Management of Acute Pain
ANLS 2012
JAKARTA, 5-6 JANUARI 2013
Definition Pain
“An unpleasant sensory and emotionalexperience associated with actual orpotential tissue damage or describedin term of such damage”
International Association forthe Study of Pain,(IASP), 1986
Klasifikasi Sindroma Nyeri
Nociceptive
Duration Pathophysiology
mixed Neuropathic
Somatic Visceral Peripheral Central
-superficial-deep
-Acute : < 3-6 months, mostly nociceptive-Chronic : > 3-6 months, mostly neuropathic
Acute Chronic
idiopatik
Klasifikasi Nyeri• Nyeri sederhana/fisiologik
nyeri timbul oleh berbagai stimuli yang tidak menimbulkan kerusakan jaringan
• Nyeri patologis/klinis
1. nyeri inflamasi (nyeri akut/nyeri nosiseptik)
nyeri timbul oleh berbagai stimuli yang me-
nimbulkan kerusakan jaringan.
2. nyeri neuropatik : nyeri krn lesi primer atau
disfungsi sistem saraf perifer atau sentral
3. nyeri idiopatik/psikogenik : nyeri yg kausanya
tidak jelas
Nociceptive
Psy
cho
logi
cal pain
ab
Haddox, 1990; Mariano, 2001
Physical state
Perception
nociceptor Reflex action
environment
Affect/mood
Evaluation
Memory &expectation Actions
Response
Symptoms &signs
Painful : Non-Painful :
Diagram Nyeri (Farrar.J.T)
BERDASARKAN INTENSITAS NYERI(Numeric Pain Rating Scale)
INTENSITAS NPRS
NYERI RINGAN 1 - 3
NYERI SEDANG 4 - 7
NYERI BERAT 7 - 10
Faces Pain Rating Scale (untuk anak)
VISUAL ANALOG SCALE (VAS)
NUMERIC PAIN RATING SCALE (NPRS)
• Post-operative Pain
• Traumatic injury-related Pain
• Burn Pain
• Acute Herpes Pain
• Acute Pain in Obstetrics
• Sickle Cell Pain
• Cancer-related Pain
Kausa Sindroma Nyeri
• Headache
– Musculoskeletal : muscle tension
– Vascular : migraine, aneurysm
– Complex : compound headache
• Musculoskeletal Pain (back pain)
