056029 Handan, Hebei Affiliated Hospital of Hebei University of Engineering Shi Jiyue
Abstract: This article reflects on the limitations of traditional postoperative analgesia clinical thinking, and applies practical thinking theory to explore the clinical treatment of postoperative systemic inflammatory response syndrome (SIRS) and various radical cancer surgery perioperative metastases through PA treatment And research feasibility.
Postoprative analgesia (PA) is a clinical treatment measure that every surgical patient must take. With the clinical promotion of patient-controlled analgesia (PCA) technology, anesthesiologists are widely involved in PA treatment, making PA gradually become a multidisciplinary Participation, the status quo of perioperative treatment with new technologies and new drugs widely used. At the same time, the theory of evidence-based medicine has challenged the traditional clinical thinking based on basic and clinical medical knowledge and based on patient complaints. In addition, contemporary clinical medicine emphasizes all patient-centered "humanized" medical models. , All require reflection on the traditional postoperative analgesia clinical thinking methods, explore new clinical thinking strategies, and further improve the level of PA research and clinical treatment.
1. Limitations of traditional PA clinical thinking
Traditional clinical thinking is a process of using basic medical knowledge and clinical medical knowledge to comprehensively analyze clinical data, logically reason, and find and resolve major contradictions from intricate clues. Surgeons or anesthesiologists have developed a cheerful, straightforward, unrestrained personality and decisive, confident, clean, and resolute clinical thinking characteristics due to their own work characteristics, which determine that they are prone to over-relying on their own experience in clinical work to produce rash or arbitrary Thinking, coupled with the fact that some physicians currently focus on clinic and ignore theory, make their clinical thinking mainly based on perceptual knowledge and self-experience summary, and not pay much attention to rational knowledge and clinical thinking methods . For example, most surgeons or anesthesiologists believe that post-operative pain is a group of symptoms commonly or inevitably experienced by surgical patients. The good analgesic effect of narcotic analgesics can minimize or eliminate the discomfort, plus the surgical patients themselves The understanding of the inevitability of postoperative pain is less demanding of postoperative pain, which makes relevant physicians face the “big problems” that directly affect postoperative recovery, such as postoperative infection, electrolyte and acid-base balance imbalance, etc. The treatment of postoperative pain appears to be simple, even if it is a major and difficult operation, it is still simply treated with the "Hibernation Series" widely used in surgical clinics for decades. However, this traditional method of intermittent intramuscular injection of narcotic analgesics based on the main complaint of patients, about 75% of patients still have moderate to severe postoperative pain. This is because after intramuscular injection of opioids, the body's blood drug concentration changes or drug metabolism shows "mountain" changes. When the blood drug concentration is in the trough or intermittent period, patients have to tolerate different degrees of pain and torture. When the concentration reaches its peak, the side effects of narcotic analgesics can occur. In addition to individual differences, serious clinical complications are heard from time to time. For example, 6 hours after transurethral prostatic hyperplasia transurethral resection of an elderly man weighing 85 kg and coronary heart disease, the bladder drainage tube was irritating and painful. The on-duty doctor only injected 2 mg of morphine intramuscularly, which caused severe respiratory depression and cardiac arrest. Full recovery and rescue still survive in a vegetative state.
Reflecting on the traditional thinking method of postoperative analgesia in clinical medicine, it is believed that the biggest characteristic of its thinking is its clear direction and specificity. This also determines the limitations of traditional postoperative analgesia. This limitation is manifested by surgeons who rely on intuition or experience in understanding postoperative pain. Especially in recent years, with the application of medical electronic engineering technology and biomedical engineering in surgical treatment of diseases, surgical "forbidden areas" are no longer Existence, the main energy of surgeons is to study the fully detailed theories and skills to improve the level of diagnosis and treatment of their own professional diseases, and the PA with "mature" experience is often programmed, intuitive thinking or even not doing any clinical Thinking for processing. For anesthesiologists who take the responsibility of eliminating surgical pain and safeguarding the lives of surgical patients as their own responsibility, their understanding of pain, that is, their understanding of the harm of pain to the body, has far exceeded that of surgeons, but they can not only control the pain and stress during surgery on the body. The impact of functional and physiological functions, and the treatment of postoperative pain, both theoretically and clinically, have proposed unique theories and techniques. However, anesthesiologists have been in the perioperative period as an auxiliary or tertiary subject for decades. The treatment is still passive. Both basic research and clinical experience are often limited to the study of pain damage mechanisms or the evaluation of the external manifestations of pain. It rarely involves the comprehensive understanding of surgical patients. Therefore, although the basis of postoperative pain Significant achievements in clinical research, but still limited to the scope of tertiary disciplines, there are few theories and methods recognized by related majors, and directly affect the promotion of PCA technology.
