Management of Acute Pain

ANLS 2012 JAKARTA, 5-6 JANUARI 2013

Definition Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage
International Association for the Study of Pain,(IASP), 1986

Klasifikasi Sindroma Nyeri

Pathophysiology

Duration
Acute Chronic

Nociceptive
Somatic
-superficial -deep

mixed

Neuropathic
Peripheral Central

idiopatik

Visceral

-Acute : < 3-6 months, mostly nociceptive -Chronic : > 3-6 months, mostly neuropathic

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 menimbulkan 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

Haddox, 1990; Mariano, 2001

Psychological

pain

b
Nociceptive

Diagram Nyeri
(Farrar.J.T)
Physical state nociceptor Perception Memory & expectation Affect/mood environment Reflex action

Response

Actions
Symptoms & signs

Evaluation Painful : Non-Painful :

BERDASARKAN INTENSITAS NYERI (Numeric Pain Rating Scale)

INTENSITAS NYERI RINGAN NYERI SEDANG NYERI BERAT NPRS 1-3 4-7 7 - 10

VISUAL ANALOG SCALE (VAS)

NUMERIC PAIN RATING SCALE (NPRS)

Faces Pain Rating Scale (untuk anak)

Kausa Sindroma Nyeri

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 .. 2

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 .. 3

Abdominal Pain
Acute exacerbation of Pancreatitis Acute abdomen : perforation, obstruction, aneurysm dissection/rupture Renal colic

Neurogenic Pain
Herniated disk Nerve compression

Kausa Nyeri (Patofisiologi)

Neuropathic Pain
Pain initiated or caused by a primary lesion or dysfunction in the nervous system (either peripheral or central nervous system)1 Examples
Peripheral Postherpetic neuralgia Trigeminal neuralgia Diabetic peripheral neuropathy Postsurgical neuropathy Posttraumatic neuropathy Central Poststroke pain Common descriptors2 Burning Tingling Hypersensitivity to touch or cold

Mixed Pain
Pain with neuropathic and nociceptive components

Nociceptive Pain
Pain caused by injury to body tissues (musculoskeletal, cutaneous or visceral)2

Examples

Examples

Low back pain with

radiculopathy Cervical radiculopathy Cancer pain Carpal tunnel syndrom

Pain due to inflammation Limb pain after a fracture Joint pain in osteoarthritis Postoperative visceral pain

Common descriptors2 Aching Sharp Throbbing

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

LBP & Lumbal Radiculopati karena HNP (mixed Pain)

Disc herniation Activation of peripheral nociceptors cause of nociceptive pain component

Lumbar vertebra

Compression and inflammation of nerve root cause of neuropathic pain component

Mekanisme Rasa Nyeri

Iskemik, Spasme Cedera, dll 1
Nosiseptor free nerve ending A myelin/fast C unmyelin/slow

Kortek Talamus
Cornu dorsalis

NAP

Substanse P
Platelet - serotonin Mass cell - histamin 1. Transduksi 2. Transmisi 3. Persepsi 4. Modulasi

Histamine K*, bradikinin Prostaglandin 5-HT

GABA, Glycine Adenosine Bombesin Cholecystokinin Dynorphin Enkephalin Neuropeptide-Y

Jenis-jenis Serabut Saraf

Fiber type A A Function Propriception somatic motor Touch, pressure fiber (mm) 12-20 2-12 Conduction velocity (m/s) 70-120 30-70 Hypoxia ++ Pressure +++ LA +

A
A B

Motor to muscle spindle

Pain,cold, touch Preganglionic otonomic

3-6
2-5 <3

15-30
12-30 3-15 +++ ++ +

C dorsal root Pain, temperature mechanoreception, reflex response C simpatetik Postganglionic sympathetic

0.4-1.2

0.5-2

++

++

+++

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

Sensory Afferent Neurons

1. Large myelinated A fibers, very fast conduction velocity, respond to innocuous stimuli. 2. Small myelinated A & C unmyelinated fibers, have slow conduction velocity, respond to noxious stimuli
Large fibers A

A
Small fibers C Peripheral sensory Nerve fibers

Dorsal root ganglion Dorsal Horn

Mekanisme Rasa Nyeri

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 .. 2

4. Modulasi : aktivitas selektif sel saraf untuk menghambat transmisi rasa nyeri via serabut saraf A, 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 interneuron pintu nyeri akan terbuka, jika serat saraf A di aktivasi terjadi eksitasi interneuron pintu nyeri akan tertutup b. Sistem opioid endogen - modulasi nyeri saraf desenden berasal dari :

a. Midbrain : periaquaduct graymatter (PAG) mengandung reseptor 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.

