SPECIAL ARTICLES
Practice Guidelines for Acute Pain Management in the Perioperative Setting
An Updated Report by the American Society of
Anesthesiologists Task Force on Acute Pain Management
P
RACTICE Guidelines are systematically developed rec-ommendations that assist the practitioner and patient in making decisions about health care.These recommenda-tions may be adopted,modified,or rejected according to clinical needs and constraints and are not intended to replace local institutional policies.In addition,Practice Guidelines de-veloped by the American Society of Anesthesiologists (ASA)are not intended as standards or absolute requirements,and their use cannot guarantee any specific outcome.Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge,technology,and practice.They provide basic rec-ommendations that are supported by a synthesis and analysis of
the current literature,expert and practitioner opinion,open fo-rum commentary,and clinical feasibility data.
This document updates the “Practice Guidelines for Acute Pain Management in the Perioperative Setting:An Updated Report by the American Society of Anesthesiolo-gists Task Force on Acute Pain Management,”adopted by the ASA in 2003and published in 2004.*
Methodology
A.Definition of Acute Pain Management in the Perioperative Setting
For these Guidelines,acute pain is defined as pain that is present in a surgical patient after a procedure.Such pain may be the result of trauma from the procedure or procedure-related complications.Pain management in the perioperative setting refers to actions before,during,and after a procedure
Updated by the American Society of Anesthesiologists (ASA)Com-mittee on Standards and Practice Parameters,Jeffrey L.Apfelbaum,M.D.(Committee Chair),Chicago,Illinois;Michael A.Ashburn,M.D.,M.P.H.(Task Force Chair),Philadelphia,Pennsylvania;Richard T.Con-nis,Ph.D.,Woodinville,Washington;Tong J.Gan,M.D.,Durham,North Carolina;and David G.Nickinovich,Ph.D.,Bellevue,Washing-ton.The previous update was developed by the ASA Task Force on Acute Pain Management:Michael A.Ashburn,M.D.,M.P.H.(Chair),Salt Lake City,Utah;Robert A.Caplan,M.D.,Seattle,Washington;Daniel B.Carr,M.D.,Boston,Massachusetts;Richard T.Connis,Ph.D.,Woodinville,Washington;Brian Ginsberg,M.D.,Durham,North Car-olina;Carmen R.Green,M.D.,Ann Arbor,Michigan;Mark J.Lema,M.D.,Ph.D.,Buffalo,New York;David G.Nickinovich,Ph.D.,Belle-vue,Washington;and Linda Jo Rice,M.D.,St.Petersburg,Florida.Received from the American Society of Anesthesiologists,Park Ridge,Illinois.Submitted for publication October 20,2011.Accepted for publication October 20,2011.Supported by the American Society of Anesthesiologists and developed under the direction of the Committee on Standards and Practice Parameters,Jeffrey L.Apfelbaum,M.D.(Chair).Approved by the ASA House of Delegates on October 19,2011.A complete list of references used to develop these updated Guidelines,arranged alphabeti-cally by author,is available as Supplemental Digital Content 1,https://www.doczj.com/doc/0210663432.html,/ALN/A780.
Address correspondence to the American Society of Anesthesi-ologists:520North Northwest Highway,Park Ridge,Illinois 60068-2573.These Practice Guidelines,as well as all published ASA Prac-tice Parameters,may be obtained at no cost through the Journal Web site,https://www.doczj.com/doc/0210663432.html,.
*American Society of Anesthesiologists Task Force on Acute Pain Management:Practice guidelines for acute pain management in the perioperative setting:An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management.A NESTHESIOLOGY 2004;100:1573–81.
Copyright ?2012,the American Society of Anesthesiologists,Inc.Lippincott Williams &Wilkins.Anesthesiology 2012;116:248–73
?What other guideline statements are available on this topic?X These Practice Guidelines update the “Practice Guidelines for Acute Pain Management in the Perioperative Setting,”adopted by the ASA in 2003and published in 2004.*?Why was this guideline developed?
X In October 2010,the Committee on Standards and Practice Parameters elected to collect new evidence to determine whether recommendations in the existing Practice Guide-line were supported by current evidence.
?How does this statement differ from existing guidelines?
X New evidence presented includes an updated evaluation of scientific literature and findings from surveys of experts and randomly selected ASA members.The new findings did not necessitate a change in recommendations.
?Why does this statement differ from existing guidelines?
X The ASA guidelines differ from the existing guidelines be-cause they provide new evidence obtained from recent sci-entific literature as well as findings from new surveys of expert consultants and randomly selected ASA members.
Supplemental digital content is available for this article.Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article.Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (https://www.doczj.com/doc/0210663432.html,).
that are intended to reduce or eliminate postoperative pain before discharge.
B.Purpose of the Guidelines
The purpose of these Guidelines is to(1)facilitate the safety and effectiveness of acute pain management in the perioperative set-ting;(2)reduce the risk of adverse outcomes;(3)maintain the patient’s functional abilities,as well as physical and psychologic well-being;and(4)enhance the quality of life for patients with acute pain during the perioperative period.Adverse outcomes that may result from the undertreatment of perioperative pain include(but are not limited to)thromboembolic and pulmo-nary complications,additional time spent in an intensive care unit or hospital,hospital readmission for further pain manage-ment,needless suffering,impairment of health-related quality of life,and development of chronic pain.Adverse outcomes associated with the management of perioperative pain include (but are not limited to)respiratory depression,brain or other neurologic injury,sedation,circulatory depression,nausea, vomiting,pruritus,urinary retention,impairment of bowel function,and sleep disruption.Health-related quality of life includes(but is not limited to)physical,emotional,social,and spiritual well-being.
C.Focus
These Guidelines focus on acute pain management in the perioperative setting for adult(including geriatric)and pedi-atric patients undergoing either inpatient or outpatient sur-gery.Modalities for perioperative pain management ad-dressed in these Guidelines require a higher level of professional expertise and organizational structure than“as needed”intramuscular or intravenous injections of opioid analgesics.These Guidelines are not intended as an exhaus-tive compendium of specific techniques.
Patients with severe or concurrent medical illness such as sickle cell crisis,pancreatitis,or acute pain related to cancer or cancer treatment may also benefit from aggressive pain https://www.doczj.com/doc/0210663432.html,bor pain is another condition of interest to anes-thesiologists.However,the complex interactions of concur-rent medical therapies and physiologic alterations make it impractical to address pain management for these popula-tions within the context of this document.
Although patients undergoing painful procedures may benefit from the appropriate use of anxiolytics and sedatives in combination with analgesics and local anesthetics when indicated,these Guidelines do not specifically address the use of anxiolysis or sedation during such procedures.
D.Application
These Guidelines are intended for use by anesthesiologists and individuals who deliver care under the supervision of anesthesiologists.The Guidelines may also serve as a resource for other physicians and healthcare professionals who man-age perioperative pain.In addition,these Guidelines may be used by policymakers to promote effective and patient-cen-tered care.
Anesthesiologists bring an exceptional level of interest and expertise to the area of perioperative pain management. Anesthesiologists are uniquely qualified and positioned to provide leadership in integrating pain management within perioperative care.In this leadership role,anesthe-siologists improve quality of care by developing and di-recting institution-wide,interdisciplinary perioperative analgesia programs.
E.Task Force Members and Consultants
The original Guidelines were developed by an ASA ap-pointed task force of11members,consisting of anesthesiol-ogists in private and academic practices from various geo-graphic areas of the United States,and two consulting methodologists from the ASA Committee on Standards and Practice Parameters.
The Task Force updated the Guidelines by means of a seven-step process.First,they reached consensus on the cri-teria for evidence.Second,original published research stud-ies from peer-reviewed journals relevant to acute pain man-agement were reviewed and evaluated.Third,expert consultants were asked to:(1)participate in opinion surveys on the effectiveness of various acute pain management rec-ommendations and(2)review and comment on a draft of the updated Guidelines.Fourth,opinions about the updated Guideline recommendations were solicited from a sample of active members of the ASA.Fifth,opinion-based informa-tion obtained during an open forum for the original Guide-lines,held at a major national meeting,?was reexamined. Sixth,the consultants were surveyed to assess their opinions on the feasibility of implementing the updated Guidelines. Seventh,all available information was used to build consen-sus to finalize the updated Guidelines.A summary of recom-mendations may be found in appendix1.
F.Availability and Strength of Evidence
Preparation of these Guidelines followed a rigorous method-ological process.Evidence was obtained from two principal sources:scientific evidence and opinion-based evidence. Scientific Evidence
Study findings from published scientific literature were ag-gregated and are reported in summary form by evidence cat-egory,as described below.All literature(e.g.,randomized controlled trials[RCTs],observational studies,case reports) relevant to each topic was considered when evaluating the findings.However,for reporting purposes in this document, only the highest level of evidence(i.e.,level1,2,or3within
?International Anesthesia Research Society,68th Clinical and Scientific Congress,Orlando,Florida,March6,1994.
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category A,B,or C,as identified below)is included in the summary.
Category A:Supportive Literature
Randomized controlled trials report statistically significant (P?0.01)differences between clinical interventions for a specified clinical outcome.
Level1:The literature contains multiple RCTs,and aggre-gated findings are supported by meta-analysis.?Level2:The literature contains multiple RCTs,but the number of studies is insufficient to conduct a
viable meta-analysis for the purpose of these
Guidelines.
Level3:The literature contains a single randomized con-trolled trial.
Category B:Suggestive Literature
Information from observational studies permits inference of beneficial or harmful relationships among clinical interven-tions and clinical outcomes.
Level1:The literature contains observational comparisons
(e.g.,cohort,case-control research designs)of clin-
ical interventions or conditions and indicates statis-
tically significant differences between clinical inter-
ventions for a specified clinical outcome.
Level2:The literature contains noncomparative observa-tional studies with associative(e.g.,relative risk,
correlation)or descriptive statistics.
Level3:The literature contains case reports.
Category C:Equivocal Literature
The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.
Level1:Meta-analysis did not find significant differences (P?0.01)among groups or conditions.
Level2:The number of studies is insufficient to conduct meta-analysis,and(1)RCTs have not found signif-
icant differences among groups or conditions or(2)
RCTs report inconsistent findings.
Level3:Observational studies report inconsistent findings or do not permit inference of beneficial or harmful
relationships.
Category D:Insufficient Evidence from Literature
The lack of scientific evidence in the literature is described by the following terms.
Inadequate:The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes.The literature either does not meet the criteria for content as defined in the“Focus”of the Guidelines or does not permit a clear interpretation of findings due to methodological concerns(e.g.,confounding in study de-sign or implementation).
Silent:No identified studies address the specified rela-tionships among interventions and outcomes.
Opinion-based Evidence
All opinion-based evidence(e.g.,survey data,open-forum testimony,Internet-based comments,letters,editorials)rel-evant to each topic was considered in the development of these updated Guidelines.However,only the findings ob-tained from formal surveys are reported.
Opinion surveys were developed for this update by the Task Force to address each clinical intervention identified in the document.Identical surveys were distributed to expert consultants and ASA members.
Category A:Expert Opinion
Survey responses from Task Force-appointed expert consultants are reported in summary form in the text,with a complete listing of consultant survey responses reported in appendix2. Category B:Membership Opinion
Survey responses from active ASA members are reported in summary form in the text,with a complete listing of ASA member survey responses reported in appendix2.
Opinion survey responses are recorded using a5-point scale and summarized based on median values.§Strongly Agree:Median score of5(At least50%of the responses are5)
Agree:Median score of4(At least50%of the responses are 4or4and5)
Equivocal:Median score of3(At least50%of the re-sponses are3,or no other response category or combination of similar categories contain at least50%of the responses) Disagree:Median score of2(At least50%of responses are 2or1and2)
Strongly Disagree:Median score of1(At least50%of responses are1)
Category C:Informal Opinion
Open-forum testimony from the previous update,Internet-based comments,letters,and editorials are all informally evaluated and discussed during the development of Guide-line recommendations.When warranted,the Task Force may add educational information or cautionary notes based on this information.
?All meta-analyses are conducted by the American Society of An-
esthesiologists methodology group.Meta-analyses from other sources
are reviewed but not included as evidence in this document.
§When an equal number of categorically distinct responses are
obtained,the median value is determined by calculating the arith-
metic mean of the two middle values.Ties are calculated by a
predetermined formula.
Practice Guidelines
Guidelines
I.Institutional Policies and Procedures for Providing Perioperative Pain Management
Institutional policies and procedures include(but are not limited to)(1)education and training for healthcare provid-ers,(2)monitoring of patient outcomes,(3)documentation of monitoring activities,(4)monitoring of outcomes at an institutional level,(5)24-h availability of anesthesiologists providing perioperative pain management,and(6)use of a dedicated acute pain service.
Observational studies report that education and training programs for healthcare providers are associated with de-creased pain levels,1–4decreased nausea and vomiting,2and improved patient satisfaction1(Category B2evidence),al-though the type of education and training provided varied across the studies.Published evidence is insufficient to eval-uate the impact of monitoring patient outcomes at either the individual patient or institutional level,and the24-h availability of anesthesiologists(Category D evidence).Observational studies assessing documentation activities suggest that pain outcomes are not fully documented in patient records(Category B2evi-dence).5–11Observational studies indicate that acute pain ser-vices are associated with reductions in perioperative pain(Cate-gory B2evidence),12–20although treatment components of the acute pain services varied across the studies.
The consultants and ASA members strongly agree that anesthesiologists offering perioperative analgesia services should provide,in collaboration with other healthcare pro-fessionals as appropriate,ongoing education and training of hospital personnel regarding the effective and safe use of the available treatment options within the institution.The con-sultants and ASA members also strongly agree that anesthe-siologists and other healthcare providers should use stan-dardized,validated instruments to facilitate the regular evaluation and documentation of pain intensity,the effects of pain therapy,and side effects caused by the therapy.The ASA members agree and the consultants strongly agree that: (1)anesthesiologists responsible for perioperative analgesia should be available at all times to consult with ward nurses, surgeons,or other involved physicians,and should assist in evaluating patients who are experiencing problems with any aspect of perioperative pain relief;(2)anesthesiologists should provide analgesia services within the framework of an Acute Pain Service and participate in developing standard-ized institutional policies and procedures;and(3)an inte-grated approach to perioperative pain management(e.g.,or-dering,administering,and transitioning therapies, transferring responsibility for pain therapy,outcomes assess-ment,continuous quality improvement)should be used to minimize analgesic gaps.