2. The status of PA in postoperative treatment
At present, it is believed that postoperative pain and discomfort, patients dare not cough, cannot turn over, sit up and get out of bed on their own, which delays the recovery of gastrointestinal and bladder functions, prolongs eating time, and affects wound healing; makes lungs functional Residual air volume, abnormal ventilation blood flow ratio, decreased lung compliance and diaphragm function, and increased respiratory complications. At the same time, postoperative pain is the continuation or external manifestation of the body's stress response caused by surgical trauma. This stress response triggers the body's sympathetic nervous system, adrenal cortex-pituitary-inferior hindbrain reflex, and causes obvious neuroendocrine dysfunction. The release of norepinephrine, epinephrine and adrenal cortex hormones increases, the level of glucagon increases, the sensitivity to insulin is significantly reduced, and the blood sugar increases, but the utilization of sugar decreases. The body is in a state of decomposition with increased energy consumption and tissue destruction. The body's hypermetabolic state and autonomic hyperfunction increase the heart rate and increase the work of the heart; it causes the coagulation and fibrinolysis system to become dysfunctional, resulting in a hypercoagulable state and thrombosis. Muscle tissue loss, immune suppression, etc. In addition, tissue damage caused by surgical trauma or postoperative pain can activate cytokines or the complement system, and release tumor necrosis factor, interleukin system, acute reactive protein, prostaglandins, oxygen free radicals, etc. Moderate stress is the body's defense response The inevitable manifestation of the disease, but the excessively strong and long-lasting stress response makes the body's inflammatory response unbalanced, induces SIRS, causes organ dysfunction, and even causes multiple organ dysfunction syndrome to cause death of the patient. Therefore, it is considered that the reduction operation In addition to the patient's condition and other reasons, postoperative pain and its stress response are the key factors that cause postoperative complications . In this regard, the traditional PA clinical thinking, which has obvious limitations, cannot comprehensively eliminate or alleviate the harm of postoperative pain to the body.
Evidence-based medicine is defined as: "Carefully, accurately and wisely apply the best and most credible research evidence currently available, combined with the clinician’s personal professional skills and years of clinical experience, while taking into account the patient’s value and wishes The three are perfectly combined to formulate the most suitable treatment measures for patients". Based on this concept, the current PA further shows the one-sidedness and specificity of traditional intramuscular pethidine analgesia, even in clinical anesthesia The popularized PCA can basically eliminate the patient’s postoperative pain in theory, significantly alleviate the body’s stress response, and reduce postoperative complications. However, it is not difficult to find that most of the PCA formulations are still targeted for surgery in clinical practice. Symptomatic treatment of postoperative pain, and some studies have confirmed that PCA may be effective in alleviating the stress response of postoperative pain, but the conclusions drawn from the pain-centric perspective have not touched the evolution of the overall physiological function of the body after surgery. From the above discussion of postoperative pain on the overall damage to the body and the recognition of the limitations of traditional PA clinical thinking, the status of PA in postoperative treatment is evaluated, and it is necessary to explore new clinical thinking methods and research new clinical treatment strategies before going further Improve the clinical treatment and research level of PA, so that PA can play its core role in perioperative treatment.
3. PA's practical thinking
Practical thinking is a philosophical thinking that starts from the most essential and closest basis of thinking-the practical activities of human society. Marx pointed out: "The main shortcoming of all previous materialisms (including Feuerbach’s materialism) is that the object, reality, and sensibility are understood only in the form of object or intuition, instead of treating them as sensibility. Human activities are understood as practice, not from the subject. Therefore, contrary to materialism, the dynamic aspects are abstractly developed by idealism. Of course, idealism does not know the reality and perceptual activity itself. .” In other words, it is necessary to regard objective existence as the objectification of the essence of the subject, and incorporate human social practice into the essential understanding of the objective object.
