英语晨读 ·
山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。
本次文献选自Ishida Y, Okada T, Kobayashi T, Funatsu K, Uchino H. Pain Management of Acute and Chronic Postoperative Pain. Cureus. 2022 Apr 9;14(4):e23999.本次学习由赵学军主任医师主讲。
Prevention of CPSP
Table 2 shows the summary of recent data concerning the prevention of CPSP. A study done by Bouman et al., in which they evaluated the incidence rate of CPSP of patients six months after open abdominal surgery, found that postsurgical epidermal anesthesia was associated with a reduction in the incidence rate of CPSP after open abdominal surgery.
CPSP的预防
表2显示了关于预防CPSP的最新数据汇总。Bouman等人进行的一项研究评估了开腹手术后6个月患者CPSP的发病率，发现术后表皮麻醉与开腹术后CPSP的发生率降低有关。
The analgesic mechanism of ketamine, an N-Methyl-D-aspartic acid (NMDA) receptor antagonist, is thought to be associated with the blockage of NMDA receptors in secondary neurons of the dorsal horn pain pathway and plays an important role in the enhancement of the spinal cord and cerebral cortex, which are factors of developing chronic pains. Meta-analysis of ketamine administration suggests that the incidence rate of the ketamine administration group was significantly reduced in statistical terms. However, most of the studies analyzed were small-sized investigations. Thus, there is a possibility of over-evaluating the effects of the treatment, and it is necessary to be cautious when discussing the preventive effects of ketamine for CPSP. Currently, a university in Melbourne, Australia, is performing a large-scale randomized controlled trial (RCT) (the ROCKet trial) study concerning the preventive effects of ketamine for CPSP. Although there is controversy concerning pregabalin and gabapentin, the most prescribed drugs for neuropathic pain, some meta-analyses report that they are effective for the prevention of CPSP. Furthermore, Koh et al. reported that duloxetine, another first-choice drug, significantly reduced the degree of postsurgical pain after 12 weeks in patients who underwent artificial knee joint replacement when compared with the control group. Duloxetine may be effective in patients with diminished descending pain inhibitory system. Concerning the effect of lidocaine on the inhibition of CPSP, a meta-analysis of 6 trials reported that the administration of lidocaine during the perioperative period significantly reduced the incidence rate of CPSP. There are reports stating that psychological factors are also risk factors for CPSP, and it is suggested that psychological interventions, such as cognitive-behavioral therapy, may prevent the development of CPSP.
氯胺酮是一种NMDA受体拮抗剂，其镇痛机制被认为与脊髓背角疼痛通路的二级神经元中NMDA受体的阻断有关，并在脊髓和大脑皮层的增强中发挥重要作用，而这是产生慢性疼痛的原因。Meta分析表明，从统计学角度来看，氯胺酮组的发病率显著降低。然而，大多数上述研究是小样板的调查性研究。因此，存在过度评估治疗效果的可能性，在讨论氯胺酮对CPSP的预防作用时必须谨慎。目前，澳大利亚墨尔本的一所大学正在进行大规模随机对照试验（RCT）（ROCKet试验），研究氯胺酮对CPSP的预防作用。尽管普瑞巴林和加巴喷丁这两种最常用于治疗神经病理性疼痛的药物存在争议，但一些荟萃分析认为它们对预防CPSP有效。此外，Koh等人报告称，与对照组相比，另一种首选药物度洛西汀显著降低了接受人工膝关节置换术患者术后12周的疼痛程度。度洛西汀可能对下行疼痛抑制系统减弱的患者有效。关于利多卡因对CPSP的抑制作用，一项对6项研究的荟萃分析认为，围手术期应用利多卡因显著降低了CPSP的发病率。有报告指出，心理因素也是CPSP的危险因素，并建议心理干预，如认知行为疗法，可能会阻止CPSP的发生。
Conclusions
Poor analgesic management after surgery not only increases acute complications but also raises the possibility of developing CPSP. As CPSP is a perioperative complication that prolongs hospitalization and interferes with ADLs and QoL, its prevention is important. It is also critical to mitigate the risks that are currently known to prevent the development of CPSP. It is necessary to recognize the risks of CPSP before surgery and to make sure preventive analgesics are performed after surgery. For patients at high risk, it is necessary to consider analgesic management in which CPSP would not develop prior to surgery and afterward. Careful perioperative interventions can improve a patient's prognosis and facilitate postsurgical pain control.
结论
术后镇痛管理不善不仅会增加急性并发症，还会增加患上CPSP的可能性。由于CPSP是一种围手术期并发症，会延长住院时间并干扰ADL和QoL，因此预防CPSP非常重要。减轻目前已知的防止CPSP发展的风险也至关重要。有必要在手术前认识到CPSP的风险，并确保术后使用预防性镇痛药。对于高危患者，有必要考虑在术前和术后不会出现CPSP的镇痛管理。仔细的围手术期干预可以改善患者的预后，促进术后疼痛控制。
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