• Ischemic Pain
• Chest Pain
– Angina/ischemia
– Esophagitis/reflux
– Pleuritic pain : effusion, pneumonia, inflammation
Kausa Sindroma Nyeri .. 2
• Abdominal Pain
– Acute exacerbation of Pancreatitis
– Acute abdomen : perforation, obstruction, aneurysm dissection/rupture
– Renal colic
• Neurogenic Pain
– Herniated disk
– Nerve compression
Kausa Sindroma Nyeri .. 3
ExamplesPeripheral
• Postherpetic neuralgia
• Trigeminal neuralgia
• Diabetic peripheral neuropathy
• Postsurgical neuropathy
• Posttraumatic neuropathy
Central
• Poststroke pain
Common descriptors2
• Burning
• Tingling
• Hypersensitivity to touch or cold
Examples
• Pain due to inflammation
• Limb pain after a fracture
• Joint pain in osteoarthritis
• Postoperative visceral pain
Common descriptors2
• Aching
• Sharp
• Throbbing
Examples
• Low back pain with
radiculopathy
• Cervical radiculopathy
• Cancer pain
• Carpal tunnel syndrom
Mixed PainPain with
neuropathic and
nociceptive
components
Neuropathic PainPain initiated or caused by a
primary lesion or dysfunction
in the nervous system
(either peripheral or
central nervous system)1
Nociceptive PainPain caused by injury to
body tissues
(musculoskeletal,
cutaneous or visceral)2
1. International Association for the Study of Pain. IASP Pain Terminology.
2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
Kausa Nyeri (Patofisiologi)
Lumbar
vertebra
Disc herniation
Activation of peripheral nociceptors –
cause of nociceptive pain component
Compression and inflammation of nerve root –
cause of neuropathic pain component
LBP & Lumbal Radiculopati
karena HNP (mixed Pain)
Iskemik, SpasmeCedera, dll
Nosiseptor free nerve
ending
HistamineK*, bradikininProstaglandin
5-HT
Mekanisme Rasa Nyeri
NAPCornu
dorsalis
A myelin/fastC unmyelin/slow
Substanse P
Platelet - serotoninMass cell - histamin
1. Transduksi2. Transmisi3. Persepsi4. Modulasi
GABA, GlycineAdenosineBombesinCholecystokininDynorphinEnkephalinNeuropeptide-Y
KortekTalamus
1
23 4
Jenis-jenis Serabut SarafFiber type Function Ø fiber
(mm)Conduction
velocity (m/s)Hypoxia Pressure LA
Aα Propriception somatic motor
12-20 70-120 ++ +++ +
Aβ Touch, pressure 2-12 30-70
Aγ Motor to muscle spindle
3-6 15-30
Aδ Pain,cold, touch 2-5 12-30
B Preganglionic otonomic
<3 3-15 +++ ++ +
C dorsal root Pain, temperature mechanoreception, reflex response
0.4-1.2 0.5-2 ++ ++ +++
Csimpatetik
Postganglionic sympathetic
0.3-1.3 0.7-2.3
A and B fibers are myelinated, C : fibers unmyelinated, LA : local anesthetic+: least susceptible, ++ : intermediated susceptibility, +++ : most susceptible
Dorsal HornDorsal root
ganglion
Peripheral sensory
Nerve fibers
A
A
C
Large
fibers
Small
fibers
Sensory Afferent Neurons1. Large myelinated Aβ fibers, very fast conduction velocity,
respond to innocuous stimuli.2. Small myelinated Aδ & C unmyelinated fibers, have slow
conduction velocity, respond to noxious stimuli
Dapat dibagi menjadi 4 tahap yaitu :
1. Tranduksi : proses timbulnya aktivitas listrik krn stimulasi noksius pd reseptor “nerve ending”
2. Transmisi : menjalarnya impul nyeri dr nosiseptor aferen primer(NAP) ke kornu dorsalis med spinalis
3. Persepsi : Impul rasa nyeri diterima talamus kmd diproyeksikan ke kortek somatosensorik & kortek asosiasi timbul kesadaran rasa nyeri
Mekanisme Rasa Nyeri
4. Modulasi : aktivitas selektif sel saraf untuk meng-hambat transmisi rasa nyeri via serabut saraf Aδ, medula spinalis, medula oblongata & midbrain. Ada 2 teori modulasi,
a. Gate control hypothese - modulasi nyeri saraf asenden yaitu jika serat saraf C di aktivasi terjadi inhibisi inter-neuron pintu nyeri akan terbuka, jika serat saraf Aδ di aktivasi terjadi eksitasi interneuron pintu nyeri akan tertutup
b. Sistem opioid endogen - modulasi nyeri saraf desenden berasal dari :
Mekanisme Rasa Nyeri .. 2
midbrain
med.obl
(a)
(b)
(b)
med.spin (c)
a. Midbrain : periaquaduct gray-matter (PAG) mengandung μreseptor yg dpt mengaktivasi opioid endogen.
b. Medula oblongata, di :- nucleus raphe magnus (NRM)
melepas serotonin.- NPRG (nucl reticularis para
giganto cellularis) melepas noradrenalin
c. Cornu dorsalis Med spinalis, dapat menghambat trasmisi nosiseptor.
Rasa nyeri ↓ atau menghilang.
2: Nosiseptor melepas substance P pemb drh
melebar & dilepas media-tor inflamasi yi Bradykinin
(redness and heat)
3: Substance P juga me-rangsang degranulasi mass
cells, dilepas zat histamin (swelling)
Pain-sensitive tissue
Painful stimulus
Prostaglandin
Substance P
Histamine
Mast cell
Blood vessel
Bradykinin
Nociceptor
Substance P
23
1
1: cedera jaringan merang-sang pembentukan prosta-
glandin sensitivitas no-siseptor ↑ (pain)
Mekanisme Rasa Nyeri
S
P C
I O
N R
A D
L
Lateral
thalamus
kortek
somasensorik
ACTH
associative
cortex
medial
thalamusreticular
formation
hypothalamus
Mediator Humoral
Perifer
Interleukin 1 & 2
TNF/tumor necr F
Bradykinin
α interferon
PGE1,PGE2, etc
Pituitary. gl
sympatic
Nerv syst
adrenal
gland
pancreas
spinothalamic
neospinothalamic
spinoreticular paramedian
propiomelano-
cortin
growth horm
prolactin
vasopressin
Nor-eph
Epineph
Enkephalins
Aldosterone
cortisol
glucagon
β endorphin
Affect
Sensation
Corticotropin-releasing factor
Vasoactive-intestinal peptide
Post-Injury Stress Response
Metabolic and Endocrine responses to injury
↑ACTH, cortisol , ADH, growth H,Catecholamine, angiotensin II, aldosterone, glocagons, IL-1, TNF, IL-6
↑catabolic hormonsEndocrine
↓insulin, testosterone↓anabolic hormons
Metabolic
↑glycogenolisis, gluconeogenesis(cortisol, glucagon, growth H, adrenalin, free fatty acid). ↓insulin secretion/activation.