Recommendations for Institutional Policies and Proce-dures.Anesthesiologists offering perioperative analgesia ser-vices should provide,in collaboration with other healthcare professionals as appropriate,ongoing education and training to ensure that hospital personnel are knowledgeable and skilled with regard to the effective and safe use of the available treatment options within the https://www.doczj.com/doc/0210663432.html,cational con-tent should range from basic bedside pain assessment to so-phisticated pain management techniques(e.g.,epidural an-algesia,patient controlled analgesia,and various regional anesthesia techniques)and nonpharmacologic techniques (e.g.,relaxation,imagery,hypnotic methods).For optimal pain management,ongoing education and training are essen-tial for new personnel,to maintain skills,and whenever ther-apeutic approaches are modified.
Anesthesiologists and other healthcare providers should use standardized,validated instruments to facilitate the reg-ular evaluation and documentation of pain intensity,the effects of pain therapy,and side effects caused by the therapy.
Analgesic techniques involve risk for adverse effects that may require prompt medical evaluation.Anesthesiologists responsible for perioperative analgesia should be available at all times to consult with ward nurses,surgeons,or other in-volved physicians,and should assist in evaluating patients who are experiencing problems with any aspect of perioper-ative pain relief.
Anesthesiologists providing perioperative analgesia ser-vices should do so within the framework of an Acute Pain Service and participate in developing standardized institu-tional policies and procedures.An integrated approach to perioperative pain management that minimizes analgesic gaps includes ordering,administering,and transitioning therapies,and transferring responsibility for perioperative pain therapy,as well as outcomes assessment and continuous quality improvement.
II.Preoperative Evaluation of the Patient Preoperative patient evaluation and planning is integral to perioperative pain management.Proactive individualized planning is an anticipatory strategy for postoperative analge-sia that integrates pain management into the perioperative care of patients.Patient factors to consider in formulating a plan include type of surgery,expected severity of postopera-tive pain,underlying medical conditions(e.g.,presence of respiratory or cardiac disease,allergies),the risk–benefit ratio for the available techniques,and a patient’s preferences or previous experience with pain.
Although the literature is insufficient regarding the effi-cacy of a preoperative directed pain history,a directed phys-ical examination,or consultations with other healthcare pro-viders(Category D evidence),the Task Force points out the obvious value of these activities.One observational study in a neonatal intensive care unit suggests that the implementa-tion of a pain management protocol may be associated with reduced analgesic use,shorter time to extubation,and shorter times to discharge(Category B2evidence).21
The ASA members agree and the consultants strongly agree that a directed history,a directed physical examination,
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and a pain control plan should be included in the anesthetic preoperative evaluation.
Recommendations for Preoperative Evaluation of the Pa-tient.A directed pain history,a directed physical examina-tion,and a pain control plan should be included in the an-esthetic preoperative evaluation.
III.Preoperative Preparation of the Patient Preoperative patient preparation includes(1)adjustment or continuation of medications whose sudden cessation may provoke a withdrawal syndrome,(2)treatments to reduce preexisting pain and anxiety,(3)premedications before sur-gery as part of a multimodal analgesic pain management program,and(4)patient and family education,including behavioral pain control techniques.
There is insufficient literature to evaluate the impact of preoperative adjustment or continuation of medications whose sudden cessation may provoke an abstinence syn-drome(Category D evidence).Similarly,there is insufficient literature to evaluate the efficacy of the preoperative initia-tion of treatment either to reduce preexisting pain or as part of a multimodal analgesic pain management program(Cat-egory D evidence).RCTs are equivocal regarding the impact of patient and family education on patient pain,analgesic use,anxiety,and time to discharge,although features of pa-tient and family education varied across the studies(Category C2evidence).22–35
The consultants and ASA members strongly agree that patient preparation for perioperative pain management should include appropriate adjustments or continuation of medications to avert an abstinence syndrome,treatment of preexistent pain,or preoperative initiation of therapy for postoperative pain management.The ASA members agree and the consultants strongly agree that anesthesiol-ogists offering perioperative analgesia services should pro-vide,in collaboration with others as appropriate,patient and family education.The consultants and ASA members agree that perioperative patient education should include instruction in behavioral modalities for control of pain and anxiety.
Recommendations for Preoperative Preparation of the Pa-tient.Patient preparation for perioperative pain manage-ment should include appropriate adjustments or continua-tion of medications to avert an abstinence syndrome, treatment of preexistent pain,or preoperative initiation of therapy for postoperative pain management.
Anesthesiologists offering perioperative analgesia services should provide,in collaboration with others as appropriate, patient and family education regarding their important roles in achieving comfort,reporting pain,and in proper use of the recommended analgesic https://www.doczj.com/doc/0210663432.html,mon misconceptions that overestimate the risk of adverse effects and addiction should be dispelled.Patient education for optimal use of patient-controlled analgesia(PCA)and other sophisticated methods,such as patient-controlled epidural analgesia,might include discussion of these analgesic methods at the time of the preanesthetic evaluation,brochures and video-tapes to educate patients about therapeutic options,and dis-cussion at the bedside during postoperative visits.Such edu-cation may also include instruction in behavioral modalities for control of pain and anxiety.
IV.Perioperative Techniques for Pain Management Perioperative techniques for postoperative pain management include but are not limited to the following single modalities: (1)central regional(i.e.,neuraxial)opioid analgesia;(2)PCA with systemic opioids;and(3)peripheral regional analgesic techniques,including but not limited to intercostal blocks, plexus blocks,and local anesthetic infiltration of incisions.
Central regional opioid analgesia:Randomized con-trolled trials report improved pain relief when use of prein-cisional epidural or intrathecal morphine is compared with preincisional oral,intravenous,or intramuscular morphine (Category A2evidence).36–39RCTs comparing preoperative or preincisional intrathecal morphine or epidural sufenta-nil with saline placebo report inconsistent findings regard-ing pain relief(Category C2evidence).40–43RCTs compar-ing preoperative or preincisional epidural morphine or fentanyl with postoperative epidural morphine or fentanyl are equivocal regarding postoperative pain scores(Cate-gory C2evidence).44,45
Meta-analyses of RCTs46–54report improved pain relief and increased frequency of pruritus in comparisons of postincisional epidural morphine and saline placebo(Cate-gory A1evidence);findings for the frequency of nausea or vomiting were equivocal(Category C1evidence).Meta-anal-yses of RCTs comparing postincisional epidural morphine with intramuscular morphine report improved pain relief and an increased frequency of pruritus(Category A1evi-dence).49,55–59One RCT reports improved pain scores and less analgesic use when postincisional intrathecal fentanyl is compared with no postincisional spinal treatment(Category A3evidence).60
One RCT reports improved pain scores when postopera-tive epidural morphine is compared with postoperative epidural saline(Category A3evidence).61Meta-analyses of RCTs62–70re-port improved pain scores and a higher frequency of pruritus and urinary retention when postoperative epidural morphine is compared with intramuscular morphine(Category A3evi-dence);findings for nausea and vomiting are equivocal (Category C2evidence).Findings from RCTs are equivocal regarding the analgesic efficacy of postoperative epidural fentanyl compared with postoperative IV fentanyl(Cate-gory C2evidence)71–74;meta-analytic findings are equivo-cal for nausea and vomiting and pruritus(Category C1 evidence).72–76
PCA with systemic opioids:Randomized controlled trials report equivocal findings regarding the analgesic efficacy of IV PCA techniques compared with nurse or staff-adminis-tered intravenous analgesia(Category C2evidence).77–80
Practice Guidelines
Meta-analysis of RCTs reports improved pain scores when IV PCA morphine is compared with intramuscular mor-phine(Category A1evidence).81–90Findings from meta-anal-ysis of RCTs comparing epidural PCA and IV PCA opioids are equivocal regarding analgesic efficacy(Category C1evi-dence).89–93Findings from meta-analyses of RCTs94–103in-dicate more analgesic use when IV PCA with a background infusion of morphine is compared with IV PCA without a background infusion(Category A1evidence);findings were equivocal regarding pain relief,nausea and vomiting,pruri-tus,and sedation(Category C1evidence).
Peripheral regional techniques:For these Guidelines,pe-ripheral regional techniques include peripheral nerve blocks (e.g.,intercostal,ilioinguinal,interpleural,or plexus blocks), intraarticular blocks,and infiltration of incisions.RCTs in-dicate that preincisional intercostal or interpleural bupiva-caine compared with saline is associated with improved pain relief(Category A2evidence).104,105RCTs report improved pain relief and reduced analgesic consumption when postin-cisional intercostal or interpleural bupivacaine is compared with saline(Category A2evidence).104–109Meta-analyses of RCTs report equivocal findings for pain relief and analgesic used when postoperative intercostal or interpleural blocks are compared with saline(Category C1evidence).110–117 Randomized controlled trials report equivocal pain relief findings when preincisional plexus blocks with bupivacaine are compared with saline(Category C2evidence).118–121 Meta-analyses of RCTs118–122report less analgesic use when preincisional plexus blocks with bupivacaine are compared with saline(Category A1evidence);findings are equivocal for nausea and vomiting(Category C1evidence).Meta-analysis of RCTs reports lower pain scores when preincisional plexus and other blocks are compared with no block(Category A1 evidence).123–127RCTs report equivocal findings for pain scores and analgesic use when postincisional plexus and other blocks are compared with saline or no block(Category C2 evidence).124,128–132RCTs report equivocal findings for pain scores and analgesic use when postincisional intraarticular opioids or local anesthetics are compared with saline(Cate-gory C2evidence).133–139
Meta-analysis of RCTs reports improved pain scores when preincisional infiltration of bupivacaine is compared with saline (Category A1evidence)140–148;findings for analgesic use are equivocal(Category C1evidence).140,145,147,148–150Meta-anal-yses of RCTs are equivocal for pain scores and analgesic use when postincisional infiltration of bupivacaine is compared with saline(Category C1evidence).140,151–160Meta-analysis of RCTs reports equivocal pain score findings when preinci-sional infiltration of bupivacaine is compared with postinci-sional infiltration of bupivacaine(Category C1evi-dence).140,145,161–164Meta-analysis of RCTs reports improved pain scores and reduced analgesic use when prein-cisional infiltration of ropivacaine is compared with saline (Category A1evidence).164–171
The consultants and ASA members strongly agree that anesthesiologists who manage perioperative pain should use therapeutic options such as epidural or intrathecal opioids, systemic opioid PCA,and regional techniques after thought-fully considering the risks and benefits for the individual patient;they also strongly agree that these modalities should be used in preference to intramuscular opioids ordered“as needed.”The consultants and ASA members also strongly agree that the therapy selected should reflect the individual anesthesi-ologist’s expertise,as well as the capacity for safe application of the modality in each practice setting.Moreover,the consultants and ASA members strongly agree that special caution should be taken when continuous infusion modalities are used,as drug accumulation may contribute to adverse events. Recommendations for Perioperative Techniques for Pain Management.Anesthesiologists who manage perioperative pain should use therapeutic options such as central regional (i.e.,neuraxial)opioids,systemic opioid PCA,and peripheral regional techniques after thoughtfully considering the risks and benefits for the individual patient.These modalities should be used in preference to intramuscular opioids or-dered“as needed.”The therapy selected should reflect the individual anesthesiologist’s expertise,as well as the capacity for safe application of the modality in each practice setting. This capacity includes the ability to recognize and treat ad-verse effects that emerge after initiation of therapy.Special caution should be taken when continuous infusion modali-ties are used,as drug accumulation may contribute to adverse events.
V.Multimodal Techniques for Pain Management Multimodal techniques for pain management include the administration of two or more drugs that act by different mechanisms for providing analgesia.These drugs may be administered via the same route or by different routes.
