Mengenal Nyeri

Andi Husni TanraKetua Program Studi Sp2 Ilmu anestesi

Fakultas Kedokteran Universitas HasanuddinMakassar

Kuliah perdana bagi peserta IPM ke-dua 7 Nov 2017 di Makassar

Pembahasan meliputi:

1. Sejarah singkat Anestesi dan IPM

2. Klasifikasi Nyeri

3. Apa itu Nyeri ? Pain perception?

4. Penutup

1. Short History of Anesthesia & IPM

Anesthesia was the first

applied science in the world

Before Eva was created from Adam’s rib,

Adam was put into sleep by Jibril

Drawn by Prof. HyodoLeader of pain clinic in Japan

First Ether Anesthesia in 1846 at Massachusetts HospitalWilliam T, Morton (left) holding globe inhalerJohn C Warren the SurgeonGilber Abbot the Patient

Di batu nisan Thomas, William G. Morton

di Massachusetts, Amerika Serikat

tertulis, disinlah berbaring:

• Penemu anestetik inhalasi.

• Atas jasanya, nyeri pembedahan dapat diatasi

• Sejak itu ilmu-pengetahuan telah mengontrolnyeri.

• Sebelum dia, pembedahan sebagai penderitaanyang luar biasa.

Charles Darwin pernah ditanyak, penemuan apa yang terbesar diabad 19?“Painless surgery” jauh lebih bermanfaat dari mesin uap atau telegaram yg ditemukan pd abad yg sama

What is Anesthesiology?

Anesthesiology is the practice of medicine dedicated to the pain relief and total care of the surgical patient before, during and after surgery.

Who is Anesthesiologist?

Anesthesiologists is a physician who focus on surgical patient and pain relief.

( perioperative pain management doctor)

1. Life Saving

2. Alleviate suffering

Two main role of anesthesiologists are:

History of Pain Managementand Critical Care Medicine

1960 an

1980an

History of Pain Management

John Bonica (1917-1994)Founding Father of Pain Management from Seattle

2010

First edition 1953

“Brian Ready “ pencetus Acute Pain Service dari

“Washington University” ,

Seattle USA 1988

He is Anesthesiologist from Washington University’s Hospital in Seattle

First Anesthesiologist who practice pain management in US. In 1990 Founder the Society for Pain Practice Management (SPPM). One of the leader of Intervention Pain Management.

Steven D. WALDMAN

ANESTHESIOLOGIST is a superman DoctorIS NOT JUST IN THE OPERATING ROOM

• Operating roomhospital

surgical center

• Labor & delivery suite

• Other procedural areas

• Intensive care unit (ICU)

• PACU

• Pain management

acute pain

chronic/ cancer pain

o Emergency Medicine

• “Code Blue” team

• Respiratory therapy

• Administration

operating room

hospital

medical school

• Education

health professionals

public

• Research

• ManagersCopyright © 2003 American Society of Anesthesiologists. All rights reserved

KepMenkes 779/Menkes/Sk/VIII/2008 ttgstandar pelayanan anestesiologi dan

reanimasi di rumah sakit

PERDATIN

Perhimpunan dokter spesialisAnestesi dan terapi intensif

Perhimpunan dokter spesialis Anestesi, Terapi Intensif dan Menejemen Nyeri

2. Classification of Pain

Pain

Tissue damage - inflammationor nociceptive pain

Nerve damage - neuropathyHeadache/periodCentral painCancer pain

Co-existence

AcuteChronic

Most accepted classification:1. Nociceptive pain (Acute pain)2. Inflammation Pain 3. Patological Pain

According to neuropathology, pain can be devided into 3 type

(by Cliford Woolf 2010)

PAIN

NociceptivePain

Inflammatory Pain

Pathological Pain

Neuropathic Pain Dysfunctional Pain

1.Nociceptive Pain

According to Neuropathology Pain can be Divided into 3 type

• Due to potential tissue damage

• To protect further damage

• E.g. touching something to hot, cold or sharp

• Also called physiological pain withdrawal reflex

• Activation of nociceptor by noxious stimulus nociceptive pain

• Adaptive and protective pain

Potential tissue damage Nociceptive pain withdrawal reflex protective mechanism

According to Neuropatology Pain can be Devided into 3 type

2. Inflammatory Pain

• Due to tissue damage and infiltration of immune calls.

• To pro more healing by causing pain hypersensitivity until healing occurs.

• Pain is one of the coordinal features of inflammatory.

