以下資訊整理自 Miller's Anesthesia 9th edition chapter 81 Acute Postoperative Pain
急性疼痛的影響
神經內分泌學 neuroendocrine stress response
- 局部性發炎物質 cytokines, prostaglandins, leukotrienes, tumor necrosis factor-α
- 下視丘-腦下垂體-腎上腺皮質 hypothalamic-pituitary-adrenocortical interactions
- 交感神經-腎上腺 sympathoadrenal interactions
脊髓上反射 Suprasegmental reflex
- 痛刺激造成
- 交感神經興奮 (increased sympathetic tone)
- 增加catecholamine與分解代謝賀爾蒙分泌 (increased catecholamine and catabolic hormone secretion), 其中分解代謝賀爾蒙包含 cortisol, adrenocorticotropic hormone, antidiuretic hormone, glucagon, aldosterone, renin, angiotensin II
- 降低合成賀爾蒙分泌 (decreased secretion of anabolic hormones)
- 上述反應引起
- 鈉水滯留 (sodium and water retention)
- 血糖上升, 代謝產物如脂肪酸, 酮體, 乳酸增加 (increased levels of blood glucose, free fatty acids, ketone bodies, and lactate)
- 上述反應結果
身體處在一個分解代謝的狀態 (hypermetabolic, catabolic state), 增加氧氣消耗, 增加代謝, 延緩病患復原速度
高凝血狀態 Hypercoagulability
- 減少抗凝血因子 (natural anticoagulants), 增加凝血前驅因子 (procoagulants), 導致凝血
- 抑制血塊溶解 (fibrinolysis)
- 強化血小板活性 (platelet reactivity)
- 增加血液黏稠度 (plasma viscosity)
- 導致
- 深層靜脈栓塞 (deep venous thrombosis)
- 移植物失敗 (vascular graft failure)
- 心肌梗塞 (myocardial ischemia)
高血糖 Hyperglycemia
- 傷口癒合不良
- 免疫功能下降
交感神經興奮 Sympathetic activation
- 增加心肌耗氧 (increase myocardial oxygen consumption) 導致心肌缺血及梗塞 (myocardial ischemia and infarction)
- 延遲腸胃道蠕動恢復 (delay return of postoperative gastrointestinal motility) 造成麻痺性腸阻塞 (paralytic ileus)
有害的脊髓反射 Detrimental spinal reflex arcs
- 抑制膈神經活性 (inhibition of phrenic nerve activity)
- 容易在上腹部及胸腔手術 (upper abdominal and thoracic surgery) 發生
- 降低術後肺部功能, 導致呼吸變淺, 咳嗽不完全, 最後造成肺部併發症
慢性持續性術後疼痛 Chronic persistent postsurgical pain (CPSP)
- 以下為慢性持續性術後疼痛預測因子
- 術後急性疼痛控制不佳
- 術式: 截肢 (limb amputation, 30%-83%), 開胸 (thoracotomy, 22%-67%), 胸骨切開 (sternotomy, 27%), 乳房手術 (breast surgery, 11%-57%), 膽囊手術(gallbladder surgery, up to 56%)
- 術後痛覺敏感 (hyperalgesia, 將非傷害性感覺誤判為痛覺) 區域大小
- 術後疼痛程度