Multimodal techniques with central regional analgesics: Meta-analyses of RCTs46,49,172–176report improved pain scores(Category A1evidence)and equivocal findings for nau-sea and vomiting and pruritus(Category C1evidence)when epidural morphine combined with local anesthetics is com-pared with epidural morphine alone.Meta-analyses of RCTs177–188report improved pain scores and more motor weakness when epidural fentanyl combined with local anes-thetics is compared with epidural fentanyl alone(Category A1 evidence);equivocal findings are reported for nausea and vomiting and pruritus(Category C1evidence).Meta-analyses of RCTs49,172,176,189–194report improved pain scores, greater pain relief,and a higher frequency of pruritus(Category A1evidence)when epidural morphine combined with bupiva-caine is compared with epidural bupivacaine alone;equivocal findings are reported for nausea and vomiting(Category C1ev-idence).RCTs report equivocal findings when epidural fentanyl combined with bupivacaine is compared with epidural bupiva-caine alone(Category C2evidence).179–181,188Meta-analysis of RCTs for the above comparison reports higher frequency of
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pruritus(Category A1evidence)180,181,188,195,196with equiv-ocal findings for nausea and vomiting(Category C1evi-dence).179–181,188,195–197RCTs report equivocal findings for pain scores,nausea and vomiting,pruritus,and motor weakness when epidural fentanyl with ropivacaine is com-pared with epidural ropivacaine(Category C2evi-dence).198–201Meta-analyses of RCTs200,202–206are equivocal for pain scores(Category C2evidence)and a higher frequency of pruritus when epidural sufentanil combined with ropivacaine is compared with epidural ropi-vacaine(Category A1evidence).Meta-analysis of RCTs is equivocal for pain scores when epidural opioids combined with clonidine is compared with epidural opioids(Category C1evidence).207–212
Multimodal techniques with systemic analgesics:Meta-analyses of RCTs213–220report improved pain scores and reduced analgesic use(Category A1evidence)when intrave-nous morphine combined with ketorolac is compared with intravenous morphine;equivocal findings are reported for nausea and vomiting(Category C1evidence).Meta-analyses of RCTs221–226report equivocal findings for pain scores, analgesic use,or nausea scores when intravenous morphine combined with ketamine is compared with intravenous mor-phine(Category C1evidence).RCTs report inconsistent find-ings for pain scores and morphine use when intravenous patient-controlled opioid analgesia(IV PCA)combined with oral cyclooxygenase-2(COX-2)selective nonsteroi-dal antiinflammatory drugs(NSAIDs)227or nonselective NSAIDs228,229are compared with IV PCA opioids alone; findings for acetaminophen are equivocal(Category C2 evidence).230Meta-analyses of RCTs report lower pain scores and reduced opioid use when IV opioids combined with calcium channel blockers(i.e.,gabapentin,pregaba-lin)is compared with IV opioids alone(Category A1evi-dence)231–240;no differences in nausea or vomiting are reported(Category C1evidence).233–236,238,241
The consultants and ASA members strongly agree that whenever possible,anesthesiologists should use multimodal pain management therapy.The ASA members agree and the consultants strongly agree that acetaminophen should be considered as part of a postoperative multimodal pain man-agement regimen;both the consultants and ASA members agree that COX-2selective NSAIDs(COXIBs),nonselective NSAIDs,and calcium channel?-2-?antagonists(gabapen-tin and pregabalin)should be considered as part of a postop-erative multimodal pain management regimen.Moreover, the ASA members agree and the consultants strongly agree that,unless contraindicated,patients should receive an around-the-clock regimen of NSAIDs,COXIBs,or acet-aminophen.Both the consultants and ASA members strongly agree that(1)regional blockade with local anesthet-ics should be considered as part of a multimodal approach for pain management;(2)dosing regimens should be adminis-tered to optimize efficacy while minimizing the risk of ad-verse events;and(3)the choice of medication,dose,route, and duration of therapy should be individualized. Recommendations for Multimodal Techniques.Whenever possible,anesthesiologists should use multimodal pain man-agement therapy.Central regional blockade with local anes-thetics should be considered.Unless contraindicated,patients should receive an around-the-clock regimen of COXIBs, NSAIDs,or acetaminophen.Dosing regimens should be ad-ministered to optimize efficacy while minimizing the risk of adverse events.The choice of medication,dose,route,and du-ration of therapy should be individualized.
VI.Patient Subpopulations
Some patient groups are at special risk for inadequate pain control and require additional analgesic considerations.Pa-tient populations at risk include(1)pediatric patients,(2) geriatric patients,and(3)critically ill or cognitively impaired patients,or other patients who may have difficulty commu-nicating.The Task Force believes that genetics and gender modify the pain experience and response to analgesic thera-pies.In addition,the Task Force believes that patient race, ethnicity,culture,gender,and socioeconomic status influ-ence access to treatment as well as pain assessment by health-care providers.
Pediatric Patients.The Task Force believes that optimal care for infants and children(including adolescents)requires special attention to the biopsychosocial nature of pain.This specific patient population presents developmental differ-ences in their experience and expression of pain and suffer-ing,and their response to analgesic pharmacotherapy.Care-givers in both the home and hospital may have misperceptions regarding the importance of analgesia as well as its risks and benefits.In the absence of a clear source of pain or obvious pain behavior,caregivers may assume that pain is not present and defer treatment.Safe methods for providing analgesia are underused in pediatric patients for fear of opioid-induced respiratory depression.
The emotional component of pain is particularly strong in infants and children.Absence of parents,security objects, and familiar surroundings may cause as much suffering as the surgical incision.Children’s fear of injections makes intra-muscular or other invasive routes of drug delivery aversive. Even the valuable technique of topical analgesia before injec-tions may not lessen this fear.
A variety of techniques may be effective in providing an-algesia in pediatric patients.Many are the same as for adults, although some(e.g.,caudal analgesia)are more commonly used in children.The Task Force believes that it is important for caregivers to recognize that pediatric patients require spe-cial consideration to ensure optimal perioperative analgesia.
The ASA members and consultants strongly agree that(1) perioperative care for children undergoing painful proce-dures or surgery requires developmentally appropriate pain assessment and therapy;(2)analgesic therapy should depend upon age,weight,and comorbidity,and unless contraindi-
Practice Guidelines
cated should involve a multimodal approach;and(3)because many analgesic medications are synergistic with sedating agents,it is imperative that appropriate monitoring be used during the procedure and recovery.The ASA members agree and the consultants strongly agree that behavioral tech-niques,especially important in addressing the emotional component of pain,should be applied whenever feasible. Recommendations for Pediatric Patients.Aggressive and proactive pain management is necessary to overcome the historic undertreatment of pain in children.Perioperative care for children undergoing painful procedures or surgery requires developmentally appropriate pain assessment and therapy.Analgesic therapy should depend upon age,weight, and comorbidity,and unless contraindicated should involve a multimodal approach.Behavioral techniques,especially important in addressing the emotional component of pain, should be applied whenever feasible.
Sedative,analgesic,and local anesthetics are all important components of appropriate analgesic regimens for painful procedures.Because many analgesic medications are syner-gistic with sedating agents,it is imperative that appropriate monitoring be used during the procedure and recovery. Geriatric Patients.Elderly patients suffer from conditions such as arthritis or cancer that render them more likely to undergo surgery.The Task Force believes that pain is often undertreated,and elderly individuals may be more vulnera-ble to the detrimental effects of such undertreatment.The physical,social,emotional,and cognitive changes associated with aging have an impact on perioperative pain manage-ment.These patients may have different attitudes than younger adult patients in expressing pain and seeking appro-priate therapy.Altered physiology changes the way analgesic drugs and local anesthetics are distributed and metabolized and frequently requires dose alterations.Techniques effective in younger adults may also benefit geriatric patients without an age-related increase in adverse effects.One observational study suggests that perioperative analgesics are provided in lower dosages to older adults than to younger adults(Cate-gory B2evidence).242The Task Force believes that,although the reasons for lower perioperative analgesic doses in the elderly are unclear,undertreatment of pain in elderly persons is widespread.
The ASA members and consultants strongly agree that(1) pain assessment and therapy should be integrated into the perioperative care of geriatric patients;(2)pain assessment tools appropriate to a patient’s cognitive abilities should be used;and(3)dose titration should be done to ensure ade-quate treatment while avoiding adverse effects such as som-nolence in this vulnerable group,who may be taking other medications.The ASA members agree and the consultants strongly agree that extensive and proactive evaluation and questioning should be conducted to overcome barriers that hinder communication regarding unrelieved pain. Recommendations for Geriatric Patients.Pain assessment and therapy should be integrated into the perioperative care of geriatric patients.Pain assessment tools appropriate to a patient’s cognitive abilities should be used.Extensive and proactive evaluation and questioning may be necessary to overcome barriers that hinder communication regarding un-relieved pain.Anesthesiologists should recognize that geriat-ric patients may respond differently than younger patients to pain and analgesic medications,often because of comorbid-ity.Vigilant dose titration is necessary to ensure adequate treatment while avoiding adverse effects such as somnolence in this vulnerable group,who are often taking other medica-tions(including alternative and complementary agents). Other Subpopulations.Patients who are critically ill,cogni-tively impaired(e.g.,Alzheimer’s disease),or who otherwise have difficulty communicating(e.g.,cultural or language barriers)present unique challenges to perioperative pain management.The Task Force believes that techniques that reduce drug dosages required to provide effective analgesia (e.g.,regional analgesia and multimodal analgesia)may be suitable for such patients.Behavioral modalities and tech-niques such as PCA that depend upon self-administration of analgesics are generally less suitable for the cognitively im-paired.The literature is insufficient to evaluate the applica-tion of pain assessment methods or pain management tech-niques specific to these populations(Category D evidence).
The consultants and ASA members strongly agree that anesthesiologists should recognize that patients who are crit-ically ill,cognitively impaired,or have communication diffi-culties may require additional interventions to ensure opti-mal perioperative pain management.Moreover,the ASA members agree and the consultants strongly agree that anes-thesiologists should consider a therapeutic trial of an analge-sic in patients with increased blood pressure and heart rate or agitated behavior,when causes other than pain have been excluded.
Recommendations for Other Subpopulations.Anesthesiol-ogists should recognize that patients who are critically ill, cognitively impaired,or have communication difficulties may require additional interventions to ensure optimal peri-operative pain management.Anesthesiologists should con-sider a therapeutic trial of an analgesic in patients with in-creased blood pressure and heart rate or agitated behavior when causes other than pain have been excluded. Appendix1:Summary of Recommendations
I.Institutional Policies and Procedures for Providing Perioperative Pain Management
?Anesthesiologists offering perioperative analgesia services should provide,in collaboration with other healthcare professionals as appropriate,ongoing education and training to ensure that hos-pital personnel are knowledgeable and skilled with regard to the effective and safe use of the available treatment options within the institution.
?Educational content should range from basic bedside pain assessment to sophisticated pain management techniques(e.g.,
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epidural analgesia,PCA,and various regional anesthesia tech-niques)and nonpharmacologic techniques(e.g.,relaxation, imagery,hypnotic methods).
?For optimal pain management,ongoing education and train-ing are essential for new personnel,to maintain skills,and whenever therapeutic approaches are modified.?Anesthesiologists and other healthcare providers should use stan-dardized,validated instruments to facilitate the regular evaluation and documentation of pain intensity,the effects of pain therapy, and side effects caused by the therapy.?Anesthesiologists responsible for perioperative analgesia should be available at all times to consult with ward nurses,surgeons,or other involved physicians.
?They should assist in evaluating patients who are experiencing problems with any aspect of perioperative pain relief.?Anesthesiologists providing perioperative analgesia services should do so within the framework of an Acute Pain Service.?They should participate in developing standardized institu-tional policies and procedures.
II.Preoperative Evaluation of the Patient
?A directed pain history,a directed physical examination,and a pain control plan should be included in the anesthetic preopera-tive evaluation.
III.Preoperative Preparation of the Patient
?Patient preparation for perioperative pain management should include appropriate adjustments or continuation of medications to avert an abstinence syndrome,treatment of preexistent pain,or pre-operative initiation of therapy for postoperative pain management.?Anesthesiologists offering perioperative analgesia services should provide,in collaboration with others as appropriate,patient and family education regarding their important roles in achieving comfort,reporting pain,and in proper use of the recommended analgesic methods.
?Common misconceptions that overestimate the risk of adverse effects and addiction should be dispelled.
?Patient education for optimal use of PCA and other sophisti-cated methods,such as patient-controlled epidural analgesia, might include discussion of these analgesic methods at the time of the preanesthetic evaluation,brochures and videotapes to educate patients about therapeutic options,and discussion at the bedside during postoperative visits.
?Such education may also include instruction in behavioral modalities for control of pain and anxiety.
IV.Perioperative Techniques for Pain Management ?Anesthesiologists who manage perioperative pain should use therapeutic options such as epidural or intrathecal opioids,sys-temic opioid PCA,and regional techniques after thoughtfully considering the risks and benefits for the individual patient.
?These modalities should be used in preference to intramuscu-lar opioids ordered“as needed.”
?The therapy selected should reflect the individual anesthesiolo-gist’s expertise,as well as the capacity for safe application of the modality in each practice setting.
?This capacity includes the ability to recognize and treat ad-verse effects that emerge after initiation of therapy.?Special caution should be taken when continuous infusion modalities are used because drug accumulation may contrib-ute to adverse events.V.Multimodal Techniques for Pain Management ?Whenever possible,anesthesiologists should use multimodal pain management therapy.
?Unless contraindicated,patients should receive an around-the-clock regimen of NSAIDs,COXIBs,or acetaminophen.?Regional blockade with local anesthetics should be considered.?Dosing regimens should be administered to optimize efficacy while minimizing the risk of adverse events.
?The choice of medication,dose,route,and duration of therapy should be individualized.
VI.Patient Subpopulations
?Pediatric patients
?Aggressive and proactive pain management is necessary to overcome the historic undertreatment of pain in children.?Perioperative care for children undergoing painful procedures or surgery requires developmentally appropriate pain assess-ment and therapy.
?Analgesic therapy should depend upon age,weight,and co-morbidity,and unless contraindicated should involve a mul-timodal approach.
?Behavioral techniques,especially important in addressing the emotional component of pain,should be applied whenever feasible.
?Sedative,analgesic,and local anesthetics are all important com-ponents of appropriate analgesic regimens for painful procedures.?Because many analgesic medications are synergistic with sedating agents,it is imperative that appropriate monitoring be used dur-ing the procedure and recovery.
?Geriatric patients
?Pain assessment and therapy should be integrated into the perioperative care of geriatric patients.
?Pain assessment tools appropriate to a patient’s cognitive abil-ities should be used.Extensive and proactive evaluation and questioning may be necessary to overcome barriers that hinder communication regarding unrelieved pain.
?Anesthesiologists should recognize that geriatric patients may respond differently than younger patients to pain and analge-sic medications,often because of comorbidity.
?Vigilant dose titration is necessary to ensure adequate treat-ment while avoiding adverse effects such as somnolence in this vulnerable group,who are often taking other medications(in-cluding alternative and complementary agents).
?Other subpopulations
?Anesthesiologists should recognize that patients who are crit-ically ill,cognitively impaired,or have communication diffi-culties may require additional interventions to ensure optimal perioperative pain management.
?Anesthesiologists should consider a therapeutic trial of an analge-sic in patients with increased blood pressure and heart rate or agitated behavior when causes other than pain have been excluded. Appendix2:Methods and Analyses
A.State of the Literature
For these updated Guidelines,a review of studies used in the development of the original Guidelines was combined with stud-ies published subsequent to approval of the original Guidelines in2003.*The scientific assessment of these Guidelines was based on evidence linkages or statements regarding potential
Practice Guidelines
relationships between clinical interventions and outcomes.The interventions listed below were examined to assess their relation-ship to a variety of outcomes related to the management of acute pain in the perioperative setting.
