乳腺癌术后疼痛及镇痛方法的研究进展

背景 乳腺癌为女性患者常见的一种恶性肿瘤,手术治疗是主要的治疗措施.乳腺癌术后疼痛具有独特的疾病特点,并且可以成为一种慢性疼痛长期影响患者的生活质量,一直是临床亟待解决的问题. 目的 阐述乳腺癌术后疼痛及镇痛方法的研究进展,为疼痛的预防和治疗提供参考. 内容 综述乳腺癌术后疼痛及其镇痛方法的研究现状. 趋向 进一步探讨乳腺癌术后疼痛综合征的治疗方法,以明确有效的防治措施.     

全髋关节置换围术期多模式镇痛

全髋关节置换术(total hip arthroplasty,THA)自发明以来已在临床上得到了很好的发展和应用,但术后疼痛严重影响着其康复.术后急性疼痛会导致敏感的患者交感神经兴奋、心跳加速甚至心肌缺血,疼痛还会限制患者的术后活动,增加静脉血栓的风险.这种疼痛会延长患者住院时间,并增加住院费用,甚至有一部分患者由急性疼痛转化为慢性疼痛[1],进而严重影响患者术后的生活质量.围术期多模式镇痛( Mtltimodal analgesia)可以有效减轻THA术后疼痛,从而改善其术后生活质量[2].     

长期接受慢性疼痛治疗患者的围术期疼痛管理进展

背景 慢性疼痛患者往往长期接受一系列的治疗措施来控制疼痛,如因某种疾病要接受手术治疗时,这类患者的围术期疼痛管理是非常棘手的. 目的 了解不同慢性疼痛治疗措施下患者的围术期疼痛管理进展. 内容 分别阐述口服阿片药物、抗抑郁药、抗惊厥药,应用脊髓刺激器及鞘内药物输注系统等慢性疼痛治疗措施下患者的围术期疼痛管理策略.趋向 对长期接受慢性疼痛治疗患者的围术期疼痛管理的研究,将有助于提高这类患者在围术期的舒适度及安全度,加快术后康复.     

腹股沟疝修补术后慢性疼痛的原因及治疗

长期以来，腹股沟疝修补手术后慢性疼痛是一常见的并发症，在很大程度上影响了病人的术后恢复。绝大多数报告提示慢性腹股沟痛（腹股沟区痛）的发生率占腹股沟疝修补术后的2％～5％，在耻骨上腹部横行半月状切口后为4％。自应用无张力疝修补术以来术后疼痛的发生率已明显降低，但该法同时也引起了新的术后疼痛综合征和其他并发症。目前，国内外对无张力疝修补术后慢性疼痛的原因作了许多研究（主要在神经损伤方面）。现就腹股沟疝修补手术后慢性疼痛谈几点认识。     

脊柱手术患者术后慢性疼痛的危险因素及对策分析

目的 探讨脊柱手术患者术后慢性疼痛的危险因素及对策分析。方法 回顾性分析2019年1月至2022年6月于本院进行子脊柱手术的患者120例的临床资料，术后随访3个月，依据是否合并慢性疼痛，分为有慢性疼痛组(44例)与无慢性疼痛组(76例)。分析术后慢性疼痛患者的疼痛分级状况，选择χ²检验对临床资料实施单因素分析，并将有统计学意义的单因素分析结果进行多元Logistic回归分析。结果 44例术后慢性疼痛患者中，32例为轻度疼痛，占比72.73%,9例为中度疼痛，占比20.45%,3例为重度疼痛，占比6.82%；单因素分析显示，特发性脊柱侧弯、术前焦虑与抑郁、术前中重度疼痛、术后3 d VAS评分>3分、出现并发症、体重较重、手术时间长、融合椎体数较多为脊柱手术患者术后慢性疼痛的影响因素，差异有统计学意义(P<0.05)；多元Logistic回归分析显示，术前中重度疼痛、术后3 d VAS评分>3分、出现并发症、融合椎体数较多为脊柱手术患者术后慢性疼痛的独立危险因素。结论 脊柱手术患者术后慢性疼痛的危险因素包括术前VAS评分大于3分、融合椎体数...     

