Department of Anesthesiology, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90095, USA.
Am J Ther. 2010 Sep-Oct;17(5):498-510. doi: 10.1097/MJT.0b013e3181ed83a0.
We have all encountered the following postanesthesia care unit dilemma a myriad of times. As the attending covering the postanesthesia care unit, the anesthesiologist will be confronted not infrequently with the following clinical scenario: "He needed 500 μg fentanyl in the operating room for a toe amputation and has received 20 mg morphine, and he's still complaining of severe pain…. Do you think he may need more morphine?" Opiates do prevail as first-line therapy for moderate to severe surgical and chronic pain states. However, their use may actually confound the clinical picture postoperatively, because opiate exposure counterintuitively may actually trigger exaggerated pain sensation. When assessing a patient experiencing exaggerated postoperative or chronic pain, several questions should come to mind. First, is this patient experiencing tolerance or hyperalgesia induced by opiate therapy? Second, does the management differ for the two etiologies? Third, what underlying mechanisms, both at the neuroanatomic and molecular/chemical levels, underlie the two processes? Fourth, how does the recent literature on opiate-induced hyperalgesia influence previously accepted views of pre-emptive analgesia? Fifth, what treatment modalities exist for opiate-induced hyperalgesia? Most importantly, sixth, how can opiate-induced hyperalgesia be prevented? In this literature review, we aim to address these questions and to hopefully change the current perception and management of perioperative and chronic pain states with opiates.
我们都曾无数次遇到过以下麻醉后护理病房的困境。作为负责麻醉后护理病房的主治医生，麻醉师经常会遇到以下临床情况：“他在手术室进行脚趾截肢手术时需要 500μg 的芬太尼，但已经给他注射了 20mg 的吗啡，他仍然感到剧烈疼痛……你认为他可能需要更多的吗啡吗？”阿片类药物是治疗中重度手术和慢性疼痛的一线药物。然而，它们的使用实际上可能会使术后情况变得复杂，因为阿片类药物的暴露会反直觉地引发过度的疼痛感觉。在评估经历术后或慢性疼痛加剧的患者时，应考虑以下几个问题。首先，患者是因为阿片类药物治疗而产生了耐受性还是痛觉过敏？其次，这两种病因的治疗方法是否不同？第三，在神经解剖和分子/化学水平上，是什么潜在机制导致了这两个过程？第四，阿片类药物引起的痛觉过敏的最新文献如何影响人们对预防性镇痛的先前观点？第五，有哪些治疗方法可以用于治疗阿片类药物引起的痛觉过敏？最重要的是，第六，如何预防阿片类药物引起的痛觉过敏？在本次文献综述中，我们旨在回答这些问题，并希望改变目前对围手术期和慢性疼痛状态的阿片类药物的认识和管理。