Institutional Policies and Procedures for Providing Perioperative Pain Management
Education and training of healthcare providers
Monitoring of patient outcomes
Documentation of monitoring activities
Monitoring of outcomes at an institutional level
24-h availability of anesthesiologists providing perioperative pain management
Acute pain service
Preoperative Evaluation of the Patient
A directed pain history(e.g.,medical record review and patient interview to include current medications,adverse effects,preex-isting pain conditions,medical conditions that would influence a pain therapy,nonpharmacologic pain therapies,alternative and complementary therapies)
A directed physical examination
Consultations with other healthcare providers(e.g.,nurses,sur-geons,pharmacists)
Preoperative Preparation of the Patient
Preoperative adjustment or continuation of medications whose sud-den cessation may provoke an abstinence syndrome Preoperative treatment(s)to reduce preexisting pain and anxiety Premedication(s)before surgery as part of a multimodal analgesic pain management program
Patient and family education
Perioperative Techniques for Pain Management
Epidural or intrathecal analgesia with opioids(vs.epidural placebo, epidural local anesthetics,or IV,intramuscular,or oral opioids) Patient-controlled analgesia with opioids:
IV PCA versus nurse-controlled or continuous IV
IV PCA versus intramuscular
Epidural PCA versus epidural bolus or infusion
Epidural PCA versus IV PCA
IV PCA with background infusion of opioids versus no back-ground infusion
Regional analgesia with local anesthetics or opioids
Intercostal or interpleural blocks
Plexus and other blocks
Intraarticular opioids,local anesthetics or combinations Infiltration of incisions
Multimodal Techniques(Epidural,IV,or Regional Techniques) Two or more analgesic agents,one route versus a single agent,one route Epidural or intrathecal analgesia with opioids combined with: Local anesthetics versus epidural opioids
Local anesthetics versus epidural local anesthetics
Clonidine versus epidural opioids
IV opioids combined with:
Clonidine versus IV opioids
Ketorolac versus IV opioids
Ketamine versus IV opioids
Oral opioids combined with NSAIDs,COXIBs,or acetamino-phen versus oral opioids Two or more drug delivery routes versus a single route
Epidural or intrathecal analgesia with opioids combined with IV, intramuscular,oral,transdermal,or subcutaneous analgesics ver-sus epidural opioids
IV opioids combined with oral NSAIDs,COXIBs,or acetamin-ophen versus IV opioids
Nonpharmacologic,alternative,or complementary pain man-agement combined with pharmacologic pain management versus pharmacologic pain management
Special Patient Populations
Pain management techniques for pediatric patients
Pain assessment techniques
Dose level adjustments
Avoidance of repetitive diagnostic evaluation(heel sticks)for neonates Pain management techniques for geriatric patients
Pain assessment techniques
Dose level adjustments Painmanagementtechniquesforotherspecialpopulations(e.g.,cognitively impaired,critically ill,patients with difficulty communicating)
Pain assessment methods specific to special populations
Pain management techniques specific to special populations
For the literature review,potentially relevant clinical studies were identified via electronic and manual searches of the literature. The electronic and manual searches covered a49-yr period from 1963through2011.More than2,000citations were identified initially,yielding a total of1,784nonoverlapping articles that ad-dressed topics related to the evidence linkages.After the articles were reviewed,1,153studies did not provide direct evidence and were elim-inated subsequently.A total of631articles contained direct linkage-related evidence.A complete bibliography used to develop these Guidelines,organized by section,is available as Supplemental Digital Content2,https://www.doczj.com/doc/0210663432.html,/ALN/A781.
Initially,each pertinent outcome reported in a study was classified as supporting an evidence linkage,refuting a linkage,or equivocal.The results were then summarized to obtain a directional assessment for each evidence linkage before conducting formal meta-analyses.Litera-ture pertaining to four evidence linkage categories contained enough studies with well-defined experimental designs and statistical informa-tion sufficient for meta-analyses(table1).These linkages were:(1) epiduralorintrathecalopioids,(2)patient-controlledanalgesia,(3)regional analgesia,and(4)two or more anesthetic drugs versus a single drug.
General variance-based,effect-size estimates or combined probabil-ity tests were obtained for continuous outcome measures,and Mantel-Haenszel odds ratios were obtained for dichotomous outcome mea-sures.Two combined probability tests were used as follows:(1)the Fisher combined test,producing chi-square values based on logarith-mic transformations of the reported P values from the independent studies,and(2)the Stouffer combined test,providing weighted repre-sentation of the studies by weighting each of the standard normal de-viates by the size of the sample.An odds ratio procedure based on the Mantel-Haenszel method for combining study results using2?2 tables was used with outcome frequency information.An acceptable significance level was set at P?0.01(one-tailed).Tests for heteroge-neity of the independent studies were conducted to assure consistency among the study results.DerSimonian-Laird random-effects odds ra-tios were obtained when significant heterogeneity was found(P?0.01).To control for potential publishing bias,a“fail-safe n”value was calculated.No search for unpublished studies was conducted,and no
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reliability tests for locating research results were done.To be accepted as significant findings,Mantel-Haenszel odds ratios must agree with com-bined test results whenever both types of data are assessed.In the ab-sence of Mantel-Haenszel odds ratios,findings from both the Fisher and weighted Stouffer combined tests must agree with each other to be acceptable as significant.
For the previous update of the Guidelines,interobserver agreement among Task Force members and two methodologists was established by interrater reliability testing.Agreement levels using a kappa (k)statistic for two-rater agreement pairs were as follows:(1)type of study design,k ?0.63–0.94;(2)type of analysis,k ?0.39–0.89;(3)evidence linkage assignment,k ?0.74–0.96;and (4)literature inclusion for database,k ?0.75–0.88.Three-rater chance-corrected agreement values were:(1)study design,Sav ?0.80,Var (Sav)?0.007;(2)type of analysis,Sav ?0.59,Var (Sav)?0.032;(3)linkage assignment,Sav ?0.73Var (Sav)?0.010;(4)literature database inclusion,Sav ?0.83Var (Sav)?0.015.These values represent moderate levels of agreement.For the updated Guidelines,the same two methodologists involved in the original Guidelines conducted the literature review.
The findings of the literature analyses were supplemented by the opinions of Task Force members after considering opinions derived from a variety of sources,including informal commen-tary and comments from postings of the draft document on the ASA web site.In addition,opinions obtained from consultant surveys,open forum commentary,and other sources used in the original Guidelines were reviewed and considered.
B.Consensus-based Evidence
Consensus was obtained from multiple sources,including (1)survey opinion from consultants who were selected based on their knowledge or expertise in acute pain management,(2)survey opinions solicited from active members of the ASA,(3)testimony from attendees of a publicly held open forum at a national anesthesia meeting (original Guidelines only),(4)Internet commentary,and (5)Task Force opin-ion and interpretation.The survey rate of return was 62%(n ?53of 85)for the consultants (table 2),and 268surveys were received from active ASA members (table 3).
For the previous update of the Guidelines,an additional survey was sent to the expert consultants asking them to indicate which,if any,of the evidence linkages would change their clin-ical practices if the Guidelines were instituted.The rate of return was 70.1%(n ?61of 87).The percentages of responding con-sultants expecting no change associated with each linkage were as follows:(1)proactive planning 82.0%,(2)education and training 88.5%,(3)education or participation of patient and family 80.3%,(4)monitoring or documentation 77.0%,(5)availability of anesthesiolo-gists 90.2%,(6)institutional protocols 86.9%,(7)use of PCA,epidu-ral,or regional techniques 90.2%,(8)use of multimodality techniques 88.5%,(9)organizational characteristics 90.2%,(10)pediatric tech-niques 95.1%,(11)geriatric techniques 91.8%,and (12)ambulatory surgery techniques 85.2%.
Sixty-five percent of the respondents indicated that the Guide-lines would have no effect on the amount of time spent on a typical case,and 24%indicated that there would be an increase of the amount of time spent on a typical case with the implementation of these Guidelines (mean time increase ?3.4min).Eighty-nine per-cent indicated that new equipment,supplies,or training would not be needed to implement the Guidelines,and 92%indicated that implementation of the Guidelines would not require changes in practice that would affect costs.
Table 1.Meta-analysis Summary
Heterogeneity
Evidence Linkages
N Fisher Chi-square P Value Weighted Stouffer Zc P Value Effect Size Odds Ratio Confidence
Interval
P Values Effect Size
Perioperative techniques
Epidural/intrathecal opioids Postincisional
Morphine vs.saline Pain scores or relief 6
51.500.001?3.500.001?0.35
0.342
0.694Nausea or vomiting 9 1.17*0.32–5.560.001Pruritus
87.35
3.84–1
4.08
0.186Morphine vs.IM morphine Pain scores 652.160.001?3.790.001?0.44
0.995
0.788Pruritus 6 6.24
2.28–17.08
0.779Postoperative
Morphine vs.IM morphine Pain scores or relief 781.290.001?7.520.001?0.57
0.097
0.001Nausea or vomiting 90.760.35–1.660.442Pruritus
5 5.45 1.62–18.360.980Urinary retention 7 3.10 1.31–7.320.865Fentanyl vs.IV fentanyl Nausea or vomiting 50.73*0.08–4.920.001Pruritus
5
1.17
0.30–4.54
0.731
PCA
IV PCA vs.IM morphine
(continued )
Practice Guidelines
Table 1.Continued
Heterogeneity Evidence Linkages
N Fisher Chi-square P Value Weighted Stouffer Zc P Value Effect Size Odds Ratio Confidence
Interval
P Values Effect Size Pain scores 852.260.001?4.01
0.001?0.220.7000.550Epidural PCA vs.IV PCA opioids
Pain scores 537.910.001?2.17
0.015?0.330.9990.951PCA with background morphine
Pain scores or relief 625.910.011?2.250.012
0.070.3150.138Analgesic use 1099.780.001 6.120.001
0.35
0.001
0.001Nausea or vomiting 9 1.010.57–1.780.666Pruritus 70.99
0.43–2.29
0.522Sedation 616.440.172?1.62
0.053?0.03
0.675
0.628
Regional analgesia
Intercostal or interpleural blocks Postoperative vs.saline Pain scores 754.120.001?1.790.037?0.38
0.6630.479Analgesic use 536.300.001?1.510.066?0.340.2630.381Plexus and other blocks Preincisional vs.saline Analgesic use 552.130.001?5.620.001?0.37
0.1460.057Nausea/vomiting 50.51
0.15–1.73
0.769Preincisional vs.no block Pain scores 545.150.001?4.41
0.001?0.320.0610.174Infiltration of incisions
Preincisional bupivacaine vs.saline Pain scores or relief 984.830.001?3.510.001?0.320.0020.001Analgesic use 621.270.047?2.010.022?0.110.6620.605Postincisional bupivacaine vs.saline Pain scores 842.530.001?2.100.018?0.170.0440.051Analgesic use 953.710.001?2.120.017?0.200.0390.024Pre-vs.postincisional bupivacaine Pain scores 639.280.001 1.020.154
0.02
0.0010.001Preincisional ropivacaine vs.saline Pain scores or relief 544.140.001?3.960.001?0.310.9640.556Analgesic use 745.510.001?3.90
0.001?0.43
0.001
0.001
Multimodality techniques
Two or more vs.single drug,same route
Epidural morphine ?local anesthetics vs.morphine Pain scores 742.950.001?2.320.010?0.22
0.466
0.167Nausea or vomiting 60.800.40–1.570.829Pruritus 6
2.020.93–4.36
0.176Epidural fentanyl ?local anesthetics vs.fentanyl Pain scores 1067.210.001?3.110.001?0.29
0.006
0.001Nausea or vomiting 110.770.46–1.270.304Pruritus 120.930.55–1.560.266Motor weakness 9
3.23 1.57–6.65
0.011Epidural morphine ?bupivacaine vs.bupivacaine Pain scores 952.910.001?3.030.001?0.25
0.470
0.245Pain relief 5 3.41 1.31–8.920.352Nausea or vomiting 8 1.250.62–2.480.858Pruritus 6
7.35 2.82–19.150.584Epidural fentanyl ?bupivacaine vs.bupivacaine Nausea or vomiting 7 1.270.58–2.800.329Pruritus 5
2.89 1.02–8.23
0.840
Epidural sufentanil ?ropivacaine vs.ropivacaine Pain scores 528.540.001?2.090.018?0.17
0.730
0.425Pruritus 6
4.32 2.31–8.07
0.705(continued )
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Table 2.Consultant Survey Responses*
Percent Responding to Each Item
N
Strongly Agree
Agree
Equivocal
Disagree
Strongly Disagree
I.Institutional Policies and Procedures for Providing Perioperative Pain Management 1.Anesthesiologists offering perioperative analgesia services should provide,in collaboration with other healthcare professionals as appropriate,ongoing
education and training of hospital personnel regarding the effective and safe use of the
available treatment options within the institution 5386.8*11.3 1.90.00.0
2.Anesthesiologists and other healthcare providers should use standardized,validated instruments to facilitate the regular evaluation and documentation of pain intensity,the effects of pain therapy,and side effects caused by the therapy 5367.9*26.4 5.70.00.0
3.Anesthesiologists responsible for perioperative analgesia should be available at all times to consult with ward nurses,surgeons,or other involved physicians and should assist in evaluating patients who are experiencing
problems with any aspect of perioperative pain relief
5356.6*26.417.00.00.0
4.Anesthesiologists should provide analgesia services within the framework of an Acute Pain Service and participate in developing standardized institutional policies and procedures
5373.6*26.40.00.0
0.0(continued )
Table 1.Continued
Heterogeneity Evidence Linkages
N Fisher Chi-square P Value Weighted Stouffer Zc P Value Effect Size Odds Ratio Confidence
Interval
P Values Effect Size Epidural opioids ?clonidine vs.opioids Pain scores 645.770.001?1.270.102?0.120.0010.001IV morphine ?ketorolac vs.IV morphine Pain scores 644.180.001?3.950.001?0.30
0.9870.992Analgesic use 672.420.001?7.170.001?0.59
0.001
0.001Nausea or vomiting 6
1.04
0.54–2.00
0.937IV morphine ?ketamine vs.IV morphine Pain scores or relief 639.950.001?0.810.209?0.110.056
0.001Analgesic use 637.120.001?1.000.159?0.080.0270.001Nausea 626.450.0090.480.316
?0.04
0.1650.037Two or more routes vs.single route
IV opioids combined with calcium channel blockers (gabapentin,pregabalin)vs.IV opioids Pain scores 754.030.001?3.820.001?0.290.7000.850Opioid use 10111.660.001?12.070.001?0.48
0.001
0.001Nausea 6 1.040.55–1.980.800Vomiting 5
0.860.41–1.83
0.970
*Random effects odds ratio.
