Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.
University of Ottawa, Ottawa, ON, Canada.
Drugs. 2019 Jul;79(11):1163-1175. doi: 10.1007/s40265-019-01156-3.
Morbid obesity (MO) is becoming increasingly prevalent worldwide and is associated with both altered physiology and increased co-morbidities. Together, these can render the perioperative pain management in patients with MO particularly challenging. With the higher incidence of sleep-disordered breathing in this patient population, traditional opioid-centric pain management can often result in opioid-induced ventilatory impairment and increased morbidity and/or mortality. Multimodal analgesia strategies based on a step-wise, severity-based, opioid-sparing approach can improve patient safety and outcomes. These protocols should be standardized and implemented in the perioperative care of patients with MO. Further advancements in acute pain management have sought to identify and treat nociceptive and pro-nociceptive components (hyperalgesia, etc.) with both pharmacologic and non-pharmacologic measures. In addition to standardizing postoperative pain management, irrespective of the anesthetic and analgesic regimen used, some patients with MO will need extended monitoring for potential respiratory adverse events. In this review, we briefly describe the obesity-associated changes in physiology and their impact on the pharmacology of pain, and provide an evidence-based clinical update on the perioperative pain management in MO. We discuss the role of opioid-sparing pharmacological adjuvants and implementation of standardized protocols, and highlight future areas of research in perioperative pain management in this patient population.
病态肥胖（MO）在全球范围内日益普遍，与生理改变和合并症增多有关。这些因素共同导致 MO 患者围手术期疼痛管理极具挑战性。由于该患者群体睡眠呼吸障碍发生率较高，传统以阿片类药物为中心的疼痛管理通常会导致阿片类药物引起的通气障碍以及发病率和/或死亡率增加。基于逐步、基于严重程度、阿片类药物节约的多模式镇痛策略可以提高患者安全性和结局。这些方案应在 MO 患者围手术期护理中标准化和实施。急性疼痛管理的进一步进展旨在通过药物和非药物措施来识别和治疗伤害性和促伤害性成分（痛觉过敏等）。除了标准化术后疼痛管理外，无论使用何种麻醉和镇痛方案，一些 MO 患者都需要延长监测潜在的呼吸不良事件。在这篇综述中，我们简要描述了肥胖相关的生理变化及其对疼痛药理学的影响，并提供了关于 MO 围手术期疼痛管理的循证临床更新。我们讨论了阿片类药物节约性药理佐剂的作用以及标准化方案的实施，并强调了该患者群体围手术期疼痛管理的未来研究领域。
