PENGELOLAAN NYERI

HERI DWI PURNOMO, dr. SpAn.

KMN
Bagian Anestesi dan Perawatan
Intensif
RSUD Moewardi/ Universitas Sebelas
Maret
Surakarta

NYERI

NYERI
Nyeri

tidak dianggap sebagai suatu prioritas.

Kurangnya pengetahuan staf medis mengenai nyeri.

Nyeri sering dianggap tak terhindarkan
Terapi nyeri sering tidak optimal

POST-OPERATIVE PAIN REMAINS

MAJOR PROBLEM IN US

73 MILLIONS surgical patients

each year in US
80% experience acute post-operative pain
20% experience SEVERE PAIN!

tchison RW. Am J Health-Syst Pharm 2007;64:2-5.

Facts about Postoperative

Pain (1)
According to Apfelbaum :
82% of adult patients
experience pain after
surgery
Among them, 86%
express moderate to
extreme pain

Apfelbaum JL. Anesth Analg 2003; 97:534-40

Bardiau FM. Anesth Analg 2003; 96:179-85

Consequences of Inadequate
Pain Management
Serious medical complications
Impair recovery
Progress to chronic pain

Beattie J. Pharm J 2005; 275:145-7

Reuben S. Acute Pain Management 2007; 173

Pain and Consequences :

Big Problems to Patient

NYERI

NEUROBIOLOGY OF PAIN
Pain

Descending
modulation
Ascending
input

Spinothalamic
tract

Dorsal Horn
Dorsal root
ganglion

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

Stage of
Nociception

12

PERJALANAN IMPULS NYERI

COX-2, COX-3 Paracetamol

OPIOID
- Systemic
- Epidural
- Subarach

PERCEPTION
Pain

Descending
modulation

Ascending
input

Ketamin, Tramadol

Clonidine

Dorsal
Horn

LOCAL ANESTHETIC
- Epidural
-Subarachnoid
-Peripheral nerve
block
Dorsal root
ganglion

TRANSMISSIO
N

Spinothala
mic
tract OPIOID
- Systemic
- Epidural
- Subarach

MODULATION

Ketamin,
Tramadol
Clonidine

Peripheral
nerve

LA
COX-1
COX-2
TRANSDUCTION

Peripheral
nociceptors

No
single drug can produce optimal analgesia without adverse
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg.
effect
1993;77:1049.

Trauma

PAIN ASSESSMENT
OPQRST
Onset : - suddenly or gradually?
- what where you doing when pain started
Provokes : - what provokes your pain
- what make your pain better or worse
Quality : - sharp or dull ? does your pain feel like?
Radiates : - does your pain radiate?
Severity : VAS/ FLACC/ Wong Baker Faces
Time : - How long ago it started?

PAIN SCALE

WONG BAKER FACES

Face 0 is very happy because he or she doesn't hurt at all.

Face 1 hurts just a little bit.
Face 2 hurts a little more.
Face 3 hurts even more.
Face 4 hurts a whole lot.
Face 5 hurts as much as you can imagine, although you
don't have
to be crying to feel this bad

PAIN MANAGEMENT

Pharmacological treatment
Non-pharmacological treatment
Pharmacological treatment

NSAIDs
Nonselective
COX-2 selective
Opioids
Local anesthesia
Adjunctive therapy, Other.

BENEFITS OF MULTIMODAL
PAIN THERAPY
1

Morphine

Reduced doses of each

analgesic

Potentiation

NSAIDs,
acetaminophe
n,
nerve blocks
1

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

Improved pain relief due to

synergistic or additive
effects
May reduce severity of side
effects of each drug

NON-PHARMACOLOGIC
TREATMENT
Physical

Massage
Heat and cold
Acupuncture

Behavioral

Relaxation
Art and play therapy
Biofeedback

Cognitive

Distraction
Imagery and Hypnosis

ALUR PENGELOLAAN NYERI

1. Semua pasien ( poli, IGD, ranap) mendapatkan pengkajian

nyeri oleh perawat.

2. Jika derajat nyeri VAS <4, NIPS <4, FLACC <4, Comfort Scale
<27 maka perawat : non-farmakologi.
3. jika skala nyeri meningkat VAS >4, CRIES >4, FLACC >4,
Comfort Scale >27. Perawat melaporkan ke DPJP untuk
pengelolaan nyeri secara medikamentosa.

ALUR PENGELOLAAN
NYERI
4. Evaluasi selama 1x24 jam, bila tidak teratasi maka DPJP harus segera
konsultasi ke tim nyeri SMF terkait.
5. Bila selama 1x24 jam bila teratasi maka tim nyeri SMF
tak teratasi maka tim nyeri SMF tim nyeri RS
6. Bila nyeri teratasi , maka tim nyeri RS DPJP.
7. DPJP konsultasi ulang ke tim nyeri SMF jika diperlukan

DPJP bila

Matur nuwun