IM ?intramuscular;IV ?intravenous;PCA ?patient-controlled analgesia.
Practice Guidelines
Table2.Continued
Percent Responding to Each Item
N Strongly
Agree Agree Equivocal Disagree
Strongly
Disagree
5.An integrated approach to perioperative
pain management(e.g.,ordering,
administering,and transitioning therapies,
transferring responsibility for pain therapy,
outcomes assessment,continuous quality
improvement)should be used to minimize
analgesic gaps5373.6*24.5 1.90.00.0 II.Preoperative Evaluation of the Patient
6.A directed pain history,a directed physical
examination,and a pain control plan
should be included in the anesthetic
preoperative evaluation5257.7*36.5 3.8 1.90.0 III.Preoperative Preparation of the Patient
7.Patient preparation for perioperative pain
management should include appropriate
adjustments or continuation of medications
to avert an abstinence syndrome,
treatment of preexistent pain,or
preoperative initiation of therapy for
postoperative pain management5377.4*18.9 3.80.00.0
8.Anesthesiologists offering perioperative
analgesia services should provide,in
collaboration with others as appropriate,
patient and family education5350.9*35.87.5 5.70.0
9.Perioperative patient education should
include instruction in behavioral modalities
for control of pain and anxiety5337.739.6*13.27.5 1.9 IV.Perioperative Techniques for Pain Management
10.Anesthesiologists who manage
perioperative pain should use therapeutic
options such as epidural or intrathecal
opioids,systemic opioid PCA,and regional
techniques after thoughtfully considering
the risks and benefits for the individual
patient5386.8*13.20.00.00.0 11.These modalities should be used in
preference to intramuscular opioids
ordered“as needed”5379.2*11.3 3.8 1.9 3.8 12.The therapy selected should reflect the
individual anesthesiologist’s expertise,as
well as the capacity for safe application of
the modality in each practice setting5379.2*17.00.0 3.80.0 13.Special caution should be taken when
continuous infusion modalities are used
because drug accumulation may
contribute to adverse events5369.8*26.4 1.9 1.90.0 V.Multimodal Techniques for Pain Management
14.Whenever possible,anesthesiologists
should use multimodal pain management
therapy5371.7*28.30.00.00.0
(continued) SPECIAL ARTICLES
Table2.Continued
Percent Responding to Each Item
N Strongly
Agree Agree Equivocal Disagree
Strongly
Disagree
15.The following drugs should be considered
as part of a postoperative multimodal pain
management regimen:
COX-2selective NSAIDs(COXIBs)5349.134.0*15.1 1.90.0
Nonselective NSAIDs5219.257.7*23.10.00.0
Acetaminophen5362.3*32.1 5.70.00.0
Calcium channel?-2-?antagonists(e.g.,
gabapentin,pregabalin)5322.650.9*26.40.00.0 16.Unless contraindicated,all patients should
receive an around-the-clock regimen of
NSAIDs,COXIBs,or acetaminophen5154.9*23.57.89.8 3.9 17.Regional blockade with local anesthetics
should be considered as part of a
multimodal approach for pain management5273.1*25.0 1.90.00.0 18.Dosing regimens should be administered
to optimize efficacy while minimizing the
risk of adverse events5286.5*13.50.00.00.0 19.The choice of medication,dose,route,and
duration of therapy should be individualized5273.1*26.90.00.00.0 VI.Patient Subpopulations
Pediatric patients
20.Perioperative care for children undergoing
painful procedures or surgery requires
developmentally appropriate pain
assessment and therapy5373.6*24.5 1.90.00.0 21.Analgesic therapy should depend upon
age,weight,and comorbidity and unless
contraindicated should involve a
multimodal approach5367.9*30.2 1.90.00.0 22.Behavioral techniques,especially important
in addressing the emotional component of
pain,should be applied whenever feasible5350.9*30.218.90.00.0 23.Because many analgesic medications are
synergistic with sedating agents,it is
imperative that appropriate monitoring be
used during the procedure and recovery5383.0*17.00.00.00.0 Geriatric patients
24.Pain assessment and therapy should be
integrated into the perioperative care of
geriatric patients5373.6*26.40.00.00.0 25.Pain assessment tools appropriate to a
patient’s cognitive abilities should be used5377.4*22.60.00.00.0 26.Extensive and proactive evaluation and
questioning should be conducted to
overcome barriers that hinder
communication regarding unrelieved pain5358.5*35.8 5.70.00.0
(continued)
Practice Guidelines
Table2.Continued
Percent Responding to Each Item
N Strongly
Agree Agree Equivocal Disagree
Strongly
Disagree
27.Dose titration should be done to ensure
adequate treatment while avoiding adverse
effects such as somnolence in this
vulnerable group,who may be taking other
medications5377.4*22.60.00.00.0 Other Subpopulations
28.Anesthesiologists should recognize that
patients who are critically ill,cognitively
impaired,or have communication
difficulties may require additional
interventions to ensure optimal
perioperative pain management5373.6*24.5 1.90.00.0 29.Anesthesiologists should consider a
therapeutic trial of an analgesic in patients
with elevated blood pressure and heart
rate or agitated behavior when causes
other than pain have been excluded5350.9*37.79.4 1.90.0
*Indicates the median.
COX-2?cyclooxygenase-2;N?number of consultants who responded to each item;NSAID?nonsteroidal antiinflammatory drug; PCA?patient-controlled analgesia.
Table3.ASA Member Survey Responses*
Percent Responding to Each Item
N Strongly
Agree Agree Equivocal Disagree
Strongly
Disagree
I.Institutional Policies and Procedures for
Providing Perioperative Pain Management
1.Anesthesiologists offering perioperative
analgesia services should provide,in
collaboration with other healthcare
professionals as appropriate,ongoing
education and training of hospital
personnel regarding the effective and safe
use of the available treatment options
within the Institution26853.0*37.7 4.1 3.7 1.5
2.Anesthesiologists and other healthcare
providers should use standardized,
validated instruments to facilitate the
regular evaluation and documentation of
pain intensity,the effects of pain therapy,
and side effects caused by the therapy26852.2*35.57.5 3.7 1.1
3.Anesthesiologists responsible for
perioperative analgesia should be available
at all times to consult with ward nurses,
surgeons,or other involved physicians and
should assist in evaluating patients who
are experiencing problems with any aspect
of perioperative pain relief26738.936.0*12.410.1 2.6
(continued) SPECIAL ARTICLES
Table3.Continued
Percent Responding to Each Item
N Strongly
Agree Agree Equivocal Disagree
Strongly
Disagree
4.Anesthesiologists should provide analgesia
services within the framework of an Acute
Pain Service and participate in developing
standardized institutional policies and
Procedures26839.939.2*14.9 3.4 2.6
5.An integrated approach to perioperative
pain management(e.g.,ordering,
administering,and transitioning therapies,
transferring responsibility for pain therapy,
outcomes assessment,continuous quality
improvement)should be used to minimize
analgesic gaps26946.544.6*7.4 1.50.0 II.Preoperative Evaluation of the Patient
6.A directed pain history,a directed physical
examination,and a pain control plan
should be included in the anesthetic
preoperative evaluation26730.339.7*18.49.4 2.2 III.Preoperative Preparation of the Patient
7.Patient preparation for perioperative pain
management should include appropriate
adjustments or continuation of medications
to avert an abstinence syndrome,
treatment of preexistent pain,or
preoperative initiation of therapy for
postoperative pain management26651.5*41.7 5.7 1.10.0
8.Anesthesiologists offering perioperative
analgesia services should provide,in
collaboration with others as appropriate,
patient and family education26828.756.7*10.1 3.70.8
9.Perioperative patient education should
include instruction in behavioral modalities
for control of pain and anxiety26922.742.8*27.1 5.9 1.5 IV.Perioperative Techniques for Pain Management
10.Anesthesiologists who manage perioperative
pain should use therapeutic options such as
epidural or intrathecal opioids,systemic
opioid PCA,and regional techniques after
thoughtfully considering the risks and
benefits for the individual patient26965.4*31.2 1.9 1.10.4 11.These modalities should be used in
preference to intramuscular opioids
ordered“as needed”26965.8*24.97.5 1.10.7 12.The therapy selected should reflect the
individual anesthesiologist’s expertise,as
well as the capacity for safe application of
the modality in each practice setting26970.6*26.8 1.90.70.0 13.Special caution should be taken when
continuous infusion modalities are used
because drug accumulation may
contribute to adverse events26867.6*30.2 1.1 1.10.0
(continued)
Practice Guidelines
Table3.Continued
Percent Responding to Each Item
N Strongly
Agree Agree Equivocal Disagree
Strongly
Disagree
V.Multimodal Techniques for Pain Management
14.Whenever possible,anesthesiologists
should use multimodal pain management
therapy26756.2*28.112.4 2.60.7 15.The following drugs should be considered
as part of a postoperative multimodal pain
management regimen:
COX-2selective NSAIDs(COXIBs)26835.847.4*14.2 1.90.7
Nonselective NSAIDs26726.657.3*12.7 2.60.8
Acetaminophen26741.944.2*12.4 1.50.0
Calcium channel?-2-?antagonists(e.g.,
gabapentin,pregabalin)26515.138.5*38.5 6.8 1.1 16.Unless contraindicated,all patients should
receive an around-the-clock regimen of
NSAIDs,COXIBs,or acetaminophen26424.234.1*25.014.4 2.3 17.Regional blockade with local anesthetics
should be considered as part of a
multimodal approach for pain management26458.3*37.1 2.7 1.10.8 18.Dosing regimens should be administered