(a)

midbrain

(b)

med.obl

(b)

med.spin

(c)

Mekanisme Rasa Nyeri

Painful stimulus

Pain-sensitive tissue

1: cedera jaringan merangsang pembentukan prostaglandin sensitivitas nosiseptor (pain)

Prostaglandin Mast cell

1
Histamine

Substance P

Blood vessel

2: Nosiseptor melepas substance P pemb drh melebar & dilepas mediator inflamasi yi Bradykinin (redness and heat)
3: Substance P juga merangsang degranulasi mass cells, dilepas zat histamin (swelling)

Bradykinin

Substance P

3
Nociceptor

Post-Injury Stress Response

S P I N A L spinothalamic neospinothalamic C O R D Lateral thalamus kortek somasensorik associative cortex

Sensation Affect

medial reticular thalamus formation paramedian spinoreticular

Corticotropin-releasing factor Vasoactive-intestinal peptide

hypothalamus

sympatic Nerv syst

Nor-eph

Mediator Humoral Perifer Interleukin 1 & 2 TNF/tumor necr F Bradykinin interferon PGE1,PGE2, etc

Pituitary. gl
propiomelanocortin growth horm prolactin vasopressin endorphin

ACTH

adrenal gland glucagon

Epineph Enkephalins Aldosterone cortisol

pancreas

Metabolic and Endocrine responses to injury

Endocrine
catabolic hormons ACTH, cortisol , ADH, growth H, Catecholamine, angiotensin II, aldosterone, glocagons, IL-1, TNF, IL-6

anabolic hormons

insulin, testosterone glycogenolisis, gluconeogenesis (cortisol, glucagon, growth H, adrenalin, free fatty acid). insulin secretion/activation.
cortisol, adrenalin, glucagon, IL-1, IL-6 dan TNF. catecholamine, cortisol, glucagon, growth H.

Metabolic
carbohydrate Hyperglycemia, glucose intolenrance, insulin resistence
Muscle prot catabolism synthesis of acute phase proteins lypolysis & oxidation

Protein

Lipid

Metabolic and Endocrine responses to injury .. 2

water and electrolyte flux
retention of water and catecholamine, aldosterone, ADH, sodium. excretion of cortisol, angiotensin II, prostaglandin potassium, functional and othersfactors. ECF with shifts to ICF

Note: ICF - intracellular fluid, EC F- extracellular fluid, TNF - tumor necrosis factor Source: acute pain management; the scientific evidence (NHMRC, 1999)

Gejala klinik Nyeri 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

Karakteristik Nyeri Somatik Dalam

kualitas nyeri : tumpul dan sakit

kurang terlokalisir dibanding nyeri superfisial

berhubungan dgn hiperalgesia kutaneus,

allodinia, lemas, reflek otot spasme , hiperaktivitas 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) Biological function (+) Avoid tissue damage

Chronic (neuropathic)

Terapi adekuat : -Cegah nyeri kronik -Cegah Yellow Flag

Biological function (-) disadvantage

Advantage *health *well being

Physical *impairment *disablity

Psychological *triad : Pain

Sleep
> Dysfunction QoL > Socioeconomic loss

Mood

Tatalaksana Sindroma Nyeri

Kausal : Medis
Antibiotika Kemoterapi radioterapi

Surgical
Perawatan luka Operasi/mengangkat tumor Fiksasi/operasi fraktur

Tatalaksana Sindroma Nyeri .. 2

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

Prinsip Terapi Nyeri Akut & Berat

Beri analgesik dosis maksimal

Alur Terapi Nyeri Kronik

(WHO ANALGESIC LADDER 1996)
Freedom from pain Opioid for moderate to severe pain +/- Adjuvant Persisting Pain

Step 3

Opioid for mild to moderate pain +/- Non opioid , +/- Adjuvant
Persisting Pain Non opioid +/- Adjuvant

Step 2

Step 1

Farmako Terapi Nyeri Inflamasi

NYERI RINGAN
FARMAKOTERAPI TINGKAT I Nama Obat Aspirin Dosis 325-650 mg, mak 4 g/hr Jadwal 4 jam sekali