度洛西汀在骨科手术多模式镇痛的研究进展

<正>术后疼痛是骨科手术术后常见并发症。据报道，有80%左右的手术患者会出现急性术后疼痛，其中30%的患者会出现剧烈疼痛。目前术后疼痛仍然存在治疗不充分的情况，而急性疼痛长时间控制不佳会进展为慢性疼痛^[1]。术后疼痛管理失效会影响患者术后康复的进程和增加患者的痛苦感，导致住院时间延长，增加患者的医疗费用。骨科手术作为外科手术中的重要组成部分，     

Lichtenstein无张力疝修补术中腹股沟区神经处理的体会

目的探讨Lichtenstein无张力疝修补术中正确处理腹股沟区神经对术后慢性疼痛的预防效果。方法对我院2007年2月至2010年3月期间收治的158例腹股沟疝患者行Lichtenstein无张力疝修补术,并在术中注意辨认及保护腹股沟区神经,保持神经床的完整性,若神经被损伤或干扰了网片的放置则予切除。结果术中髂腹下神经、髂腹股沟神经和生殖股神经生殖支辨认率分别为87.97%(139/158)、82.28%(130/158)和34.18%(54/158)。术后并发症发生率为5.06%(8/158),其中切口皮下积液5例,阴囊血肿2例,切口感染1例,均通过理疗、切口换药后治愈。随访12个月,无复发病例。术后1个月有轻度疼痛者63例(39.87%),中度疼痛者34例(21.52%),无重度疼痛者,平均疼痛评分为0.83分;术后6个月时慢性疼痛发生率为5.06%(8/158),其中轻度疼痛者7例(4.43%),中度疼痛者1例(0.63%);术后12个月时只有4例(2.53%)患者偶感轻微疼痛或不适,平均疼痛评分为0.03分。多分类logistic回归分析显示:神经切除对术后疼痛无明显影响(P>0.05);未辨清髂腹股沟神经会增加术后早期(1个月)中度疼痛的风险(疼痛风险比值=3.373,P=0.030)。结论只要严格遵照Lichtenstein手术操作规范,术中正确处理腹股沟区神经,就能降低患者术后慢性疼痛的发生,改善其生活质量。     

腹股沟疝修补术后慢性腹股沟疼痛危险因素的研究进展

目的总结国内外对腹股沟疝修补术后慢性疼痛(CPIP)发生危险因素的研究现状。方法检索近年来国内外有关CPIP发生影响因素的文献并作综述。结果 CPIP的危险因素主要有术前疼痛、术后急性疼痛、复发性腹股沟疝、小疝囊、较高的体质量指数(BMI)、手术方式等,年龄、性别以及补片类型是否对CPIP存在影响争议较大。此外,近年发现,高血压和既往慢性疼痛病史也可能是CPIP发生的危险因素。结论 CPIP发生的危险因素仍需进一步研究。     

脊髓环氧合酶与术后疼痛

前列腺素（prostaglandins,PGs）是广泛存在于动物和人体内的一组重要的组织激素,在疼痛的产生过程中发挥着重要作用,其中最主要的是前列腺素E2（PGE2）和前列环素（PGI2）。近年来研究发现,PG受体也存在于脊髓背根神经节,这是感觉传人神经轴索进入脊髓以及脊髓感受伤害的起始部位。行为学研究也证实,鞘内注射PGs可以引出伤害性感受反应。环氧合酶（cyclooxygenase,COX）是以花生四烯酸为底物生成前列腺素（prostaglandins,PGs）途径中的限速酶。非甾体抗炎药（NSAIDs）干预伤害性感受的过程在脊髓,可能是通过减少神经系统中前列环素的合成来实现的。术后疼痛是急性疼痛的一种常见形式,各种类型手术的病人术后没有得到有效的镇痛是急性疼痛转为慢性疼痛的主要原因之一,近年来脊髓中COX参与术后疼痛的研究取得了一些进展。     