to optimize efficacy while minimizing the
risk of adverse events26471.2*27.3 1.10.40.0 19.The choice of medication,dose,route,and
duration of therapy should be
individualized26670.7*27.1 1.1 1.10.0 VI.Patient Subpopulations
Pediatric patients
20.Perioperative care for children undergoing
painful procedures or surgery requires
developmentally appropriate pain
assessment and therapy26563.4*35.1 1.50.00.0 21.Analgesic therapy should depend upon
age,weight,and comorbidity and unless
contraindicated should involve a
multimodal approach26858.6*34.7 4.5 2.20.0 22.Behavioral techniques,especially important
in addressing the emotional component of
pain,should be applied whenever feasible26634.242.5*21.4 1.50.4 23.Because many analgesic medications are
synergistic with sedating agents,it is
imperative that appropriate monitoring be
used during the procedure and recovery26869.4*30.20.40.00.0 Geriatric Patients
24.Pain assessment and therapy should be
integrated into the perioperative care of
geriatric patients26860.1*37.7 1.80.40.0 25.Pain assessment tools appropriate to a
patient’s cognitive abilities should be used26858.6*39.9 1.10.40.0 26.Extensive and proactive evaluation and
questioning should be conducted to
overcome barriers that hinder
communication regarding unrelieved pain26535.941.1*20.0 3.00.0
(continued) SPECIAL ARTICLES
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SPECIAL ARTICLES
围术期血液管理专家共识（2017） 2017-12-13 11:56 来源：未知编辑：shuangkai 点击: 467 仓静（共同执笔人）叶铁虎田玉科（共同负责人）吴新民张卫（共同负责人）张洁杨辉（共同执笔人）岳云姚尚龙黄文起廖刃围术期血液管理是指包括围术期输血以及减少失血、优化血液制品、减少输血相关风险和各种血液保护措施的综合应用等。围术期输血是指在围术期输入血液或其相关成分，包括自体血以及异体全血、红细胞、血小板、新鲜冰冻血浆和冷沉淀等。成分输血是依据患者病情的实际需要，输入相关的血液成分。血液管理的其他措施包括为避免或减少失血及输入异体血所使用的药物和技术。 一、术前评估 1. 了解既往有无输血史，有输血史者应询问有无输血并发症； 2. 了解有无先天性或获得性血液疾病； 3. 了解患者出血史、家族出血史及详细用药史； 4. 了解有无服用影响凝血功能的药物（例如，华法林、氯吡格雷、阿司匹林、其他抗凝药和可能影响凝血的维生素类或草药补充剂）造成的凝血病史； 5.了解有无血栓病史（例如，深静脉血栓形成、肺栓塞）； 6.了解有无活动性出血或急、慢性贫血情况； 7. 一般体格检查（例如瘀点、瘀斑、苍白）； 8.了解实验室检查结果，包括血常规、凝血功能检查、肝功能、血型鉴定（包括ABO血型和Rh血型）、乙肝和丙肝相关检查、梅毒
抗体以及HIV抗体等； 9. 术前重要脏器功能评估，确定可能影响红细胞最终输注需求（例如血红蛋白水平）的器官缺血（例如心肺疾病）的危险因素； 10. 告知患者及家属输血的风险及益处； 11. 为使患者做好准备，如果可能，术前应提前（例如若干天或周）进行充分评估。 二、术前准备 1. 填写《临床输血申请单》，签署《输血治疗同意书》； 2. 血型鉴定和交叉配血试验； 3.咨询相关专科医师或会诊。择期手术患者应暂停抗凝治疗（例如华法林、抗凝血酶制剂达比加群酯），对特定患者可使用短效药（例如肝素、低分子量肝素）进行桥接治疗；除有经皮冠状动脉介入治疗史的患者外，如果临床上可行，建议在术前较充足的时间内停用非阿司匹林类的抗血小板药（例如噻吩并吡啶类，包括氯吡格雷、替格瑞洛或普拉格雷）；根据外科手术的情况，考虑是否停用阿司匹林； 4. 当改变患者抗凝状态时，需充分衡量血栓形成的风险和出血增加的风险； 5. 既往有出血史的患者应行血小板功能检测，判断血小板功能减退是否因使用抗血小板药所致； 6.了解患者贫血的原因（慢性出血、缺铁性贫血、肾功能不全、溶血性贫血或炎症性贫血等），并根据病因治疗贫血，首先考虑铁剂治疗；
ESA发布围术期严重出血管理指南 欧洲麻醉学会(ESA)近期发布了 “围手术期严重出血管理指南”，旨在对现有证据进行评估，为临床应 用提供建议。 欧洲麻醉学会（ESA）近期发布了“围术期严重出血管理指南”，旨在对现有证据进行评估，为临床应用提供参考，相关内容发表在2013年6月出版的《欧洲麻醉学杂志》（Eur Anaesthesiol）上。 过去20年间，关于围术期输血策略的研究证据显著增加。这些证据不仅反映了输血医学 的复杂性，也体现了输血替代方法的发展，以及建立在循证医学基础上围术期输血实践的巨大 进步。因此，迫切需要更新输血指南，以使医务工作者与时俱进地利用研究证据。 ESA指南工作组通过3种方法对已发表的相关文献进行检索。① 2010年12月，ESA指南工作组采用“麻醉”、“手术”、“出血”等术语对MEDLINE和荷兰医学文献数据库（Embase）近10年来发表的相关数据进行了检索。② 2011年5月至2012年5月，针对需要较多数据的 研究领域，对MEDLINE和Embase进行了更详细的检索。③对麻醉干预的系统综述进行了更广 泛的检索。共纳入2 686篇文献。采用评估、进展和评价分级系统（GRADE）制定了“围术期 严重出血管理指南”。 该指南旨在对现有证据进行评估，为临床应用提供建议，指导临床医师采用安全、具成 本效益的策略，最大限度减少围术期严重出血及保存血液。该指南的主要内容包括：通过了解 患者情况和实验室检查，鉴别围术期出血风险增加的患者；采取策略，纠正术前贫血及微循环 和大循环（macrocirculation）失衡，优化患者对出血的耐受程度；采取恰当的促凝干预策略，以减少出血量，降低发病率和死亡率，减少医疗费用。该指南主要就以下方面提出了建议： 凝血状况评估 该指南建议，在进行手术或有创操作之前，使用结构化的患者访视法或问卷法了解患者 的出血史、家族出血史及详细用药史（1C）。 该指南建议，对于择期手术，与进行常规凝血试验[活化部分凝血活酶时间（APTT）、凝 血酶原时间（PT）和血小板计数]相比，通过标准化调查问卷了解患者的出血史和用药史更可 取（1C）。
慢性阻塞性肺疾病患者 非肺部手术麻醉及围术期管理的专家共识 （2017） 王东信（执笔人）王天龙（负责人）欧阳文严敏梅伟李民肖玮穆东亮何舒婷梁新全 慢性阻塞性肺疾病（chronic obstructive pulmonary disease，COPD）是常见的呼吸系统疾病，严重危害患者的身心健康。手术患者合并COPD会使术后肺部并发症风险增加，心脏、肾脏等肺外器官并发症风险增加，并导致住院时间延长、医疗费用提高、围术期死亡率增加。为了提高COPD患者的围术期管理质量，特制定COPD 患者接受非肺部手术的麻醉及围术期管理专家共识。 一、COPD的定义、病理生理学特征及诊断标准 （一）COPD的定义 COPD是一种可预防、可治疗的常见病，其特征是持续存在的呼吸道症状和气流受限，是由吸入有毒气体或颗粒引起的气道和（或）肺泡异常所致。COPD特征之一的慢性气流受限，是由小气道病变（如阻塞性细支气管炎）和肺实质破坏（肺气肿）共同导致，两者所起的相对作用因人而异。 （二）COPD的病理生理学特征 COPD的病理生理改变包括气道和肺实质慢性炎症所致粘液分泌增多、气流受限和过度充气、气体交换异常、肺动脉高压和肺心病以及全身不良反应。粘液分泌增多和纤毛功能失调导致慢性咳嗽、咳
痰。小气道炎症、纤维化和管腔分泌物增加引起第一秒用力呼气量（forced expiratory volume in one second，FEV1）和FEV1占用力肺活量（forced vital capacity，FVC）比值（FEV1/FVC）降低。小气道阻塞后出现气体陷闭，可导致肺泡过度充气；过度充气使功能残气量增加、吸气量下降，引起呼吸困难和运动能力受限。过度充气在疾病早期即可出现，是引起活动后气促的主要原因。随着疾病进展，气道阻塞、肺实质和肺血管床的破坏加重，使肺通气和换气能力进一步下降，导致低氧血症及高碳酸血症。长期慢性缺氧可引起肺血管广泛收缩和肺动脉高压，肺血管内膜增生、纤维化和闭塞造成肺循环重构。COPD后期出现肺动脉高压，进而发生慢性肺源性心脏病及右心功能不全。 慢性炎症反应的影响不仅局限于肺部，亦产生全身不良效应。COPD患者发生骨质疏松、抑郁、慢性贫血、代谢综合征及心血管疾病的风险增加。这些合并症均可影响COPD患者的围术期及预后，应进行评估和恰当治疗。 （三）COPD的诊断标准及分级 1. 诊断标准任何有呼吸困难、慢性咳嗽或咳痰，和（或）COPD 危险因素暴露史的患者，都应考虑COPD诊断。对于确诊或疑似COPD的新患者，必须采集详细病史。确诊COPD要求进行肺功能检查，使用支气管扩张剂后FEV1/FVC<0.70可确定存在持续性气流受限，结合具有相应症状和有害刺激物质暴露史可诊断COPD。 2. 气流受限严重程度分级评估气流受限严重程度的肺功能检
SPECIAL ARTICLES Practice Guidelines for Acute Pain Management in the Perioperative Setting An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management P RACTICE Guidelines are systematically developed rec-ommendations that assist the practitioner and patient in making decisions about health care.These recommenda-tions may be adopted,modified,or rejected according to clinical needs and constraints and are not intended to replace local institutional policies.In addition,Practice Guidelines de-veloped by the American Society of Anesthesiologists (ASA)are not intended as standards or absolute requirements,and their use cannot guarantee any specific outcome.Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge,technology,and practice.They provide basic rec-ommendations that are supported by a synthesis and analysis of the current literature,expert and practitioner opinion,open fo-rum commentary,and clinical feasibility data. This document updates the “Practice Guidelines for Acute Pain Management in the Perioperative Setting:An Updated Report by the American Society of Anesthesiolo-gists Task Force on Acute Pain Management,”adopted by the ASA in 2003and published in 2004.* Methodology A.Definition of Acute Pain Management in the Perioperative Setting For these Guidelines,acute pain is defined as pain that is present in a surgical patient after a procedure.Such pain may be the result of trauma from the procedure or procedure-related complications.Pain management in the perioperative setting refers to actions before,during,and after a procedure Updated by the American Society of Anesthesiologists (ASA)Com-mittee on Standards and Practice Parameters,Jeffrey L.Apfelbaum,M.D.(Committee Chair),Chicago,Illinois;Michael A.Ashburn,M.D.,M.P.H.(Task Force Chair),Philadelphia,Pennsylvania;Richard T.Con-nis,Ph.D.,Woodinville,Washington;Tong J.Gan,M.D.,Durham,North Carolina;and David G.Nickinovich,Ph.D.,Bellevue,Washing-ton.The previous update was developed by the ASA Task Force on Acute Pain Management:Michael A.Ashburn,M.D.,M.P.H.(Chair),Salt Lake City,Utah;Robert A.Caplan,M.D.,Seattle,Washington;Daniel B.Carr,M.D.,Boston,Massachusetts;Richard T.Connis,Ph.D.,Woodinville,Washington;Brian Ginsberg,M.D.,Durham,North Car-olina;Carmen R.Green,M.D.,Ann Arbor,Michigan;Mark J.Lema,M.D.,Ph.D.,Buffalo,New York;David G.Nickinovich,Ph.D.,Belle-vue,Washington;and Linda Jo Rice,M.D.,St.Petersburg,Florida.Received from the American Society of Anesthesiologists,Park Ridge,Illinois.Submitted for publication October 20,2011.Accepted for publication October 20,2011.Supported by the American Society of Anesthesiologists and developed under the direction of the Committee on Standards and Practice Parameters,Jeffrey L.Apfelbaum,M.D.(Chair).Approved by the ASA House of Delegates on October 19,2011.A complete list of references used to develop these updated Guidelines,arranged alphabeti-cally by author,is available as Supplemental Digital Content 1,https://www.doczj.com/doc/0210663432.html,/ALN/A780. Address correspondence to the American Society of Anesthesi-ologists:520North Northwest Highway,Park Ridge,Illinois 60068-2573.These Practice Guidelines,as well as all published ASA Prac-tice Parameters,may be obtained at no cost through the Journal Web site,https://www.doczj.com/doc/0210663432.html,. *American Society of Anesthesiologists Task Force on Acute Pain Management:Practice guidelines for acute pain management in the perioperative setting:An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management.A NESTHESIOLOGY 2004;100:1573–81. Copyright ?2012,the American Society of Anesthesiologists,Inc.Lippincott Williams &Wilkins.Anesthesiology 2012;116:248–73 ?What other guideline statements are available on this topic?X These Practice Guidelines update the “Practice Guidelines for Acute Pain Management in the Perioperative Setting,”adopted by the ASA in 2003and published in 2004.*?Why was this guideline developed? X In October 2010,the Committee on Standards and Practice Parameters elected to collect new evidence to determine whether recommendations in the existing Practice Guide-line were supported by current evidence. ?How does this statement differ from existing guidelines? X New evidence presented includes an updated evaluation of scientific literature and findings from surveys of experts and randomly selected ASA members.The new findings did not necessitate a change in recommendations. ?Why does this statement differ from existing guidelines? X The ASA guidelines differ from the existing guidelines be-cause they provide new evidence obtained from recent sci-entific literature as well as findings from new surveys of expert consultants and randomly selected ASA members. Supplemental digital content is available for this article.Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article.Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (https://www.doczj.com/doc/0210663432.html,).
