Joshi G P
University of Texas Southwestern Medical Center, Dallas.
Int Anesthesiol Clin. 1994 Summer;32(3):113-26. doi: 10.1097/00004311-199432030-00009.
Inadequately treated pain is a major cause of unanticipated hospital admissions after ambulatory surgery. The ability to provide adequate pain relief by simple methods that are readily available to the day-care patient in his or her home environment is one of the major challenges for providers of ambulatory surgery and anesthesia. The increasing number of extensive and painful surgical procedures (e.g., laparoscopic cholecystectomy, laminectomy, knee construction, hysterectomies) being undertaken on an ambulatory basis presents new challenges with respect to acute postoperative pain. Hence the availability of more sophisticated and effective treatment modalities, such as ambulatory PCA and continuous local and regional anesthetic blocks, with minimal side effects, are necessary to optimize the benefits of ambulatory surgery for both patient and health care provider. However, outcome studies are needed to evaluate the effect of these newer therapeutic approaches with respect to postoperative side effects and other important recovery parameters. Recent studies suggest that factors other than pain per se must be controlled to reduce postoperative morbidity and facilitate the recovery process. Not surprisingly, the anesthetic technique can influence analgesic requirement in the early postoperative period. Although oral analgesic agents will continue to play an important role, the adjunctive use of local anesthetic agents is likely to assume an even greater role in the future. Use of drug combinations (e.g., opiates and local anesthetics, opiates and NSAIDs) may provide improved analgesia with fewer side effects. Finally, safer and simpler analgesic delivery systems are needed to improve our ability to provide cost-effective pain relief after ambulatory surgery. In conclusion, as a result of our enhanced understanding of the mechanisms of acute pain and the physiological basis of nociception, the provision of "stress-free" anesthesia with minimal postoperative discomfort is now possible for most patients undergoing elective surgical procedures. The aim of an analgesic technique should be not only to lower the pain scores but also to facilitate earlier mobilization and reduce perioperative complications. If future clinical investigations clarify the issues that have been raised by laboratory studies, clinicians may be able to effectively treat postoperative pain using combinations of "balanced," "preemptive," and "peripheral" analgesia. More important, improved analgesic techniques will increase patient satisfaction and enhance their perception of ambulatory anesthesia and surgery.
疼痛治疗不充分是门诊手术后意外住院的主要原因。通过简单方法在家中就能为日间手术患者提供充分的疼痛缓解，这对门诊手术和麻醉提供者来说是一项重大挑战。越来越多的大型疼痛手术（如腹腔镜胆囊切除术、椎板切除术、膝关节重建术、子宫切除术）在门诊进行，这给术后急性疼痛带来了新的挑战。因此，需要有更复杂、有效的治疗方式，如门诊患者自控镇痛（PCA）以及持续局部和区域麻醉阻滞，且副作用最小，以优化门诊手术对患者和医疗服务提供者的益处。然而，需要进行结果研究来评估这些新治疗方法对术后副作用和其他重要恢复参数的影响。最近的研究表明，除了疼痛本身之外，其他因素也必须得到控制，以降低术后发病率并促进恢复过程。不出所料，麻醉技术会影响术后早期的镇痛需求。虽然口服镇痛药将继续发挥重要作用，但局部麻醉药的辅助使用在未来可能会发挥更大的作用。联合使用药物（如阿片类药物和局部麻醉药、阿片类药物和非甾体抗炎药）可能会提供更好的镇痛效果，且副作用更少。最后，需要更安全、更简单的镇痛给药系统，以提高我们在门诊手术后提供具有成本效益的疼痛缓解的能力。总之，由于我们对急性疼痛机制和伤害感受生理基础的深入了解，现在对于大多数接受择期手术的患者来说，提供“无应激”麻醉并使术后不适最小化已成为可能。镇痛技术的目标不仅应是降低疼痛评分，还应促进更早的活动并减少围手术期并发症。如果未来的临床研究能够阐明实验室研究所提出的问题，临床医生或许能够使用“平衡”“超前”和“外周”镇痛的组合有效地治疗术后疼痛。更重要的是，改进的镇痛技术将提高患者满意度，并增强他们对门诊麻醉和手术的认知。