腹股沟管补片放置与Gilbert术后疼痛

目的比较腹股沟管补片放置与否对Gilbert术后疼痛发生的影响。 方法选择2014年2月至2017年2月,嘉兴市第二医院施行部分单侧Gilbert术式患者269例。按手术方式分为传统Gilbert组（腹膜前间隙及腹股沟管中均放置补片）与改良Gilbert组（仅腹膜前间隙放置补片,对腹股沟管补片修剪去大部分,仅在内环口处留下少量补片用于缝合固定）。比较各组术后近期疼痛、术后慢性疼痛、不同慢性疼痛性质的发生率及随访期间的复发率等。 结果2组随访期内的术后复发率比较,差异无统计学意义（P=1.000）。传统Gilber组术后发生近期疼痛158例,其中中度30例,重度7例;发生术后腹股沟区慢性疼痛（chronic postoperative inguinal pain,CPIP）44例,其中中度17例,重度6例。改良Gilber组术后发生近期疼痛32例,其中中度2例,重度1例;发生CPIP4例,其中中度1例,重度0例。改良Gilbert组较传统Gilbert组,术后近期的中重度疼痛发生率、CPIP的总体发生率、术后中重度CPIP的发生率、表现为活动时诱发疼痛的CPIP的发生率均明显较传统Gilbert组低,差异均有统计学意义（P=0.034、0.048、0.036、0.049）。 结论仅腹膜前间隙放置补片而剪去大部分腹股沟管补片改良Gilbert术可以有效减少Gilbert术后中重度近期疼痛的发生率、慢性疼痛的总发生率及中重度慢性疼痛的发生率,能够降低术后慢性疼痛中活动时诱发疼痛的发生率,且随访期间未增加疝复发率。     

Perioperative magnesium infusion and postoperative pain

Background: NMDA receptor activation is considered one of the mechanisms involved in postoperative pain and hypersensitivity. Magnesium is the physiological blocker of the NMDA-receptor-complex-associated calcium ionophore. The aim of this study was to determine if a pre-, intra- and postoperative infusion of magnesium would reduce postoperative pain.
Methods: In a prospective, randomised, double-blinded and placebo-controlled study, 24 patients undergoing elective hysterectomy in standardised general anaesthesia received a 5 h infusion of either placebo or magnesium laevulinate (initial bolus 8 mmol: then 8 mmol/h) starting with induction of anaesthesia. Postoperative analgesia was by PCA morphine for the first 48 h and patients were followed for 5 d with regular assessments of pain and side-effect scores.
Results: Overall, pain scores were similar with magnesium and placebo infusion, although patients in the magnesium group experienced more episodes of severe or unbearable pain (pla-cebo=6%, magnesium=16%, P=0.02). Median pain scores were higher in the magnesium group only at 3 h postoperatively ( P = 0.04): afterwards there were no significant differences. Except for the first postoperative hour (placebo=12.8±4.7 mg, mag-nesium=9.3±3.2 mg, P=0.04), cumulative morphine consumption was similar. Gastrointestinal complication rates and patient satisfaction were similar in both groups.
Conclusions: Perioperative magnesium infusion does not improve postoperative analgesia. At the doses used in this study, the use of magnesium is associated with short-term decreases in postoperative analgesia.     

Pharmacokinetics and pharmacodynamics of sublingual sufentanil for postoperative pain management

Achieving successful treatment of postoperative pain remains a challenge. Recently, a sufentanil sublingual tablet system has been developed for treatment of moderate‐to‐severe postoperative pain. The phenylpiperidine sufentanil is a potent analgesic that rapidly crosses the blood–brain barrier and selectively activates central μ‐opioid receptors. The system makes use of a hand‐held dispenser system, which contains forty 15‐μg sufentanil sublingual micro‐tablets. The patient can release one tablet at 20‐min intervals using a unique radiofrequency adhesive tag, which is wrapped around the patient's thumb. In this review, the authors discuss the pharmacology of sublingual sufentanil with reference to its suitability in the treatment of postoperative pain, the current evidence for the sublingual sufentanil system in postoperative pain treatment, and advantages and limitations of the sublingual system. We conclude that sufentanil is suited for the transmucosal route due to its pharmacokinetic profile, including rapid onset, absence of active metabolites and low tissue accumulation. The efficacy and safety of the sufentanil sublingual tablet system has been shown in over 600 patients in a limited set of studies; further independent studies are required to determine the position of the system among other forms of postoperative pain treatment. We conclude that the sublingual sufentanil tablet system allows effective pain relief, and allows patients to control their own pain relief and early postoperative mobility.     

