Toar JM Lalisang

Digestive Surgery Division

Cipto Mangunkusumo Hospital.Jakarta

25 % of patients do not think their doctors

know how to control their pain,

20% feel that their doctor does not consider

their pain a problem,

and 1 in 8 state their physician never asks

them about their pain.

4 of 5 patients think they must live with their

pain.

1 Patients also need to feel that their pain is

important and that there are many options for
improving their pain and level of daily
activities.

Unpleasant sensation and emotional experience

accompanied
with potential and actual tissue damage

PAINFUL ?

Pain Seminar, Lecture #4, PAIN MECHANISMS: CNS, p. 29

Disease

pain

Doctor

disease

Patient

Pain

Pain is always subjective

Bel
iev
e

You
r

Pai
n

Patients
Self-report of pain is the
gold Standard for assessment
IASP 1999; Portenoy RK, Lesage P. lancet, 1999

1.

Pulse

2.

Blood pressure

3.

Temperature

4.

Respiratory rate

*Trademarks are the property of their respective owners.

American Pain Society Web site.

Pain:
The Fifth
Vital Sign *
1

Vital signs are taken seriously.

If pain were assessed with the same zeal as
other vital signs are, it would have a much
better chance of being treated properly.

We need to train doctors and nurses to treat

pain as a vital sign.

Quality care means that pain is measured

and treated
James Campbell

Not only as a symptom

But

Disease of pain

Investigators view

MILD

MODERATE

SEVERE

10

Patients view

NO PAIN

PAIN

Muscle atrophy &

weakness
Weight loss/gain
Negative self-talk
Poor sleep
Missing work

Pain

Disability

Distress
Less active
Decreased motivation
Increased isolation

Belief that pain is not harmful to the patient

Normal consequence of surgery and injury

Concerns that pain relief will obscure a surgical

diagnosis or mask signs of surgical complications

Underestimation of a patients pain

Failure to recognize variability in patients

perceptions of pain

Lack of regular and frequent assessment of pain

and any pain relieving measures

 Fear

that the patient will become addicted to

opioids
Inadequate perioperative pain education
regarding postoperative analgesia
Patients reluctance to request analgesia and/or
fear of taking pain medications
Lack of understanding of the wide variability in
opioid requirements among patients, and the
need to titrate analgesics to meet the needs of
each patient
Lack of recognition that age is a better predictor
of opioid requirement than weight in the adult
patient
Prolonged dosing intervals/short-acting opioids
have short elimination half-lives
Lack of accountability for pain management

Worst Pain: Moderate to Severe

Average Pain: Moderate to Severe

Beauregard L et al. Can J Anaesth. 1998;45:304-311.

Pain as a
Symphony
Complex dynamic
Sensors
Emotions
Memory
Hormones

Opiat & NSAID

Powerfull drugs treating
pain
MANY SIDE EFFECT
GI problem
Dependence

Perception

Pain Transmission

Pain

Medulation
Descending
modulation
Ascending
input

Spinothalamic
tract

Dorsal Horn
Dorsal root
ganglion

transmission

Peripheral
nerve

Peripheral
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

Trauma

Surgeon makes wounds for treatment.

Wounds caused pain

Type of surgery
pain

Severe postoperative

Lower abdominal surgery

Major joint surgery

Osteotomies Maxillofacial surgery

Perineal SURGERY

Thoracotomies Upper abdominal surgery

2to 3 days

3to 4 days

Multi modal approach

Preemptive analgesia

Procedure specific pain management

2 analgesic agents that act by

different mechanisms via a single

route for providing superior analgesic
efficacy with equivalent or reduced
adverse effects.
epidural opioids with epidural local anesthetics or
clonidine,
Intravenous opioids in combination with ketorolac
or ketamine.

2routes of administration
may be more effective
epidural or intrathecal opioid analgesia with
intravenous, intramuscular, oral, transdermal
subcutaneous analgesics
intravenous opioids combined with oral NSAIDs,
COXIBs, or acetaminophen

Multi Modal Analgesic (KEHLET, 1993)

Lowering each dosage

Effective in sinergy &
additive
Decrease side effect

Kehlet H et al. Anesth Analog. 1993;77:1048-1056.

Kenapa harus multi modal?

