1、,Perioperative pain management of acute to chronic pain after surgery,麻醉科,弟子规,骑下马 乘下车 过犹待 百步余长者立 幼勿坐 长者坐 命乃坐,公共卫生环境,新型镇痛药的发展是落后的,阿片类药物是唯一一类广泛并成功使用的镇痛剂,制药业不愿进一步开发新产品,临床试验证明镇痛剂的功效的任务非常艰巨,2010年，美国FDA 牵头组建了一个名为ACTION的团队，要求研究者以及企业对PPP的预防进行基础和临床研究。,Analgesic ClinicalTrial InnovationsOpportunities Networks
2、,启动和促进广泛的利益相关者的战略合作明确以共享数据，最佳实践和创新思维作为目的,这些利益相关者将会贡献他们的资源来促进对话以及发展特殊项目，这样可以快速有效的进行镇痛药物的开发,关键目的,AND,产业、学术界、专业组织、病人团体其他政府机构等,数据、科学技术、基础设施和金融资源,The ACTION committee has made some recommendations for conducting clinical trials for PPP prevention. Clinical trials examining PPP need to include preoperativ
3、e, intraoperative, and early and late postoperative parameters and the outcome needs to be assessed at the defined time point.,Persisitent pain after surgery of greater than three months duration.IASP,Postoperative Persisitent Pain（PPP）,Time frame,two or three months?,role out other causes,Whether i
4、t is two months or three months?,epidemiological and clinical trials it is vital to select a conservative time frame,undergo various clinical tests to rule out other pathological causes,Time frame,two or three months?,role out other causes,instability of the tibial femoral jiont or patellar maltrack
5、ing,ESR CRP,white blood cell count,Time frame,two or three months?,role out other causes,the operated surgical site,Time frame,two or three months?,role out other causes,the operated surgical site,consequence from PPP on physical and social function,the degree of disability decrease health related q
6、uality of life,the cost of treatment can be predicted the value of prevention will be appreciated,SO,The cost for treatment of PPP and the degree of disability from PPP are high and therefore any measures undertaken to decrease the incidence of PPP will have a significant impact on the health care r
7、esources.,Preoperative risk factors,Intraoperative risk factors,Postoperative risk factors,3,1,2,社会心理因素,术前疼痛,影响APP向PPP转化认知和情绪过程是最能影响慢性疼痛形成的个体危险因素疼痛恐惧及术前焦虑与增强的APP及PPP的增加有关,PPP的预测因子、独立危险因素、诱因,年龄,性别,其它,丹麦的一项研究，认为子宫切除术术后出现PPP的危险因素,术前盆腔痛，既往剖宫产史，存在其它疼痛问题，以疼痛为理由行子宫切除的患者,Preoperative risk factors,Intraopera
8、tive risk factors,Postoperative risk factors,3,1,2,手术区域存在主要神经经过的手术，发生率高,术中神经损伤可能只是一个重要的危险因素,其他因素决定了神经损伤的患者最终是否发展为神经病理性疼痛,大量的临床数据证实神经损伤可能是疼痛慢性化的重要因素,Intraoperative risk factors,截肢、开胸、乳腺、腹股沟疝修补术,不是所有术中报告有神经损伤的症状的手术都出现PPP,不幸的是没有一项更深层次的解剖结构及神经生理功能方面的研究,神经保护,Does early postoperative analgesic therapies decrease the PPP incidence?,Postoperative risk factors,急性疼痛转为慢性疼痛的机制复杂且认知太少,PPP,APP,目前多数临床试验主要是针对术后急性疼痛尤其是住院患者,术后疼痛增加被认为是PPP 得独立危险因素。有充分的理由认为严重急性术后疼痛的患者更敏感，也更容易发展成为PPP。来自丹麦的一项回顾性研究显示，子宫切除术后严重的APP，是术后一年存在PPP的一项危险因素。,
