Rawal N
Department of Anesthesiology, Orebro Medical Centre Hospital, Sweden.
Reg Anesth Pain Med. 1999 Jan-Feb;24(1):68-73. doi: 10.1016/s1098-7339(99)90168-2.
Despite unprecedented interest in understanding pain mechanisms and pain management, a significant number of patients continue to experience unacceptable pain after surgery. Recent surveys show that there has been no apparent improvement since an early study in 1952 (15). It is increasingly clear that the solution to the problems of postoperative pain management lies not so much in the development of new techniques but in developing an organization to exploit existing expertise. The most obvious components of an acute pain team include anesthesiologists, surgeons, nurses, and physiotherapists. Protocols encourage consistent standards of safe and effective care and should be used as a framework to individualize treatment. The concept of skilled pain therapists collaborating to provide improved postoperative analgesia within the framework of an organized APS appears to be universally applicable. Acute pain service models have been described from the United States, the United Kingdom, Germany, Switzerland, and Sweden. The U.S. model, which consists of anesthesiologist-based comprehensive pain management teams, is quite effective but is more expensive, and it is not transferable to Europe. A recent United Kingdom survey showed that there is a large degree of variation in what is thought to constitute an APS in the U.K. (16). A nurse-based anesthesiologist-supervised APS in which pain is evaluated in every patient who undergoes surgery has been developed in Sweden. Pain above 3 on the 10-grade VAS is promptly treated. Clearly, neither the anesthesiologist nor the APN guarantees good pain management on wards. In this low-cost model, the role of the anesthesiologist is to teach and train ward nurses, to supervise the APN, and to select patients for special pain therapies such as epidural, PCA, and peripheral nerve blocks. All senior anesthesiologists (section chiefs) working in the operating room are part of this APS. The means of providing satisfactory analgesia are already present in most hospitals. Careful planning and a multidisciplinary approach to pain management will ensure that resources are optimally utilized, and the quality of pain management is consistently maintained.
尽管人们对了解疼痛机制和疼痛管理有着前所未有的兴趣，但仍有相当数量的患者在术后持续遭受难以忍受的疼痛。最近的调查显示，自1952年的一项早期研究以来，情况并未有明显改善（15）。越来越明显的是，术后疼痛管理问题的解决方案不在于开发新技术，而在于建立一个组织来利用现有专业知识。急性疼痛治疗小组最明显的组成部分包括麻醉医生、外科医生、护士和物理治疗师。方案鼓励采用一致的安全有效护理标准，并应作为个体化治疗的框架。由熟练的疼痛治疗师协作，在有组织的急性疼痛服务框架内提供更好的术后镇痛，这一理念似乎普遍适用。美国、英国、德国、瑞士和瑞典都描述了急性疼痛服务模式。美国模式由以麻醉医生为基础的综合疼痛管理团队组成，效果相当显著，但成本更高，且无法移植到欧洲。英国最近的一项调查显示，在英国，人们对急性疼痛服务的构成存在很大差异（16）。瑞典开发了一种由护士主导、麻醉医生监督的急性疼痛服务模式，对每一位接受手术的患者进行疼痛评估。视觉模拟评分法（VAS）10分制中疼痛评分高于3分的患者会立即接受治疗。显然，麻醉医生和急性疼痛护士都不能保证病房内的疼痛管理良好。在这种低成本模式中，麻醉医生的作用是教导和培训病房护士，监督急性疼痛护士，并为特殊疼痛治疗（如硬膜外麻醉、患者自控镇痛和外周神经阻滞）挑选患者。所有在手术室工作的资深麻醉医生（科室主任）都是这个急性疼痛服务团队的成员。大多数医院已经具备提供满意镇痛的手段。精心规划和采用多学科方法进行疼痛管理，将确保资源得到最佳利用，并持续保持疼痛管理的质量。