Hyperglycemia, glucose intolenrance, insulin resistence
carbohydrate
↑cortisol, adrenalin, glucagon, IL-1, IL-6 dan TNF.
Muscle prot catabolism↑synthesis of acute phase proteins
Protein
↑catecholamine, cortisol, glucagon, growth H.
↑lypolysis & oxidationLipid
Metabolic and Endocrine responses to injury .. 2
↑catecholamine, aldosterone, ADH, cortisol, angiotensin II, prostaglandin and othersfactors.
retention of water and sodium. ↑ excretion of potassium, ↓functional ECF with shifts to ICF
water and electrolyte flux
Note: ICF - intracellular fluid, EC F- extracellular fluid, TNF - tumor necrosis factor
Source: acute pain management; the scientific evidence (NHMRC, 1999)
Gejala klinikNyeri Nosiseptif Akut
• Onset mendadak• kualitasnya tajam, tertikam, tertusuk• Lokalisasi• Self-limiting• mungkin ada manifestasi fisiologis dgn berbagai
sistem organ yg lain.• Response Autonom: palpitasi, ↑tekanan darah,
berkeringat , etc• Biasanya kausa jelas• Dipengaruhi keadaan fisiologis
KarakteristikNyeri Somatik Dalam
• kualitas nyeri : tumpul dan sakit
• kurang terlokalisir dibanding nyeri superfisial
• berhubungan dgn hiperalgesia kutaneus, allodinia, lemas, reflek otot spasme , hiper-aktivitas simpatis.
Tatalaksana Nyeri Akut
• Tujuan : mencegah nyeri akut menjadi kronik
– Terapi nyeri akut harus adekuat
– Cegah “yellow flags”
• Terapi
– Kausal : merawat luka, reposisi dan fiksasi fraktur, operasi.
– Farmakologik : analgetik opioid, non-opioid, analgetik ajuvan (AED, antidepresan, dll)
– Non Farmakologik : terapi fisik, psikologis, dll
Cegah Nyeri Akut Jadi Kronik
Acute(nociceptive)
Chronic (neuropathic)
Biologicalfunction (+)
Biological function (-)
Avoidtissue damage
disadvantage
Psychological *triad :
Physical*impairment*disablity
Pain
MoodSleep
> Dysfunction ↓QoL> Socioeconomic loss
Advantage*health*well being
Terapi adekuat :-Cegah nyeri kronik-Cegah Yellow Flag
Kausal :
• Medis
– Antibiotika
– Kemoterapi
– radioterapi
• Surgical
– Perawatan luka
– Operasi/mengangkat tumor
– Fiksasi/operasi fraktur
Tatalaksana Sindroma Nyeri
• Terapi farmakologik :
– Analgetik non opioid
– Analgetik opioid
– Antikonvulsan
– antidepresan
• Terapi non-farmakologik :
– neurostimulasi (TENS),
– psikologis (kognitif behavior, relaksi, hipnosis).
• Terapi invasif/operasi
– Perawatan luka
– Fiksasi/operasi fraktur
Tatalaksana Sindroma Nyeri .. 2
Prinsip Terapi Nyeri Akut & BeratBeri analgesik dosis maksimal
Alur Terapi Nyeri Kronik(WHO ANALGESIC LADDER 1996)
Non opioid +/- Adjuvant
Opioid for mild to moderate pain+/- Non opioid , +/- Adjuvant
Opioid for moderate to severe pain+/- Adjuvant
Step 1
Step 2
Step 3
Persisting Pain
Persisting Pain
Freedom from pain
Farmako Terapi Nyeri Inflamasi
NYERI RINGAN
FARMAKOTERAPI TINGKAT I
Nama Obat Dosis Jadwal
Aspirin 325-650 mg, mak 4 g/hr 4 jam sekali
Asetaminofen 325-650mg 4-6 jam sekali
FARMAKOTERAPI TINGKAT II
Ibuprofen 200mg 4-6 jam sekali
Sodium Naproxen Awal 440mg, selanjutnya 220mg 8-12 jam sekali
Ketoprofen 12,5mg 4-6jam sekali
Farmako Terapi Nyeri Inflamasi .. 2
NYERI SEDANG
FARMAKOTERAPI TINGKAT III
Nama Obat Dosis Jadwal
AsetaminofenPenyesuaian dosisi misal
Aspirin 1000mg
4 jam sekali
Ibuprofen 4-6 jam sekali
Sodium naproxen 8-12 jam sekali
Ketoprofen 4-6 jam sekali
FARMAKOTERAPI TINGKAT IV
Jika terapi tk. III, OAINS yg dipilih dapat diganti, pilihan OAINS ke-2 sebaiknya drkelompok kimia yg berbeda (lihat tabel analgesik non-opioid yg sering digunakan