• Adaptive and protective pain

2. INFLAMMATION PAIN

Clinical Signs:• Calor (heat)• Dolor (pain)• Rubor (redness)• Tumor (swelling)• Functio laesa (loss of function) Bimolecular changes

in inflammation

Pain may occur without noxious stimuli

Prostaglandin threshold nyeri

EP

receptor PKA

PKC

Increased

neuronal

membrane

excitability

PGE2

NaV1.8

TTx-resistant

sodium channel

Neuron

firing threshold

decreases

Tissue injury

COX-2 expressed

P

Spinal cord

Adaptive, high-threshold painEarly warning system ((protective))

Adaptive, low-threshold painTenderness promotes repair (protective)

PeripheralInflammationPositivesymptoms

NociceptionrSensory neuron

HeatColdIntense mechanical forceChemical irritants

MacrophageMast cellNeutrophilGranulocyte

Inflammation

Tissue damage

Noxious stimuli

Inflammatory pain

Nociceptive painA

B

Pain Autonomic response

Withdrawal reflex

Spontaneous painPain hypersensitivity

Modify by: AHT

Rational use of NSAID or Steroid

Pathological Pain

According to Patophysiology Pain can be Devided into 3 type

• Maladaptive pain and non protective pain

• This is not a symptom or protective pain but a disease state

Due to damage of nervus system

Neuropathic Pain Dysfunctional Pain

No damage of the NS

• Panthom pain• Herpetic neuralgesia• Trigemeanial neuralgesic• Diabetic neurophatic

• Fibromyolgia• IBS tension• Head achl• TMJ disease

Pathological Pain

Neuropathic Pain

• After damaging of the nervous system

Post limb amputation

Post herpetic neuralgia

Trigeminal neuralgia

Diabetic neuropathic

etc

Dysfunctional Pain

• No such damaging of the nervous system

Fibromyalgia

Irritable bowel synd.

Tension headache

TMJD, Interstitial cystitis

etc.

WRAMC Feb1, 2005

Is not a symptom but a disease of the nervous system

AbnormalCentral processing

Maladaptive, low-threshold painDisease state of nervous system

PeripheralNerve damage

Neural lesionPositive and negativesymptoms

Neuropathic pain

Spontaneous painPain hypersensitivity

Injury

Stroke

Modified by AHT

. Nyeri neuropatik;

Adalah nyeri yang terjadi akibat adanya kerusakanpada saraf, baik saraf perifer atau saraf sentral.Jadi nyeri akibat terjadinya disfungsi saraf baikperifer maupun sentral.

3. Nyeri Neuropatik

Burning, feeling like the feet are on fire

Stabbing, like sharp knives Lancinating, like electric shocks

Freezing, like the feet are on ice,

although they feel warm to touch

Modified by Meliala 2006

Gejala nyeri nya laindari biasanya

Stimulus-Response dari ke 3 jenis nyeri

Nociceptivepain

Inflammatorypain

Neuropathicpain

No stimulus

No stimulus

No stimulus

Responseduration

Responseduration

Responseduration

Pain

Pain

Pain

touch

touch

touch

NYERI NOSISEPTIF

NYERI INFLAMASI

NYERI PATOLOGIS

?Air Hangat

Api

Tanpa rangsangan

Analogi

Klasifikasi Nyeri

• 1. Menuru neurobiologinya dibagia atas

1.1. Nyeri nosisptif

1.2. Nyeri inflamasi

1.3. Nyeri patologik

- Nyeri neuropatik

- Nyeri disfungtional

• 2. Menurut durasinya dibagi; Akut dan Kronik

CJ. Woolf, J Clin Invest. 2010

Kesimpulan akademiknya

Dalam klinik nyeri hanya dibagi atas :

1. Menuru Jenisnya (Type nyeri)

1. Nyeri nosisptif

2. Nyeri neuropatik

2. Menurut durasinya dibagi; Akut dan Kronik

3. Menurut intensitasnya :

1. Nyeri ringan (mild pain)

2. Nyeri sedang (moderate)

3. Nyeri berat (seveare pain)

Kesimpulan klinik

3. Pain perception

Apakah orang ini merasa nyeri?

• Ada Rangsang kuat

• Ada Kerusakan jaringan

• wajahnya tidakmemperlihatkan kalau dianyeri. Tidak nyeri.

Bagm. menerangkannya?

Nociception without pain,There is a nociception but no Pain

Apakah pasien ini merasa nyeri?Tanpa suatu stimulus

Pain without nociception no nociception but pain

CRPS. (Complex RegionalPain Syndrome)

AllodyniaHiperlagesia

Bagaimana dengan pasien ini?

Wajahnya sangat nyeriTak ada lagi jaringan rusak. Sudah sembuh.

PHN Post Herpetic NeuralgiaVery painful, allodynia & Hiperalgesia

Pentingnya Nyeri Nosisepsi

• Pentingnya nyerinosiseptif dalamkehidupan manusiasebagai alat proteksidapat kita bayangkandengan melihatpenderta ini. Hidupnyatidak bisa panjangkarena tidak bisamerasa nyeri.

Congenital insensitivity to pain( chennelopathy)

Nyeri adalah suatu rahmat, tanpa sensasi nyeri,kita mudah mencederai diri kita tanpa sadar.