Dari sisi obatnya
Tidak ada satu pun analgesik yang sempurna
dan dapat mengatasi semua jenis nyeri

Masing-masing memiliki kelemahan

dan keunggulan
Secara klinis akan memberikan hasil yang
lebih baik daripada pemakaian analgesik
tunggal

Dari sisi nyerinya

1.Sebagian besar nyeri bersifat

multi facet dan multi source.

2.Nyeri akan bersifat dinamis dan

berubah sesuai progresifitas
penyakitnya.

PERCEPTION
Pain

OPIOID
- Systemic
- Epidural
- Subarach
Tramadol

Descending
modulation

Dorsal Horn

LOCAL ANESTHETIC
- Epidural
- Subarachnoid
Dorsal root
ganglion

Ascending
input

TRANSMISSION

Spinothalamic
tract

Peripheral
nerve

Peripheral
nociceptors

No single drug can produce optimal analgesia without adverse effect

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

LA
COX-1
COX-2
TRANSDUCTION
Trauma

29

PERCEPTION:
Tramadol, opioid

MODULATION:
Tramadol,opioids,
antidepressants

TRANSMISSION:
Paracetamol, tramadol
opioids

Mekanisme Multi Modal

TRANSDUCTION:
NSAIDs,
COX-2 inhibitors,
local anesthetics

Pre-emptive

introduction of an
analgesic regimen
before the onset of
noxious stimuli
prevent
sensitization of the
nervous system to
subsequent stimuli
that could amplify
pain

Preventive

analgesia:

any perioperative
analgesic regimen able
to control pain-induced
sensitization of the
central nervous system
to decrease both the
development and the
persistence of
pathologic pain

the pain intensity and its consequences may

be procedure-related
Some analgesic modalities may only apply
to certain surgical procedures
The risk-benefit ratio of different analgesics
may also vary according to the surgical
procedure
the risk and clinical implications of
postoperative bleeding associated with
certain analgesics are also procedurespecific
Postoperative pain may also depend on the
choice of surgical technique

Tramadol+
APAP

 NSAIDS

Nonspecific
COX-2 specific
Opioids
Local

anesthesia

Adjunctive

therapy

Gastrointestinal1,2

Hematologic

Peptic ulceration; gastrointestinal hemorrhages

Esophagitis and strictures
Small and large bowel erosive disease

Inhibition of platelet aggregation

Increased risk of bleeding

Reversible acute renal failure

Fluid and electrolyte disturbance/edema
Chronic renal failure and interstitial fibrosis
Interstitial nephritis
Nephrotic syndrome

Exacerbation of
Hypertension
Congestive heart failure
Angina

Cardiorenal1

Brooks P. Am J Med. 1998;104(suppl 3a):9S-13S.

Girgis L et al. Drugs Aging. 1994;4(2):101-112.
3
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.
1
2

Pain relief requirements can vary greatly

from one individual to another, and even in
the same individual from one time to
another.
Side-effects also vary from person to
person. The prescription therefore needs to
be tailor-made to benefit the patient

Multimodal analgesia using local anesthetic, NSAIDs and opiates provides

improved pain control, decreased nausea, and faster discharge following
laparoscopic cholecystectomy. (I, A [Michaloliakou et al., 1996])
Pain following upper abdominal surgery produces inspiratory muscle
dysfunction. This dysfunction is reduced with analgesia. (I, A
[Vassilakopoulos et al., 2000])
IV PCA morphine produces better analgesia than IM morphine, without any
increase in postoperative hypoxemia. (I, A [Wheatley et al., 1992])
Patients using IV PCA morphine used more morphine and had better
analgesia than patients receiving IM morphine on demand. IV PCA patients
also experienced more fatigue and had less vigor than patients receiving
IM morphine. (I, A [Passchier et al., 1993])
Epidural analgesia, with a combination of opiates and local anesthetic,
provides better pain control during rest and activity, and is the treatment
of choice. It is also associated with more rapid recovery of bowel function.
(I, A [George et al., 1994; Mann et al., 2000; Liu et al., 1995]; III, A
[Mulroy et al., 1996])
Epidural analgesia is associated with less postoperative myocardial
ischemia (than IV PCA with morphine). (II-2, A [deLeon-Casasola et al.,
1995])
For optimal analgesia, the thoracic epidural route should be used for pain
relief after upper abdominal surgery. (I, A [Wiebalck et al., 1997; Chisakuta
et al., 1995; George et al., 1994])

