Dahl V, Raeder J C
Department of Anaesthesia, Baerum Hospital, Norway.
Acta Anaesthesiol Scand. 2000 Nov;44(10):1191-203. doi: 10.1034/j.1399-6576.2000.441003.x.
Although significant improvement has been made in the treatment of pain in the postoperative period, many patients still experience unnecessary discomfort resulting in distress, higher morbidity and prolonged stay in hospital. The standard pillar of postoperative treatment of severe pain is the use of opioids. However, adverse reactions to opioids make their use unfavourable. A better understanding of the pathophysiology of pain has helped clinicians to a more balanced approach to postoperative pain treatment. The development of the multimodal approach to postoperative analgesia, with the use of different drugs acting via different routes to give good analgesia, with minimal side-effects, represents a major development in the treatment of postoperative pain. Early, aggressive mobilisation and feeding must follow in order to restore normal conditions quickly. Alternatives to opioids should be used as extensively as possible. Local anaesthesia, used as regional blocks or as wound infiltration, is most beneficial. Paracetamol has good basic analgesic properties, and should probably be used in dosages higher than recommended today. The combination with a NSAID results in better and longer-lasting analgesia. The intravenous form propacetamol will increase the possibilities of its use. The new concept of selective COX-2 inhibiting NSAIDs will result in analgesic and anti-inflammatory drugs with fewer side-effects. The well-known inexpensive group of corticosteroids have good analgesic and anti-emetic properties, and are especially interesting to use in patients who do not tolerate NSAIDs. The alpha2-receptor agonists like clonidine, when administered epidurally or intrathecally, are useful adjuncts, but their adverse effects on sedation and hypotension limit their use. NMDA-receptor antagonists are of limited value in the postoperative period. Adenosine and neostigimine are still on a research level but may lead to new, clinically useful analgesic drugs. In the future, cannabinoids, cholecystokinin-receptor antagonists and neurokinin-1 antagonists may become important analgesic drugs.
尽管术后疼痛治疗已取得显著进展，但仍有许多患者经历不必要的不适，导致痛苦、更高的发病率和更长的住院时间。术后重度疼痛治疗的标准支柱是使用阿片类药物。然而，阿片类药物的不良反应使其使用存在弊端。对疼痛病理生理学的更好理解有助于临床医生采用更平衡的术后疼痛治疗方法。术后镇痛多模式方法的发展，即使用通过不同途径发挥作用的不同药物以实现良好镇痛且副作用最小，代表了术后疼痛治疗的一项重大进展。必须尽早积极进行活动和进食，以便迅速恢复正常状态。应尽可能广泛地使用阿片类药物的替代药物。局部麻醉，无论是用作区域阻滞还是伤口浸润，都最为有益。对乙酰氨基酚具有良好的基本镇痛特性，可能应使用高于目前推荐剂量的用量。与非甾体抗炎药联合使用可产生更好且更持久的镇痛效果。静脉注射用丙泊酚将增加其使用的可能性。选择性COX - 2抑制性非甾体抗炎药的新概念将产生副作用更少的镇痛和抗炎药物。众所周知的廉价皮质类固醇组具有良好的镇痛和止吐特性，对于不耐受非甾体抗炎药的患者尤其值得使用。像可乐定这样的α2受体激动剂，经硬膜外或鞘内给药时是有用的辅助药物，但其对镇静和低血压的不良反应限制了其使用。NMDA受体拮抗剂在术后阶段价值有限。腺苷和新斯的明仍处于研究阶段，但可能会带来新的、具有临床实用价值的镇痛药。未来，大麻素、胆囊收缩素受体拮抗剂和神经激肽 - 1拮抗剂可能会成为重要的镇痛药。