Epidural morphine for postoperative pain relief in children

Epidural morphine for postoperative pain relief is in general use, and has proved to be very efficient in adults. The epidural technique and the use of epidural morphine are much less frequent in children. For 2 years we have prospectively followed 76 children who had epidural morphine for postoperative pain relief after major abdominal surgery. The age distribution was from newborn to 13 years, with a median age of 12 months. It was estimated that 94% of the patients had good analgesia for the first 24 postoperative hours and no other opioids were given. The side effects were few, but one case of respiratory depression was seen and 20% of the children had pruritus. There were four dural punctures and three catheters slipped out accidentally, but otherwise the treatment was continued as long as it was considered necessary (1–11 days). The use of postoperative ventilatory support decreased during the investigation. We observed a change in the sleeping pattern with an increased number of sleep–induced myoclonia during the administration of epidural morphine. In conclusion, the use of epidural morphine in children for postoperative pain relief is very efficient. The minimal effective dose has not been established as yet, but 50 Hg/kg every 8 h, supplemented with small doses of bupivacaine, provides excellent analgesia in the immediate postoperative period after major abdominal surgery. The side effects are few, but the risk of respiratory depression is always present and observation in the intensive care unit or recovery for the first 24 h is strongly recommended.     

Acute to chronic postoperative pain in children: preliminary findings

Background/purpose

Chronic postoperative pain is a well-established clinical phenomenon that is associated with adverse outcomes. The incidence of this clinical phenomenon in children, however, is not well established. The purpose of this study was to identify the incidence of chronic pain in children after surgery.

Methods

Following a screening process, a total of 113 children and their parents were enrolled in this cross-sectional study. Data regarding persistence and characteristics of pain after surgery were obtained.

Results

Approximately 13% of the children, most of whom underwent orthopedic procedures, reported the existence of symptoms of chronic postoperative pain. Most of the children indicated that the pain started immediately after surgery, was localized to the surgery site, and was intermittent. Children reported a median duration of pain of 4.1 months, and approximately half of the children experienced pain most days of the week. Up to 30% of the children reported interference of pain in functioning in areas such as extracurricular activities and sleep.

Discussion

Given the large number of children at risk for experiencing chronic postoperative pain, preventative efforts are necessary. Large-scale cohort prospective studies are needed to confirm the results of this cross-sectional study.     

Monitoring of skin conductance to assess postoperative pain intensity

Background. Pain is known to alter the electrogalvanic propertiesof the skin. The aim of this pilot study was to investigatethe influence of postoperative pain on skin conductance (SC)readings. Methods. After obtaining ethical approval and written informedconsent, 25 postoperative patients were asked to quantify theirlevel of pain on a numeric rating scale (NRS, 0–10) atdifferent time points in the recovery room. As a parameter ofSC, the number of fluctuations within the mean SC per second(NFSC) was recorded. Simultaneously, the NRS was obtained frompatients by a different observer who was blinded to the NFSCvalues. Results. Data from 110 readings of 25 patients (14 female, 11male; 21–67 yr) were included. NFSC showed a significantcorrelation with the NRS (r=0.625; P<0.01), whereas heartrate and blood pressure showed no or very weak correlation withthe NRS. NFSC was significantly different between patients withno (NRS=0), mild (NRS=1–3), moderate (NRS=4–5) andsevere (NRS=6–10) pain (no: 0.047, mild: 0.089, moderate:0.242, severe: 0.263; P<0.0001). Post hoc, a cut-off valuefor NFSC (0.1) was calculated above which a pain score >3on the NRS was predicted with sensitivity of 89% and specificityof 74%. Conclusions. The severity of postoperative pain significantlyinfluences SC. Using cut-off values, NFSC may prove a usefultool for pain assessment in the postoperative period.     

Strategies for postoperative pain management

Despite advances in our understanding of the neurobiology of nociception, postoperative pain continues to be undertreated. There are many modalities that may provide effective postoperative analgesia, including systemic (e.g. opioids, non-steroidal anti-inflammatory agents) and regional analgesic options. The particular modality or modalities utilized for a particular patient will depend on the risk-benefit profile and patient preferences. Ideally, analgesic options should be incorporated into a multimodal approach to facilitate patient recovery after surgery.