Kita tidak mengenal lagi istilahRangsang nyeri

• Yang ada hanyalah:

Rangsang kuat (Noxious Stimulus) dan

Rangsang lemah (innocuous Stimulus)

Cortex

Thalamus

MidbrainProjectionTo PGA

BrainstemReticularformation

Spinothalamic tract

Spinoreticular tract

Dorsal hornOf spinal cord

Cell body in DRG

Noxious stimulus

Sensory Location, intensity

Nociceptors

C fiber

A fiber

Nyeri Memiliki dua dimensi (inderawidan psikologis).

Pain perception Limbic System

EmotionalFear, anxiety

Nyeri Merupakan Output dari Otak

• Pain does not exist until the brain determines it does.

• Nyeri tidak akan dirasakan hingga otakmempersepsi bahwa ada nyeri Otak menggunakan peta virtual untuk mengarahkan

output nyeri ke daerah yang dicurigai dalam bahaya.

Proses ini merupakan komunikasi antara otak danjaringan tubuh sebagai pertahanan terhadap kerusakan

So far what we know is :

• We know that pain is processed in the Brain.

• How it processes, not clear yet.

• Do we have pain center in the Brain?

also not clear.

• Brain areas and structures that are involved in pain processing

What happen in the brain?

(Dillworth et al., 2012)

SomatoSensoryCortices (SSC1&2)

InsularCortex (IC)

PreFrontalCortex (PFC)

AnteriorCingulate

Cortex (ACC)

Thalamus

Hippocampu

s

Amygdala

Pain is Integrating of Sensory and Emotional experiences

Thalamus

Pre Frontal cortex

(PFC)

Hippocampus

Insular cortex(IC)

SomatosensoryCortex (S1 & S2)

Anterior Cingulated

Cortex (ACC)

Amygdala

SomatosensoryCortices

InsularCortex

PrefrontalCortex

AnteriorCingulate

Cortex

Thalamus

Signals from periphery and spinal cord

Hippocampus

Amygdala

SomatosensoryCortices

InsularCortex

PrefrontalCortex

AnteriorCingulate

Cortex

Thalamus

• Thalamus

– Primary relay center for transmission to somato-sensory and emotional signals

Hippocampu

s

AmygdalaSignals from periphery and spinal cord

• Anterior Cingulate Cortex (ACC)

– Affective/ emotional component • (e.g. sense of suffering)

SomatosensoryCortices

InsularCortex

PrefrontalCortex

AnteriorCingulate

Cortex

Thalamus

Hippocampus

AmygdalaSignals from periphery and spinal cord

• Prefrontal Cortex– Cognitive aspects of pain

• Meaning of pain, what to do about the pain

SomatosensoryCortices

InsularCortex

PrefrontalCortex

AnteriorCingulate

Cortex

Thalamus

Hippocampu

s

AmygdalaSignals from periphery and spinal cord

• Somatosensory Cortices– Primary (S1): Location of pain– Secondary (S2): intensity of pain

SomatosensoryCortices

InsularCortex

PrefrontalCortex

AnteriorCingulate

Cortex

Thalamus

Hippocampu

s

AmygdalaSignals from periphery and spinal cord

S1

S2

• Insular Cortex– Survival instinct– Active with the presence of threat

• Lack of oxygen, pain, low blood sugar

SomatosensoryCortices

InsularCortex

PrefrontalCortex

AnteriorCingulate

Cortex

Thalamus

Hippocampus

AmygdalaSignals from periphery and spinal cord

• Hippocampus (kuda Laut)

– Aversive input pain memory, menyimpan emosional

memory.

SomatosensoryCortices

InsularCortex

PrefrontalCortex

AnteriorCingulate

Cortex

Thalamus

Hippocampus

AmygdalaSignals from periphery and spinal cord

• Amygdala (almon) (penjaga emosi, perintahnya membuat kita tidak rasional, membajak

otak)

– Excecution decision, what to do due to pain

– Emotional reaction to pain

SomatosensoryCortices

InsularCortex

PrefrontalCortex

AnteriorCingulate

Cortex

Thalamus

Hippocampus

AmygdalaSignals from periphery and spinal cord

Pain : From simplicity to complexity

Rene Descartes 1649

EmotionalSensory

Cognitive

Tracey & Mantyh 2007

16th Century

21st Century

Prior experiences

Attention Mood (Psychological

state)

Ecpectation

The meaning

of pain

PainExperience

Noxiousstimulus

Attention

Attention

Psychological state

Expectation

Reagan Was shot 21” before taken this picture

The meaning of pain

Penutup

• Nyeri adalah penggabungan perasaan sensorikdan emosional yang dipengaruhi olehberbagai faktor.

• Nyeri memiliki dua dimensi yg jelas, dimensiinderawi dan emosional

• Peran dimensi emosional lebih dominandibanding inderawi utamanya pada nyerikronik.

Sekian

• Terimakasih, semoga adamanfaatnya.

• Wassalamu al w.w.