casala 2010-4-16 10:55
發布新版慢性疼痛指引
作者：Allison Gandey
出處：WebMD醫學新聞
April 1, 2010 — 十多年來第一次，美國麻醉科醫師特別工作小組更新了它的慢性疼痛指引。
新版建議的目標在幫助醫師治療疼痛，達到最佳疼痛控制、促進生理與心理健康、使副作用最少化。
愛荷華市愛荷華大學醫院的Richard Rosenquist醫師領導來自美國各地的開業與學界麻醉科醫師組成的12人特別工作小組，此一小組也和美國地區麻醉及疼痛醫學會成員合作。
這份新版指引登載於4月的Anesthesiology期刊。
建議運用於慢性非癌症、神經痛、身體痛或內臟疼痛的病患，該工作小組聚焦在診斷式關節阻斷、神經阻斷、軸索鴉片類藥物試驗等介入型診斷方式。
【聚焦在介入型診斷方式】
該團隊同意，應整合來自病患病史、體檢與診斷評估的資料，以提供具有最適當風險利益比率的個人化治療計畫，此治療應從侵犯程度最小的方式開始，隨著需要才增加。
工作小組報告指出，若可能的話，應和照護病患的其他醫師有直接且持續的聯絡，以確保有最佳照護。
對於慢性疼痛病患，新版指引提倡多元介入方式。工作小組建議，應發展包括定期追蹤評估的一種長期方式，且納入成為整體治療策略的一部分，此外，若可行，則使用跨科別照護計畫。
【新版指引細節】
* 燒灼技術
* 針灸
* 阻斷
* 肉毒桿菌
* 電子神經刺激
* 硬脊膜外類固醇
* 腦脊髓膜內藥物治療
* 微創脊椎手術
* 藥物處置
* 物理治療
* 心理治療
* 激痛點注射
工作小組將慢性疼痛定義為任何未與腫瘤直接相關之病原的疼痛，與一種醫療狀況或超過預期的暫時性組織傷害有關，一般可治癒，但是對於個人的功能或健康情況有不良影響。
慢性疼痛的藥物包括抗痙攣劑、抗憂鬱劑、苯重氮基鹽、NMDA受體拮抗劑、非類固醇抗發炎劑、鴉片類藥物、骨骼肌鬆弛劑、外用製劑等，工作小組逐一討論細節且建議監測和處置不良事件及病患順從性。
新版指引涵蓋了1997年初版中未納入的進階範圍，新版指引的頁數幾乎是舊版的兩倍之多，可以上線連結獲得完整版指引。
並未提供美國麻醉醫師協會12人工作小組的財務宣告。
New Chronic Pain Guidelines Published
By Allison Gandey
Medscape Medical News
April 1, 2010 — For the first time in more than a decade, an American Society of Anesthesiologists taskforce has updated its chronic pain guidelines.
The new recommendations are designed to help clinicians who treat pain. The objectives are to optimize pain control, enhance physical and psychological well-being, and minimize adverse outcomes.
Richard Rosenquist, MD, from the University of Iowa Hospital, Iowa City, led the 12-member taskforce of anesthesiologists in both private and academic practice from various parts of the United States. The group also worked with members of the American Society of Regional Anesthesia and Pain Medicine.
The new guidelines appear in the April issue of Anesthesiology.
The recommendations apply to patients with chronic noncancer, neuropathic, somatic, or visceral pain. The taskforce focused on interventional diagnostic procedures including diagnostic joint block, nerve block, and neuraxial opioid trials.
Focus on Interventional Diagnostic Procedures
The team agreed that findings from the patient history, physical examination, and diagnostic evaluation should be combined to provide an individualized treatment plan focused on optimizing the risk-to-benefit ratio. Treatment should progress from a lesser to greater degree of invasiveness.
"Whenever possible," the taskforce reports, "direct and ongoing contact should be made and maintained with the other physicians caring for the patient to ensure optimal care."
The new guidelines advocate for multimodal interventions for patients with chronic pain. The taskforce suggests that a long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy. In addition, when available, multidisciplinary programs may be used.
The new guidelines detail
ablative techniques,
acupuncture,
blocks,
botulinum toxin,
electrical nerve stimulation,
epidural steroids,
intrathecal drug therapies,
minimally invasive spinal procedures,
pharmacologic management,
physical therapy,
psychological treatment, and
trigger point injections.
The taskforce defines chronic pain as pain of any etiology not directly related to neoplastic involvement associated with a medical condition or extending in duration beyond the expected temporal boundary of tissue injury and normal healing and adversely affecting the function or well-being of the individual.
Drugs for chronic pain include anticonvulsants, antidepressants, benzodiazepines, N-methyl-D-aspartate receptor antagonists, nonsterioidal anti-inflammatories, opioid therapy, skeletal muscle relaxants, and topical agents. The taskforce discusses each in detail and recommends strategies for monitoring and managing adverse effects and patient compliance.
The new guidelines cover a range of advances not included in the initial version published in 1997. As a result, the number of pages has more than doubled in the new publication. The complete guidelines are available online.
Financial disclosures for the 12 members of the American Society of Anesthesiologists taskforce were not provided.
Anesthesiology. 2010;112:810-833.