclofenac is an alternative to opiates in the management of postoperative pain. It is especially useful in patients in whom opiates cause side-effects.     

Pain management after ambulatory surgery

Numerous studies have reported inadequate pain management after ambulatory surgery. Uncontrolled pain is associated with increased incidence of nausea, anxiety and delirium, prolonged postanesthesia care unit stay, delayed discharge from ambulatory facility, unanticipated hospital admissions and delayed resumption of normal activities. The management of pain after ambulatory surgery poses unique challenges because of the need to balance pain relief with concerns of side effects ans safety. The goal of pain management should be to minimize pain, not only at rest but also during mobilization. Preoperative education of patients regarding the modalities of pain treatment, the pain assessment tools and the degree of pain that they might expect is an important part of pain management. The preemptive and multimodal techniques provide more effective analgersia with reduced incidence of side effects. Local anesthetic techniques should be utilized whenever possible as they are simple, have a high success rate and a low incidence of compilations. Local anesthetic techniques administered before the initiation of the surgery may decrease anesthetic requirements, provide for an earlier recovery and decrease postoperative analgesic requirements. Nonsteroidal antiinflammatory drugs have opioid-sparing effects, which may reduce the incidence of opioid-related side effects. Pain after discharge from the ambulatory facility should be controlled with regular dosing with oral nonsteroidal antiiflammatory drugs and opioid analgesic combination. Oral medications should be administered as early as possible and before the reduction of analgesic effects of parenterally adminisitered drugs. It is important that oral medications are administered at regular intervals rather than on an 'as needed' basis. Regular dosing with pain medications provides superior analgesia as this prevents pain from becoming severe and decreases the incidence of breakthrough pain. Finally, adequate and appropriate application of currently available information and therapies would significantly improve postoperative pain management.     

Postoperative headache after the lateral suboccipital approach: craniotomy versus craniectomy.

The lateral suboccipital approach to the cerebellopontine angle is typically performed as a small craniectomy. Incisional pain and headache following cerebellopontine angle surgery have been reported. Adherence of the cervical muscles to the dura, which is richly innervated, with consequent traction has been suggested to be responsible for postoperative headache. Therefore, postoperative headache probably could be reduced by replacing the bone flap between the muscles and the dura. In a prospective non-randomized study this hypothesis was tested by comparing craniectomy and craniotomy. 40 patients underwent removal of an acoustic neuroma via the retrosigmoid approach. Patients with a history of migraine, with additional intracerebral tumors or recurrencies as well as patients who developed a CSF fistula postoperatively were excluded. 29 patients were eligible for further evaluation. 13 patients underwent a craniotomy, 16 patients a craniectomy. All patients were subject to a standardized telephone interview three months and one year after surgery. Comparing the craniotomy group to the craniectomy group no difference was observed regarding age, sex, tumor size and duration of operation. 3 months as well as 12 months postoperatively headache was significantly (p < 0.05) less frequent in the craniotomy group as compared to the craniectomy group. In conclusion, an osteoplastic craniotomy significantly reduces postoperative headache and is therefore highly recommended.     

Preincision 0.25% bupivacaine scalp infiltration and postcraniotomy pain: a randomized double-blind,placebo-controlled study