Pain control with intercostal nerve block in combination with opiates is more
effective than opiates alone after subcostal incisions. Intercostal nerve blocks
do not significantly improve analgesia following midline incisions. (I, B [Engberg
et al., 1985])
Phenol with local anesthetic has been shown to increase the duration of
intercostal block and improve analgesia following cholecystectomy. (I, B
[Maidatsi et al., 1998])
Infiltration of the incision/wound with local anesthesia improved postoperative
analgesia provided by epidural bupivicaine/morphine during mobilization and
reduced the need for supplemental intramuscular morphine. (I, B [Bartholdy et
al., 1994])
Ketorolac given before or after laparoscopic cholecystectomy reduced
postoperative pain and facilitated the transition to oral pain medication. (I, A
[Lane, 1996])
Pain relief promotes return of respiratory function. (I, A [Vassilakopoulos et al.,
2000])
Aggressive perioperative management with epidural, NSAIDs, early feeding,
and ambulation is associated with improved recovery and rapid discharge after
laparoscopic colonic surgery. (II-3, B [Kehlet et al., 1999]; II-3, A [Bardram et
al., 1995])
Laparoscopic cholecystectomy is associated with less pain than open
cholecystectomy. (I, A [McMahon et al., 1994])
Patient-controlled epidural analgesia with a background infusion is more
effective than patient-controlled epidural analgesia alone after gastrectomy. (I,
A [Komatsu et al., 1998])

Multimodal analgesia using local anesthetic,

NSAIDs, and opiates provides improved pain
control, decreased nausea, and faster discharge
following laparoscopic cholecystectomy. (I, A
[Michaloliakou, 1996])
Active removal of residual pneumoperitoneum
reduces postoperative pain following
laparoscopic cholecystectomy. (I, A [Fredman et
al., 1994])
Suprahepatic suction drains placed by the
surgeon have been shown to reduce shoulder
tip pain following laparoscopic cholecystectomy.
(II-3, B [Jorgensen et al., 1995])

Epidural analgesia produces better pain control

at rest and with activity. It is also associated
with earlier return to normal mental status in
the elderly, better satisfaction, and more rapid
recovery of bowel function. (I, A [Liu et al.,
1995; Mann et al., 2000])
Aggressive perioperative management with
epidural, NSAIDs, early feeding, and ambulation
is associated with improved recovery and rapid
discharge after laparoscopic colonic surgery. (II3, A [Bardram et al., 2000]; II-3, B [Kehlet,
1999; Bardram et al., 1995])

Epidural opiates in the postoperative period

provide better analgesia with fewer side
effects than IV PCA morphine. (I, A
[Eriksson-Mjoberg et al., 1997])
Ambulation in the perioperative period is
associated with a decreased risk of
thromboembolic complications and more
rapid recovery of bowel function. (II-3, A
[Bardram et al., 2000])

Benefits of Effective Pain Management

are simple and straightforward.
Effective pain management can:
Increase patient satisfaction.
Increase the speed of recovery.
Decrease hospital length of stay.
Decrease overall hospital costs.
Reduce the likelihood of chronic pain.
Decrease the likelihood of complications.
Increase productivity.
Decrease suffering.
Improve quality of life.

Summary

Pain is a major health problem and remains

a challenge to healthcare providers

Pain is subjective and must be frequently

assessed on an individual patient basis.

Undertreatment of pain can lead to serious

negative sequelae, including:

Cardiac complications
Respiratory depression
Anxiety
Depression

Benefits of pain management are:

Long-acting opioids are proven effective

for treatment of around-the-clock pain.

Thorough documentation and patient

contracts allow healthcare professionals
to safely provide effective pain
management to their patients.

Increased speed of recovery

Decreased length of hospital stay and
overall hospital costs
Decreased likelihood of developing chronic
pain
Increased patient satisfaction and
productivity

 Post

operative pain is still a

challenging problem, with a wide
variations of treatment options

Therefore

treatment of post operative

pain needs a good collaboration of
several disciplines to provide good
post operative pain care.

Which one is your patient ???????

To chose an adequate painkiller

Solve the problems without create a problems

THX for U Attention