骨科围手术期病人的护理 1、术后指导患者卧位屈髋屈膝活动，髋关节不超过( C )度 A、120 B、45 C、90 D、30 2、骨科手术皮肤准备需要超出上下关节的范围，而且手术( A )天前应开始准备 A、3 B、4 C、2 D、5 3、病人手术前( B )小时禁饮 A、8 B、4 C、2 D、6
4、术后要( B )小时测量体温1次 A、8 B、4 C、2 D、6 5、出现下列( D )症状时表明肢体血液循环障碍，应及时告诉医生 A、指(趾)甲苍白、按压不变色 B、患肢出现高度肿胀、皮肤发凉 C、肢端不能随意活动、稍加被动活动即感剧烈疼痛 D、以上均是 文案编辑词条 B 添加义项 ? 文案，原指放书的桌子，后来指在桌子上写字的人。现在指的是公司或企业中从事文字工作的职位，就是以文字来表现已经制定的创意策略。文案它不同于设计师用画面或其他手段的表现手法，它是一个与广告创意先后相继的表现的过程、发展的过程、深化的过程，多存在于广告公司，企业宣传，新闻策划等。 基本信息 中文名称 文案
外文名称 Copy 目录 1发展历程 2主要工作 3分类构成 4基本要求 5工作范围 6文案写法 7实际应用 折叠编辑本段发展历程 汉字"文案"(wén àn)是指古代官衙中掌管档案、负责起草文书的幕友,亦指官署中的公文、书信等;在现代，文案的称呼主要用在商业领域，其意义与中国古代所说的文案是有区别的。 在中国古代，文案亦作" 文按 "。公文案卷。《北堂书钞》卷六八引《汉杂事》:"先是公府掾多不视事，但以文案为务。"《晋书?桓温传》:"机务不可停废，常行文按宜为限日。" 唐戴叔伦《答崔载华》诗:"文案日成堆，愁眉拽不开。"《资治通鉴?晋孝武帝太元十四年》:"诸曹皆得良吏以掌文按。"《花月痕》第五一回:" 荷生觉得自己是替他掌文案。" 旧时衙门里草拟文牍、掌管档案的幕僚，其地位比一般属吏高。《老残游记》第四回:"像你老这样抚台央出文案老爷来请进去谈谈，这面子有多大!"夏衍《秋瑾传》序幕:"将这阮财富带回衙门去，要文案给他补一份状子。" 文案音译 文案英文:copywriter、copy、copywriting
2020版普通外科围手术期疼痛管理上海专家共识（全文） 普通外科围手术期疼痛可增加病人术后发生并发症的风险，影响其术后早期活动和康复。如在手术开始阶段未对疼痛进行有效控制，持续的疼痛刺激可引起中枢神经系统发生病理性重塑，急性疼痛有可能发展为难以控制的慢性疼痛。实施规范化的围手术期疼痛管理对于普通外科病人的术后康复具有重要意义。为此，上海市医学会麻醉科专科分会和上海市医学会普外科专科分会组织相关领域专家，综合国内外相关文献并结合上海市麻醉科和普外科医生的临床实践，撰写《普通外科围手术期疼痛管理上海专家共识（2020版）》，以期为普通外科的围手术期镇痛管理提供参考。 1 普通外科围手术期疼痛管理的原则 1.1 规范化镇痛管理普通外科手术的术后镇痛可纳入全院的术后疼痛管理架构中，成立全院性或以麻醉科为主的包括普通外科医师和护士在内的急性疼痛管理（acute pain service，APS）小组，可有效提高普通外科围手术期的镇痛质量。APS小组的工作范围和目的包括：（1）治疗围手术期疼痛，评估和记录镇痛效果，处理不良反应和镇痛治疗中的问题。（2）进行术后镇痛必要性和相关知识的宣教。（3）提高手术病人的舒适度和满意度。（4）减少术后疼痛相关并发症［1］。 1.2 预防性镇痛现代疼痛管理理念倡导预防性镇痛，即术前给予有效的麻醉或神经阻滞，并在疼痛出现前给予足够的镇痛药［如选择性环氧合酶-2（COX-2）抑制剂］，以减少创伤应激，防止中枢敏化，降低痛阈
值，减少术后镇痛药的用量和延长镇痛时间。 1.3 多模式镇痛多模式镇痛是指联合应用不同的镇痛方法和不同作用机制的镇痛药物，采用不同的给药途径，作用于疼痛发生的不同部位、时相和靶点，从而达到镇痛作用相加或协同的目的，减少药物的不良反应［2］。多模式镇痛是目前较为理想的围手术期镇痛管理方案。 目前，临床实践中推荐的联合用药方案包括阿片类药物分别与选择性COX-2抑制剂、非选择性非甾体抗炎药（non-steroid anti-inflammatory drug，NSAID）和（或）对乙酰氨基酚等合用。普通外科围手术期多模式镇痛推荐在超声引导神经阻滞或椎管内镇痛的基础上，联合应用多种镇痛药物。对于采用自控镇痛的病人，应用自控镇痛药物结束后，建议继续口服或静脉使用NSAID药物以减轻术后残余疼痛。 1.4 个体化镇痛不同病人对疼痛和镇痛药物的反应存在个体差异，普通外科不同手术的疼痛强度和持续时间也存在较大差异，与手术部位、类型密切相关；应根据病人的疼痛程度，选择口服或静脉给药、硬膜外镇痛、病人自控镇痛（patient controlled analgesia，PCA）等不同镇痛方式。个体化镇痛应综合考虑各种因素，制定最优化的疼痛管理方案。此外，个体化镇痛还应考虑病人因素，使病人应用最小的药物剂量即可达到最佳的镇痛效果。有条件时，可检测基因多态性，进行疼痛程度分层管理，指导阿片类药物的使用［3］。 2 普外科围手术期疼痛管理的药物 镇痛药物的应用是普通外科围手术期镇痛管理的基石。目前，普外科围手
围手术期血液管理的实践指南 一份来自美国麻醉医师协会围术期血液管理工作队最新的报告 实践指南是系统开发的建议，协助医生和病人关于医疗保健的决策。这些建议根据临床需要和约束可以采用、修改或拒绝，并不是为了取代本地制度政策。此外，由美国麻醉医师学会开发的实践指南并不是作为标准或者绝对要求，他们的应用并不能保证特定的结果。实践指南的修订根据医学知识、技术与实践的发展。他们通过综合分析最新文献、专家和医生的意见、公开论坛的评论和临床可行性数据提供基本的意见。本文档是2005年由ASA改编，2006年出版的最新材料，“围手术期输血和辅助治疗：一个由美国麻醉医师学会特别工作组更新的关于围手术期输血与辅助治疗的最新的报告。” 方法论 围手术期血液管理的定义 围手术期血液管理是指围手术期的输血和辅助疗法。围手术期血液输血是指术前、术中、术后血液和血液成分（例如异体或自体血、红细胞、血小板、冷沉淀离子产品新鲜血浆冷沉淀FFP、PF24或解冻血浆）的管理。辅助治疗是指用药物和技术来减少或防止血液损失和异体血输注的需要。 指南的目的 最新指南的目的是提高输血的围术期管理和辅助治疗，减少关于输血、出血或贫血的风险。 重点 这些指南的重点放在围术期管理经历手术或其他侵入性操作的患者发生大量出血或预期的出血量。这包括但不限于：1接受体外循环心脏手术的患者、急诊手术、产科手术、器官移植手术以及非心脏手术2之前存在的血液病或获得性凝血缺陷患者3危重病手术或其他介入过程手术患者4不接受围术期输血的患者。这些指南以外的重点是新生儿、婴幼儿、儿童体重小于35kg和不接受手术的病人。 专责小组认为出血的生理可能受麻醉药的舒张作用的影响，因此对于一些临床或者手术等情况，这些指南的建议可能不能应用。从业者需要用他们自己对临床情况的判断应用包括在这些指南里的更广义的建议。 应用 这些准则适用于住院和门诊手术，在操作室内的介入手术以及其他需要输血或辅助治疗地方（例如介入放射科、重症监护病房）。这些准则直接适用于由麻醉医师和提供医疗护理方向或者麻醉医师超级视野下的管理的个人管理的护理。这些准则也趋向于向其他医生和涉及病人围手术期护理的护理人员的提供资料。 工作队成员和顾问 2012年，标准和实践参数的ASA委员会要求对于2006年出版的更新指南进行重新评估。本次修订由文献评价和由专家顾问和ASA成员通过最新的调查发现所做的评估组成。总结建议见附录1. 这个修订是由ASA委任的10名成员小组组成的，小组成员有私人麻醉医师、来自美国不同地区有学术实践的麻醉医师、专攻于输血医学的病理学家和来自标准和实践参数ASA委员会的两名咨询方法论者。 工作队通过七个步骤的过程完成指南。首先，他们在有效输血证据和辅佐治疗的标准上达成共识。第二，涉及接受输血患者的围手术期管理的同行评审期刊发表的最初调查研究被审查。第三，要求专家顾问小组1参加各种围术期管理策略有
中国加速康复外科围手术期管理专家共识(2016) 一、前言 加速康复外科(enhanced recovery after surgery,ERAS)指为使患者快速康复,在围手术期采用一系列经循证医学证据证实有效的优化处理措施,以减轻患者心理与生理的创伤应激反应,从而减少并发症,缩短住院时间,降低再入院风险及死亡风险,同时 降低医疗费用。 近年来,ERAS理念在全球的应用已逐步拓展至骨科、心胸外科、妇产科、泌尿外科、普通外科等领域,均取得了良好效果。但目前ERAS理念在国内尚处于不断完善与发展的过程中,正在逐步形成中国特色的ERAS路径。在此背景下,普通外科、麻醉科、胸心外科、神经外科等领域的专家结合文献及ERAS在国内开展的实际情况,共同制定此共识,以进一步规范并促进多学科综合诊疗模式下ERAS理念在国内临床实践中的应用。 二、术前准备 完善的术前准备可使患者具有充分的心理准备与良好的生理条件,包括术前宣教、营养筛查、预防性应用抗菌药物及抗血栓治疗、个体化的血压与血糖控制及相应的管理方案等。 一)术前宣教
多数患者在术前存在不同程度的恐慌与焦虑情绪,担心手术的成功与安全,害怕术中术后的疼痛及并发症,个别患者还会产生严重的紧张、恐惧、悲观等负面情绪,均会造成不良的应激反应,妨碍手术的顺利进行与术后的康复。个体化的宣教就是ERAS成功与否的独立预后因素［1］,医护人员应在术前通过口头或书面形式向患者及家属介绍围手术期治疗的相关知识及促进康复的各种建议,缓解患者紧张焦虑情绪,以使患者理解与配合,促进术后快速康复。 (二)营养不良的筛查与治疗 营养不良就是术后并发症的独立预后因素［2］,筛查与治疗营养不良就是术前评估的重要内容,在促进快速康复方面具有重要意义。欧洲营养与代谢协会建议采用以下指标判断患者就是否存在重度营养风险:(1)6个月内体重下降10%～15%或更高;(2)患者进食量低于推荐摄入量的60%,持续>10 d;(3)体重指数 <18、5 kg/m2;(4)清蛋白<30 g/L(无肝肾功能不全)。术前营养支持的方式优先选择经口营养或肠内营养,根据患者个体情况设定每日营养目标［3］。一项随机对照临床试验的结果显示,对严重营养不良患者(营养不良风险调查评分≥5分)进行术前营养支持,可将术后并发症发生率降低50%;对于此类患者推荐术前7～10 d行肠内营养治疗;若仍无法满足基本营养需求(＜推
小儿围手术期液体和输血管理指南（2014） 中华医学会麻醉学分会 王英伟左云霞师阳连庆泉（共同执笔人/负责 人）丽华建敏曾睿峰（共同执笔人） 目录 概述 小儿液体管理特点 围手术期输液 围手术期输血 一、概述 小儿围术期液体管理不当，液体输入过多或不足，未及时纠正水与电解质紊乱，均可引起诸多问题，且较成人更易危及生命。参照中华医学会麻醉学分会2009年《小儿围术期液体和输血管理指南》，并根据患儿特点，特制定本指南。 本指南将涉及以下容： 1、各年龄组儿童液体生理需要量的计算方法 2、小儿围术期体液缺乏的评价和纠正
3、各年龄组儿童术中液体治疗的推荐意见 4、围术期血容量评估及输血的建议 二、小儿液体管理特点 要实现婴幼儿液体的正确管理，就必须了解小儿的生理特点以及伴随其生长发育所发生的变化。 （一）体液总量和分布 人体大部分由体液组成，胎儿期到儿童期的生长发育过程中，机体体液的比例发生着巨大的变化。年龄越小，体液所占体重比例越大，主要是间质液量的比例较高，而血浆和细胞液量的比例与成人相近（表35-1）。 （二）体液成分 小儿体液成分与成人相似，唯新生儿在生后数日血钾、氯、磷和乳酸偏高，血钠、钙和碳酸氢盐偏低，细胞、外液的化学成分见表35-2。
（三）各年龄组体液代的特点 1、新生儿出生后的最初几天，水的丢失可使体重下降5%～15%。出生第1天的液体需要量相对较低，数天后液体丢失及需求相对增加，每日水转换率（100ml/kg）亦明显高于成人（35ml/kg），体液总量、细胞外液和血容量与体重之比均大于成人（表35-3）。 新生儿心血管代偿能力差，两侧心室厚度相近，液体过荷易出现全心衰。体液丢失过多，易致低血容量、低血压，严重者可使肺血流量减少，引起低氧血症和酸中毒，致使动脉导管开放并可能恢复胎儿循环。
冠心病患者非心脏手术麻醉及围术期管理的专家共识(2017版中国麻醉学指南与专家共识)
冠心病患者非心脏手术麻醉及围术期管理的 专家共识（2017） 马骏王伟鹏（执笔人）王晟包睿艾艳秋张铁铮夏中元晏馥霞徐军美（负责人）徐美英缪长虹 随着外科手术技术的发展，临床上冠心病患者非心脏手术的适应证愈来愈广，手术种类以腹部、泌尿、骨科手术居多，而急症、失血多、高龄伴多系统疾病患者的麻醉风险更高，使围术期心血管事件的风险增加，如心肌梗死、心力衰竭和死亡。据《中国心血管病报告2016》报道，我国心血管病患者发病率和死亡率仍处于上升阶段，其中冠心病患者约有1100万人。冠心病患者需要行非心脏手术的也在逐年增加，近期患有心肌梗死或不稳定型心绞痛的患者如果需要行紧急或急诊手术，风险则更高。认识并理解围术期心血管风险因素，在麻醉前进行全面评估，对降低患者施行非心脏手术的并发症的发生和病死率具有重要意义。 本文将阐述择期、紧急或急诊非心脏手术的缺血性心脏病患者的麻醉前评估、麻醉治疗和术后即刻管理。 一、术前评估 （一）心血管事件风险评估 1.总则所有接受择期非心脏手术的缺血性心脏病患者，应进行围术期心血管事件风险评估。该风险与外科手术类型（表1)和