FARMAKOTERAPI TINGKAT V
Opioid (misal : codein)
FARMAKOTERAPI TINGKAT VI
Tramadol 50-100mg 4-6 jam
Farmako Terapi Nyeri Inflamasi .. 3NYERI BERAT
FARMAKOTERAPI TINGKAT VII
Nama Obat Indikasi Mekanisme
Morfin Bila th/ non-narkotik tdk efektif dan terdapat riwayat th/ narkotik untuk nyeri
4 jam sekali
Campuran agonis -antagonis pentazosin
Blok aktivasi komponen mμkomplek reseptor
Agonis parsial idem
Analgetik Non Opioid yang Paling Sering Digunakan
Nama Obat Dosis Jadwal
Aspirin 325-1000mg 4-6 jam sekali
Kalium diklofenak 50-200 mg 8 jam sekali
Natrium diklofenak 50 mg 8 jam sekali
Ibuprofen 200-800 mg 4-8 jam sekali
indometasin 25-50 mg 8-12 jam sekali
Ketoprofen 25-75 mg 6-12 jam sekali
Asam Mefenamat 250 mg 6 jam sekali
naproxen 250-500 mg 12 jam sekali
Nama Obat Dosis Jadwal
Piroxicam 10-20 mg 12-24 jam sekali
Tenoxsicam 20-40 mg 24 jam sekali
Meloxicam 75 mg 24 jam sekali
Celecoxib 100 mg 12 jam sekali
Nimesulfid 100 mg 12 jam sekali
Ketoralax 10-30 mg 4-6 jam sekali
Asetaminofen 500 mg 6-8 jam sekali
Tramadol 50-100 mg 8 jam sekali
Analgetik Non Opioid yang Paling Sering Digunakan .. 2
Jenis Obat Pot Equal-analgesic Keterangan
Oral parenteral
Morphine 30mg 10mg Long acting oral 8-12 jam yg dpt diberikanrektal, hati-hati pd pts CRF dpt myoclonus
hydromorphone 7.5mg 1.5mg Opioid poten, bisa utk pts disfungsi renal
Oxycodone 20mg - Long acting diberikan o/rectal/8-12jam
Methadone 5mg ** Waktu paruh >24jam, penyesuaian dosisharus hati2, diberikan 6-8 jam utk th/ nyeri, dipakai utk nyeri neuropatik, ratio equal analgesik berubah dg dosis morphinoral >100mg, konsul spesialis
Derby, 1998 American Pain Society, Principles of Analgesic Use in theTreatment of Acute Pain and Cancer Pai, 5th edition, 2003
Analgesik Opioid
Jenis Obat Pot Equal-analgesic Keterangan
Oral parenteral
Levorphanol 4mg 2mg Poten opioid dgn bbrp aktivitas NMDA antagonis
Meperidine 300mg 75mg Metabolisme normoperidine, stimulan CNS, dpt menimbulkan kejang pd pts dgn gagalginjal.
Fentanyl *** - 100mcg Short-acting, bisa patch transdermal danbuccal
Codein 200mg 130mg 5-10% ras kaukusia tdk bisa merubah codeinke morphin, SE nausea dan konstipasi > dpopioid lain, efek narkose pd pts gagal ginjal
Hydrocodone 30mg - Sering dikombinasi dgn analgesik non-opioid,
Derby, 1998 American Pain Society, Principles of Analgesic Use in theTreatment of Acute Pain and Cancer Pai, 5th edition, 2003
Analgesik Opioid .. 2
Non Farmakologi
1.Physical treatment
- Heat: diathermy, ultrasonic.
- Cold: compress, ice massage, vapo-coolant spray.
- Massage
- Exercise
- Ortosis.
- TENS, accupuncture.
2. Psychological therapy
Relaxation, biofeedback, education, hypnosis.
Spinal Cord Stimulator
SCS - equipment
Kesimpulan
1. Nyeri akut adalah respon fisiologis atasstimulasi noksius (mengancam/merusakjaringan atau tubuh).
2. Persepsi nyeri bersifat individual, dasarmekanisme fisiologisnya sangat komplek
3. Tatalaksana nyeri kronik/neuropatik ber-sifat multidisiplin meliputi terapi farmasinon farmasi, dan terapi bedah.
www.physiologyonline.org
• Nyeri akut: mekanismetubuh utk melindungi & mencegah, supaya jaring-an yang cedera tdk ber-tambah parah, jaringantsb dibatasi kemampuangerak/mobilitasnya.
• Waktu berkisar 1-3 bulan
• Th/ jika tidak adekuatCHRONIC PAIN
Nyeri Nosiseptive (Akut)
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