According to this concept, the postoperative pain should be considered in the overall treatment of rehabilitation treatment of surgical patients, that is, the overall impact of PA methods or drugs on the body's physiological or pathophysiological functions during the rehabilitation of postoperative patients is measured and considered. Based on the current PA basic and clinical research data, applying practical thinking methods believe that there are at least three issues that can highlight the role of PA in perioperative treatment:
1. Patient-centered "humanized" PA: According to the method of practical thinking and the theory of evidence-based medicine, it is not difficult to find that the deficiency of traditional PA is the lack of the overall impact of postoperative pain on the patient. To understand the nature of postoperative pain from a holistic perspective, we must first confirm that the postoperative pain is a "social person" rather than a diseased "organism". The pain is not only affected by the degree of trauma and condition, but also related to society and society. Economy, culture and life experience are related, and different PA methods must be selected according to their willingness or needs to seek medical treatment; secondly, PA should respect the social dignity and power of patients, that is, trauma and surgery patients have the right to be free from pain and maintain image dignity; The third is the need to maintain the mental health of surgical patients, eliminate tension, fear, and anxiety caused by surgical pain, and promote the recovery of the disease. Therefore, PA not only needs narcotic analgesics to eliminate or relieve pain, but also needs "humanized" life care and psychological control guidance, etc., to eliminate or relieve postoperative pain from the improvement of overall medical care services.
2. Prevention and treatment of PA and SIRS: The core of practical thinking is to look at the essence through the phenomenon, while the surface phenomenon of PA is to eliminate or relieve the pain caused by surgical trauma, and the essence of postoperative pain is the external defense response of the body caused by tissue damage caused by surgical trauma. In performance, its essence is the continuation of the stress response, which is the external manifestation of the body's inflammatory response and anti-inflammatory response. Research data in recent years have confirmed that PCA can help reduce postoperative stress response, inhibit the release of tumor necrosis factor (TNF), interleukin (IL) series of inflammatory cytokines, etc., thereby reducing postoperative inflammatory reactions [5-7]; Critical care medical research data during the same period confirmed that SIRS is an infection or non-infectious factor that acts on the body, causing a large amount of inflammatory cytokines to be released, causing a systemic inflammatory response caused by an imbalance of inflammation and anti-inflammatory reactions, resulting in a series of clinical symptoms [1, 8-10 ], the author’s clinical studies in recent years have shown that effective PA can help reduce or eliminate postoperative SIRS. Because different anesthetic analgesics have different effects on cytokines or immune responses in patients with postoperative pain, PCA has different formulations. The effects of preventing and treating SIRS are different in critically ill patients. Among them, local anesthetics combined with fentanyl and midazolam for epidural PCA are the most effective methods to prevent and treat SIRS through PA.
3. Prevention and treatment of metastatic invasion of PA and perioperative cancer treatment: Practical thinking is the sublimation of reflective thinking. The essential difference between it and traditional clinical thinking is the correctness of thinking from the comprehensive analysis of results. Radical cancer surgery is the main body of current clinical surgical treatment. Radical cancer surgery, as its name implies, completely eradicates cancerous lesions or tissues and prolongs the lives of patients. Although surgical skills have improved significantly at present, there is no radical operation in the true sense. Interference and squeezing of cancer during surgery is the main reason for postoperative metastasis or invasion. In recent years, studies have shown that cyclooxygenase-2 (COX-2) is highly expressed in gastrointestinal cancer, breast cancer, ovarian cancer and other cancers and cancer tissues. Further research suggests that COX-2 can inhibit cancer cell apoptosis and promote blood vessels in cancer tissues. Regeneration and other aspects play an important role[11,12], while the results of the PCA study during the same period showed that COX inhibitors such as lornoxicam and rofecoxib were used for preemptive analgesia and PA in surgical patients and achieved good results Therefore, the author believes that the use of COX inhibitors in the perioperative period, especially the COX inhibitor PA, may be an effective way to prevent cancer metastasis and invasion.
In summary, traditional intramuscular analgesics and current PCA clinical thinking have different degrees of limitations, and practical thinking combined with evidence-based medicine theory will open up new thinking space for PA clinical thinking, from the overall treatment needs of patients Improve PA's medical care service level.