患者体能状态（图1）有关。在现有证据和专家意见基础上，参照美国及欧洲冠心病患者围术期心脏评估及处理流程（图2，表2），其基本原理概述在本共识中。该流程从临床医师的角度关心患者，提供知情同意，并帮助指导围术期管理，以尽量降低风险。这种相互合作的“围术期团队”是围术期评估的基石，它依赖于外科医师、麻醉科医师及主要照顾者等相关参与者的密切沟通。 表1. 美国心脏病学会/美国心脏协会（ACC / AHA）指南摘要： 非心脏手术的心脏风险分级 主要心血管不良事件（major adverse cardiovascular events，MACE ）（主要包括三个终点事件：心血管死亡、心肌梗死和卒中。*术前一般不需要进一步的心脏检测。门诊手术是指在手术当天入院并在同一天返回家的手术。
围手术期患者指南 患者朋友们，您住院后如果需要手术治疗，那么我们先了解一下关于手术要注意什么？ 一、术前注意事项 1、如果您有吸烟的习惯，这时候一定要戒烟了，以免术后卧床出现憋喘、痰多等肺炎的症状。 2、手术后因为您暂时不能下床，所以要在床上解大、小便；为了您术后能够顺利在床上排大、小便，请 您术前三天就按照护士的指导在床上练习解大、小便，一定要遵守吆！ 4.术前一天您及家属不要随意离开病房了，要等待手术医生、麻醉医生的术前签字和手术室护士的访视。 5.术前一天晚上如果您因手术紧张而睡眠不好时，一定告诉护士，可以给予安眠药物帮助您入睡，良好的 睡眠可以使手术过程更安全。 6.术前一天您需要洗头、剪指甲、更换清洁衣服。 7.从术前一天夜间零时开始，您不能吃东西和喝水了，防止手术中出现麻醉意外。 二、手术当日注意事项 1.手术当天早晨女患者月经来潮要及时告诉医生或护士，手术要停止进行。 2、您如果有活动的假牙、手表、首饰等，请取下来交给家属保管，排空小便。护士为您佩戴的腕带不要 自行取下，这是患者身份识别的依据，对预防发生差错作用重大。 3.手术需要的X光片、CT片等要提前准备好，等待手术室护士来接您进入手术室。 4.紫外线消毒时，家属朋友们请不要在室内停留或直视灯管，以免出现红眼、皮肤改变。 三、术后注意事项 1.您手术结束后，要进入病房监护室监护6-12小时，让您平稳的度过麻醉复苏期。监护期间留有一名陪人看护您，监护仪出现报警声，立即通知护士，护士也会随时巡视。监护期间，家属不要在室内接听电话，以免信号干扰监护仪发生故障。其他人员请不要随意进入监护室，更不要大声说话，以保证您安静地休息。 2、手术结束，麻醉作用消失后您可能会感觉疼痛，这时要及时告诉护士，不要忍着。疼痛可以引起您的脉搏、血压及情绪的变化，甚至影响睡眠，所以一定要及时、有效止疼，如果一种止痛药效果不好，可以继续更换其他更强效的止痛药，术后止痛对伤口愈合没有任何不良影响，请您及家属打消不必要的顾虑。 3、术后如果您插有尿管或刀口引流管，护士会告诉您注意事项，家属请不要去触碰管道，这些管道将由护士来管理。如果发现伤口纱布渗血明显，及时告诉护士，不用惊慌。 4、术后您如果感觉口腔干燥、异味，可以告诉护士，给您喂一勺水湿润口腔，但切不可多饮水，以免出现意外情况。术后如果您感觉冷，不要让家属轻易给你使用热水袋，因麻醉作用没有消失，您对冷、热感觉丧失，容易烫伤，可以告知护士加盖棉被。您术后会感觉很累，可以让家属轻轻地按摩您的双腿。 5、术后6小时以后，您可以喝水及米粥，但不要过多，以免引起腹胀或加重腹胀；术后有时发生腹胀、 恶心，及时告知护士。术后第二天，一般可以恢复正常饮食，但以清淡、好消化的软饭为主，多吃蔬菜和水果，避免辛辣等刺激性食物，不用过早大补营养，以免降低食欲。 6、术后护士会根据您的病情指导您进行康复训练，一定要按时坚持去做，对术后早日下床和恢复肢体功 能效果非常好。手术是治疗骨折的一种方法，手术后的康复训练非常重要，康复做不好，可能会留下并发症。手术后如无禁忌，护士会指导您在床上自主活动，进行早期康复训练。 7、术后三天内，您需要安静休养，烦请家属、亲友不要过多探视，但家属一定要好好照顾我们的病人哦！
高血压是常见的心血管疾病，是威胁中老年人健康的主要疾病之一。《中国心血管病报告2012》指出，目前我国高血压患病率为24%，估算全国高血压患者达2.66亿，并逐渐呈现出年轻化的趋势，合并高血压的手术患者数量也在不断增加。围术期高血压可增加手术出血、诱发或加重心肌缺血、导致脑卒中以及肾脏衰竭等并发症。我国高血压呈现三高三低流行病学特点，即发病率、伤残率与死亡率高；知晓率、服药率与控制率低，从而大大增加了
TC：总胆固醇；LDL-C：低密度脂蛋白胆固醇；HDL-C：高密度脂蛋白胆固醇；LVMI：左心室质量指数；IMT：颈动脉内膜中层厚度；BMI：体质量指数。 二、围术期高血压的病因： （一）原发性高血压 约占90%～95%，是遗传易感性和环境因素相互作用的结果，一些其他因素如体重超重、口服避孕药、睡眠呼吸暂停低通气综合征等。 （二）继发性高血压 约占5%～10%，血压升高是某些疾病的一种表现，主要见于肾脏疾病、内分泌疾病、血管疾病、颅脑疾病以及妊娠期高血压等。 （三）紧张焦虑 主要由于患者对麻醉、手术强烈的恐惧感所致，这类患者仅在入手术室后测量血压时才出现高血压，回到病房或应用镇静剂后, 血压即可恢复正常。 （四）麻醉 麻醉期间发生高血压的原因较多，主要与麻醉方式、麻醉期间的管理以及一些药物应用有关。 1. 麻醉过浅或镇痛不全； 2. 浅麻醉下气管内插管或拔管；
3. 缺氧或CO2蓄积。 （五）手术操作 一些手术操作如颅脑手术牵拉、嗜铬细胞瘤手术肾上腺血流阻断前等，可引起短时的血压增高。对引起继发性高血压的肾血管病变、嗜铬细胞瘤、原发性醛固酮增多症等, 术中都有可能发生严重的高血压, 甚至心、脑血管意外。 （六）其他 除上述外, 较为常见的引起血压升高的原因还有：①液体输入过量或体外循环流量较大； ②颅内压升高；③升压药物使用不当；④肠胀气；⑤尿潴留；⑥寒冷与低温；⑦术毕应用纳络酮拮抗阿片类药物的呼吸抑制作用；⑧术后伤口疼痛、咳嗽、恶心呕吐等；⑨术后因麻醉对血管的舒张作用消失，血容量过多。 三、高血压患者术前评估及术前准备 （一）实施手术与麻醉耐受性的评价 1.高血压病程与进展情况高血压病程越长，重要脏器越易受累，麻醉危险性越大；高血压病程虽短，但进展迅速者，即恶性高血压，早期就可出现心、脑、肾并发症，麻醉危险性很大。 2.高血压的程度1、2级高血压（BP< 180/110mmHg），麻醉危险性与一般病人相仿，手术并不增加围术期心血管并发症发生的风险。而3级高血压（BP≥180/110mmHg）时，围术期发生心肌缺血、心力衰竭及脑血管意外的危险性明显增加。 3.靶器官受累情况高血压伴重要脏器功能损害者, 麻醉手术的危险性显著增加。对于高血压患者, 应注意了解有无心绞痛、心力衰竭、高血压脑病、糖尿病, 以及脂类代谢紊乱等合并症。
骨科病人围手术期疼痛管理进展 发表时间：2016-02-15T16:25:48.320Z 来源：《中西医结合护理》2015年10月第10期供稿作者：周洁丽钟建群陈聂芬 [导读] 广西岑溪市人民医院急诊科围手术期包括患者手术前、手术中及手术后的一段时间，是指从患者决定接受手术开始。 周洁丽钟建群陈聂芬广西岑溪市人民医院急诊科 543200 【关键词】疼痛管理；骨科；超前镇痛；多模式镇痛；个体化镇痛【中图分类号】R816.8【文献标识码】A【文章编号】2096-0867（2015）-10-256-02 疼痛是骨科患者的常见症状，术后疼痛为患者带来较多不便与痛苦，受到患者的广泛关注。术后疼痛影响患者生活质量，还影响患者的恢复情况，如何有效管理控制疼痛，目前已经成为医务人员和患者共同关心的问题。本文主要概括总结骨科病人围手术期疼痛对机体的影响、疼痛评估方法、疼痛控制及护理干预等，以期为骨科病人围手术期疼痛管理提供依据。 围手术期包括患者手术前、手术中及手术后的一段时间，是指从患者决定接受手术开始，直到进行手术后基本康复为止的时间范围。根据国际疼痛协会对疼痛做出的定义，疼痛是指令人不愉快的感觉和情绪感受，且常伴有实际或者潜在的组织损伤［1］。患者接受骨科手术之后，伴随麻醉作用的消失将会感受到切口的疼痛。骨科手术后1d 内患者的疼痛程度最为强烈，持续时间多为3～4d ［2］。目前人们对疼痛的认识随着生活水平的提高发生着变化，对镇痛的要求也逐步提高［3］。在术后疼痛方面，现代中国主要经历了4 个时期：（1）20 世纪70 年代以前：这一时期的镇痛治疗不够充分，以肌肉注射哌替啶为主。 （2）80～90 年代：主要采用硬膜外小剂量吗啡。（3）90 年代以后：即为患者自控镇痛(PCA)时期。近几年来大量研究表明，疼痛存在多靶点机制，单一药物难以实现对多种疼痛的镇痛效果，且存在较多不良反应。目前多模式镇痛已发展成为镇痛主要方式。现将近年来骨科病人围手术期疼痛管理进展进行综述。 1.疼痛对机体影响根据李兰芹［4］的研究，疼痛属于一种机体自身的保护性功能。疼痛不仅对人的生理带来不良影响，还会对心理造成不利。疼痛具有引发高血压、心脏病的复发的风险，造成患者代谢、免疫、内分泌系统的功能障碍；疼痛还会使患者焦虑不安，产生抑郁、失眠等症状，导致精神系统的障碍［5-6］。实行骨科手术后，患者的睡眠情况在术后3d 内受影响的程度最大，患者睡眠时间、睡眠质量均受影响，表现为入睡困难、睡后易醒等，术后当天最为严重。根据黄天雯、何翠环等［7］研究，骨科患者围术期疼痛还会造成术后并发症，包括关节僵硬、深静脉血栓、肌萎缩等，严重影响患者的康复效果。 2.疼痛的评估疼痛评估有助于识别疼痛，还可以判断治疗的效果，是规范性疼痛处理的首要内容。目前疼痛评估的主要方法包括：(1)视觉模拟评估法(visual analogue scale，VAS)：也叫作直观类比标度法，是最常用的疼痛评估工具，分为线性图和脸谱图两类。 线性图中较为常用的是中华医学会疼痛医学会监制的VAS卡，分10 个等级，数字越大则疼痛强度越大，评估时采用直尺量出疼痛强度数值作为疼痛强度评分；脸谱图适用于评估意识正常、大于7 岁小儿的各种疼痛。主要以VAS 标尺为基础，标尺旁边标有笑或哭的脸谱，易于儿童理解。（2）文字描述评估分量表( verbal descniptors scale，VDS)：此法包括一系列描述疼痛的形容词，每个形容词都有相应的评分，最轻疼痛为0分，每增加1 级加1 分。（3）数字评估分量表( numerical ratingscale，NRS)：将疼痛分为4 个等级，由患者在10 分制的标尺上进行自评，无疼：0 级；轻度疼痛：1～3 级；中度疼痛：4～6 级；重度疼痛：7～10 级。（4）WonG-baker 面部表情疼痛量表：主要适用于交流困难的患者，包括3～5 岁儿童、老年人、意识不清患者或者无法用语言准确表达的患者。观察患者行为并用6 种不同的面部表情表达疼痛程度。（5）Mcgill 疼痛分级：将疼痛分为5 级，采用问答法完成，等级越高疼痛越强烈。从患者实际情况出发，选择最恰当的评估方法进行疼痛评估，老年人及文化程度低的人适宜采用面部表情评估量表，而对于文化程度高的人，适宜采用数字评估量表或者文字描述评估量表［8］。 3.疼痛的管理3. 1 疼痛的非药物治疗（1）与患者进行良好有效的沟通；（2）物理治疗：冷敷、热敷、按摩、针灸、经皮电刺激等；（3）分散注意力疗法；（4）放松疗法；（5）自我行为疗法。 针对不同种类的疼痛，要向患者强调不同的注意事项，依照患者具体实际，合理选择疼痛治疗方式。 3.2 疼痛的药物治疗3.2.1 三个阶梯疗法是由WHO 在1986 年推荐的疗法，在一定程度上弥补了疼痛管理缺陷，主要以疼痛评估结果为依据给予药物处理。第l 阶段：采用非阿片类药物治疗；第2 阶段：对于第l 阶段止痛药效果不理想的患者，采用可待因、盐酸曲马多缓释片等弱阿片类药物进行治疗；第3 阶段：对于重度疼痛患者，采用盐酸哌替啶、吗啡等强阿片类药物治疗。 阿片类药物存在呼吸抑制、恶心呕吐等多种并发症，呼吸抑制的发生率为0.1%［9-10］。 3.2.2 患者自控镇痛泵属于一种新型的止痛技术，由患者根据疼痛程度自我控制给药时间和剂量［11］。这种方式给药的准确性较高，具有血药浓度稳定、反应迅速、携带方便、操作简单等优点。镇痛泵内的药物主要包括芬太尼等阿片类镇痛药，具有抑制呼吸中枢、抑制胃肠道蠕动作用。当镇痛作用消失后其不良反应仍可能存在，且如果使用不当，该类药物具有成瘾性。 3.2.3 多模式镇痛( multimodal analgesia，MMA) 主要指通过联合应用多种药物和镇痛方法干预痛觉感知，或者调整疼痛的阈值，实现镇痛效果的协同或者叠加，从而达到最佳镇痛效果。该镇痛模式的概念涵盖了超前镇痛、术中局部用药及术后按时给药等。对于疼痛原因清楚、性质明确的疼痛，应当及时给予预防性治疗，预防性治疗时具有用药少效果好的特点。还应当注意给药间隔和给药剂量的个体化，要依据患者的疼痛程度和治疗反应对镇痛治疗进行调整以确保效果。根据袁志峰等［12］研究，采用多模式镇痛组患者的临床效果显著优于单纯镇痛组患者。管大伟等［13］研究表明，在人工全膝关节置换多模式镇痛中，氨酚曲马多镇痛效果显著且安全性较高，可以改善患者早期膝关节功能，提高了患者满意度，并保证了不良反应发生率及严重程度的稳定性。 3.2.4 区域阻滞常用的方法包括：椎旁神经阻滞、硬膜外阻滞、外周神经阻滞、胸膜腔或腹膜腔阻滞和术后持续伤口局部镇痛等方法。该方法镇痛效果好，且具有不影响患者神志、便于术后及早锻炼恢复、价格低操作简单等优点，越来越受到重视。 3.2.5 经皮下持续给药该方法是近几年新发展起来的镇痛方法，在患者手术后清醒之后，在其上臂三角肌处皮下采用留置针穿刺，连接镇痛泵并持续泵入止痛药，止痛效果和静脉给药相比没有显著差异。常用的药物主要有芬太尼、托烷司琼及氟哌利多等。采用该方法，药物无需经过肠胃，具有生物利用度高、起效快等优点，还可以避免药物对静脉造成刺激［14］。 3.3 护理干预对骨科手术患者术后进行适当护理干预，可以有效减轻疼痛，提高患者满意度，常用方法包括心理护理、放松疗法及音乐疗法等。（1）心理干预：骨科患者大多存在焦虑、紧张等情绪，相关研究表明，这些负性心理可加重术后疼痛。在护理工作中做到尊重