Asetaminofen Ibuprofen
Sodium Naproxen

325-650mg
FARMAKOTERAPI TINGKAT II

4-6 jam sekali 4-6 jam sekali

8-12 jam sekali

200mg
Awal 440mg, selanjutnya 220mg

Ketoprofen

12,5mg

4-6jam sekali

Farmako Terapi Nyeri Inflamasi .. 2

NYERI SEDANG
FARMAKOTERAPI TINGKAT III

Nama Obat
Asetaminofen

Dosis
Penyesuaian dosisi misal Aspirin 1000mg

Jadwal
4 jam sekali

Ibuprofen
Sodium naproxen Ketoprofen

4-6 jam sekali

8-12 jam sekali 4-6 jam sekali

FARMAKOTERAPI TINGKAT IV Jika terapi tk. III, OAINS yg dipilih dapat diganti, pilihan OAINS ke-2 sebaiknya dr kelompok 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 .. 3

NYERI BERAT
FARMAKOTERAPI TINGKAT VII Nama Obat Morfin Indikasi Bila th/ non-narkotik tdk efektif dan terdapat riwayat th/ narkotik untuk nyeri Mekanisme 4 jam sekali

Campuran agonis antagonis pentazosin Agonis parsial

Blok aktivasi komponen m komplek reseptor idem

Analgetik Non Opioid yang Paling Sering Digunakan

Nama Obat
Aspirin

Dosis
325-1000mg

Jadwal
4-6 jam sekali

Kalium diklofenak Natrium diklofenak Ibuprofen indometasin Ketoprofen Asam Mefenamat naproxen

50-200 mg 50 mg 200-800 mg 25-50 mg 25-75 mg 250 mg 250-500 mg

8 jam sekali 8 jam sekali 4-8 jam sekali 8-12 jam sekali 6-12 jam sekali 6 jam sekali 12 jam sekali

Analgetik Non Opioid yang Paling Sering Digunakan .. 2

Nama Obat
Piroxicam Tenoxsicam

Dosis
10-20 mg 20-40 mg

Jadwal
12-24 jam sekali 24 jam sekali

Meloxicam Celecoxib Nimesulfid Ketoralax Asetaminofen Tramadol

75 mg 100 mg 100 mg 10-30 mg 500 mg 50-100 mg

24 jam sekali 12 jam sekali 12 jam sekali 4-6 jam sekali 6-8 jam sekali 8 jam sekali

Analgesik Opioid
Jenis Obat Morphine Pot Equal-analgesic Oral 30mg parenteral 10mg Long acting oral 8-12 jam yg dpt diberikan rektal, hati-hati pd pts CRF dpt myoclonus Opioid poten, bisa utk pts disfungsi renal Long acting diberikan o/rectal/8-12jam Keterangan

hydromorphone 7.5mg 1.5mg Oxycodone 20mg -

Methadone

5mg

**

Waktu paruh >24jam, penyesuaian dosis harus hati2, diberikan 6-8 jam utk th/ nyeri, dipakai utk nyeri neuropatik, ratio equal analgesik berubah dg dosis morphin oral >100mg, konsul spesialis

Derby, 1998 American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pai, 5th edition, 2003

Analgesik Opioid .. 2
Jenis Obat Levorphanol Pot Equal-analgesic Oral 4mg parenteral 2mg Poten opioid dgn bbrp aktivitas NMDA antagonis Keterangan

Meperidine

300mg 75mg

Metabolisme normoperidine, stimulan CNS, dpt menimbulkan kejang pd pts dgn gagal ginjal.
Short-acting, bisa patch transdermal dan buccal

Fentanyl ***

100mcg

Codein

200mg 130mg

5-10% ras kaukusia tdk bisa merubah codein ke morphin, SE nausea dan konstipasi > dp opioid lain, efek narkose pd pts gagal ginjal
Sering dikombinasi dgn analgesik nonopioid,

Hydrocodone

30mg

Derby, 1998 American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pai, 5th edition, 2003

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.

SCS - equipment
Spinal Cord Stimulator

Kesimpulan
1. Nyeri akut adalah respon fisiologis atas stimulasi noksius (mengancam/merusak jaringan atau tubuh). 2. Persepsi nyeri bersifat individual, dasar mekanisme fisiologisnya sangat komplek 3. Tatalaksana nyeri kronik/neuropatik bersifat multidisiplin meliputi terapi farmasi non farmasi, dan terapi bedah.

Nyeri Nosiseptive (Akut)

Nyeri akut: mekanisme tubuh utk melindungi & mencegah, supaya jaringan yang cedera tdk bertambah parah, jaringan tsb dibatasi kemampuan gerak/mobilitasnya. Waktu berkisar 1-3 bulan Th/ jika tidak adekuat CHRONIC PAIN
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