This prospective, double-blind, randomized, and placebo-controlled trial was performed to evaluate the effect of preincisional scalp infiltration with 0.25% bupivacaine on the postoperative pain perception and analgesic requirement of patients undergoing elective supratentorial craniotomy. Twenty patients (bupivacaine group) received scalp infiltration with 25 mL of 0.25% bupivacaine followed by intravenous 5 mL of saline as placebo 5 minutes before incision, and another 21 patients (fentanyl group) received scalp infiltration with a similar volume of 0.9% saline solution followed by 2 microg/kg of intravenous fentanyl 5 minutes before incision. Following standard anesthesia technique, basal, preincisional, and postincisional hemodynamic data were recorded. Postoperative pain was assessed at 1, 6, 12, 24, and 48 hours by using a 10-cm visual analog scale. Diclofenac sodium was used as rescue analgesic in the postoperative period. Results showed rescue analgesic was required only during the first 12 hours. In each group the same number of patients needed rescue analgesia, but bupivacaine delayed this requirement 105 (30-720; median [range]) minutes compared with 60 (15-720; median [range]) minutes for the fentanyl group (P = 0.13). But there was no difference in the amount of analgesic consumed at different time intervals. Six of 20 patients in the bupivacaine group required rescue analgesic at the end of 1 hour compared with 9 of 21 fentanyl patients (P = 0.61). At 6 hours, the fraction of patients who required rescue analgesia were 7 of 20 and 11 of 21, respectively (P = 0.44). In conclusion, bupivacaine preincision scalp infiltration did not have any significant effect on postcraniotomy pain and analgesic requirement. However, bupivacaine may delay the requirement of the first analgesic dose.     

Parecoxib for analgesia after craniotomy

Background: Pain after craniotomy is often under-treated. Opiates carrydistinct disadvantages. Non-steroidal anti-inflammatory drugshave an anti-platelet action and carry a bleeding risk. Cyclo-oxygenase2 inhibitors such as parecoxib are not associated with a bleedingrisk and would be welcome analgesics if shown to be effective. Methods: In a prospective double-blind, randomized, placebo-controlledstudy, we investigated the analgesic effect of a single doseof parecoxib 40 mg given at dural closure in 82 patients undergoingelective craniotomies. Remifentanil was used intraoperatively,and i.v. morphine was titrated to the requirement in the post-anaestheticunit. On the ward, i.m. morphine 5 mg as required and regularacetaminophen was prescribed. Morphine use and visual analoguepain scores were recorded at 1, 6, 12, and 24 h after surgery. Results: Parecoxib reduced pain scores at 6 h and morphine use at 6 and12 h after operation. However, overall, it had only minimalimpact on postoperative analgesia. We found a wide variabilityin analgesic requirements where 11% of patients required noopioids and 16% required more than 15 mg i.v. morphine 1 h afterthe surgery. Conclusions: We found only limited evidence to support parecoxib as an analgesicafter craniotomy.     

The effects of tramadol and morphine on immune responses and pain after surgery in cancer patients

There has been growing interest in determining the possible immune consequences of opioid administration for the management of postoperative pain. We studied the effects of morphine and tramadol on pain and immune function during the postoperative period in 30 patients undergoing abdominal surgery for uterine carcinoma. Phytohemoagglutinin-induced T lymphocyte proliferation and natural killer cell activity were evaluated immediately before and after surgery, and 2 h after the acute administration of either 10 mg of morphine IM or 100 mg tramadol IM for pain. In all patients, phytohemagglutinin-induced lymphoproliferation was significantly depressed by surgical stress. However, in the morphine-treated group, proliferative values remained lower than basal levels for 2 h after treatment, whereas in tramadol-administered patients proliferative values returned to basal levels. Natural killer cell activity was not significantly affected by surgery nor by morphine administration, whereas tramadol significantly enhanced the activity of natural killer cells. Both drugs produced a comparable reduction in postoperative pain. We conclude that, as previously observed in the experimental animal, tramadol and morphine, when administered in analgesic doses, induce different immune effects. Implications: Recent studies suggest that opioids can have an adverse impact on the immune system. Because surgical stress also induces immune dysfunction, the search for analgesic drugs devoid of immunosuppressive effects is of import. This study compared the effects on immune responses of morphine and of the atypical opioid analgesic, tramadol, given for postoperative pain to gynecological cancer patients. Tramadol and morphine showed comparable analgesic activity; however, tramadol, in contrast to morphine, induced an improvement of postoperative immunosuppression and, therefore, may be preferred to morphine for the treatment of postoperative pain.