Manajemen Nyeri

Oleh:
Anggun Nurul Fitria, S.Ked
04084821517137
Risma Arnis Putri, S.Ked
04054821618028
Hatina Agsari, S.Ked
04084821618154

Pembimbing:
dr. Yusni Puspita, SpAn, KAKV, KIC, M.Kes

DEPARTEMEN ILMU ANESTESIOLOGI DAN TERAPI INTENSIF

FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA
PALEMBANG
2016

Pendahuluan

Nyeri
(The Internationl Association
for The Study of Pain 1979)

Definisi

Proteksi reaksi terhadap suatu trauma

dapat menghindar terjadi kerusakan

jaringan tubuh.
Defensif immobilsasi organ tubuh yang
mengalami inflamasi atau patah sehingga
bisa mempercepat penyembuhan
Penuntun diagnostik Kualitas nyeri, onset
dan lokasi dapat menjadi suatu petunjuk
diagnosis.

Klasifikasi Nyeri

Nyeri akut
Nyeri Kronik
Cancer Pain
Chronic Non cancer pain
Nyeri nosiseptif
Nyeri somatik
Nyeri viseral
Nyeri Neuropatik
Nyeri Psikogenik

Type of Pain

Features

Acute pain

Pain usually concordant with degree of tissue

damage, which remits with resolution of the injury
Reflects activation of nociceptors and/or sensitized
central neurons
Often associated with ANS and other protective
reflex responses

Chronic pain

Low levels of identified unerlying pathology that

do not explain the presence and/or extent of the
pain
Continuous or intermitten with or without acute
excarcebation
Depressed mood and vegetative symptomps,
disruption of work, and social relationship

Cancer pain

Strong relationship between tissue pathology and

levels of pain
Limited time frame that permits aggressive pain
management

Chronic non cancer pain

Weak relationship between tissue pathology and

levels of pain
Prolonged, potentially life-long pain

Gambaran nyeri akut, nyeri kronik, cancer pain, dan chronic non cancer pain.
ANS: Autonomic Nervous System (Sumber: Coda et al, 2001; Turk et al,
2001; Jacobsen et al, 2001; Dunajcik, 1999)

Mekanisme Nyeri
Reseptor

nyeri (Nosireseptor)

Kulit (Kutaneus), somatik dalam (deep

somatic) dan daerah viseral

Nosireseptor

Kutaneus

Serabut A delta: Kecepatan transmisi 6-

30 m/det, bermielin.
Serabut C: kecepatan transmisi 0,5
m/det, tidak bermielin.
Nosiresptor

somatik:

Terdapat pada tulang, pem. darah, otot.

Nosiresptor
Tissue
Injury

Viseral:

Organ-organ viseral jantung, hati, usus.

Sensitif terhadap penekanan, iskemia

dan inflamasi.

Lanjutan..
Transduksi
Stimulus nosiseptor potensial aksi.

Transmisi
Konduksi impuls transmisi dari neuron aferen

primer ke kornu dorsalis medula spinalis.

Modulasi
Medula spinalis terjadi intraksi eksitasi dan inhibisi.
Bila zat eksitasi >> dari zat inhibisi maka akan

dilajutkan ke bagian otak lalu timbul persepsi nyeri.

Persepsi
Nyeri di relay menuju otak menghasilkan

pengalaman yang tidak menyenangkan.

SSC FLC
Cortex and
Thalamus

VPL

MT

Hypothalamus
and Pituitary

Sympathetic
Outflow

PAG

HypothalamicPituitary Outflow
Midbrain

LC

Descending
Pathaways

Ascending
Pathaways
Brainstem

NRM

Peripheral
Nociceptor
C-Fiber Sensory
Afferent

NSTT
Delta Sensory
Afferent

PSTT

Spinal Cord

Sympathetic
Efferent

A-Alpha Motor
Efferent

Skala Pengukuran Nyeri

Tujuan:
Evaluasi efektivitas dari terapi analgesik.
Apakah manajemen nyeri sudah adekut?
Apakah analgesik dan sosis harus

diubah?
Apakah manajemen nyeri paska operasi
perlu ditambah?
Adakah intervensi tambahan yang
diperlukan?
Keluhan

nyeri pasien dilakukan se-

Skala Pengukuran Nyeri

Skala

ketegorikal:

Nyeri ringan, nyeri sedang dan nyeri berat.

Verbal Rating Score (VRS) dengan menggunakan angka
0-5
Numerical Rating Score (NRS) dengan menggunakan
angka 0-10.
Visual Analogue Scale (VAS) dengan skala 1-10.
Faces Pain Score dengan skala wajah mulai dari senyum
sampai berlinangan air mata. Nilai 0-5.
McGill Pain Questionare dengan 11 pertanyaan dimensi
sensoris dan 4 pertanyaan dimensi afektif. Nilai 0-3.
Behavioral Pain Scale (BPS) pasien dengan pengaruh
sedasi dan menggunakan ventilator. Skor antara 3-12 dan
skor <5 nyeri terkontrol adekuat.Sumber: Setiyohadi, 2014

Skala pengukuran nyeri Numerical Rating Score (NRS)

Skala Pengukuran Nyeri Faces Pain Score

Bevavioral Pain Scale (BPS)

Sumber: Setiyohadi, 2014 dan Donellan et al, 2

Manajemen Nyeri
Farmakologi

(WHO Three-step
Analgesic Ladder)
Langkah 1: nyeri sedang dan berat

analgesik non opioid.

Langkah 2: ditambahkan opioid lemah
seperti kodein.
Langkah 3: meningkatkan dosis opioid
atau dengan opiod keras seperti morfin.

Analgesik

Non Opioid
Mekanisme dan efek:
Menghambat enzim sikloksigenase (COX)

memblok sintesis prostaglandin.

Non opiod memiliki efek anti inflamasi,
antipiretik dan analgesik.
Efek analagesik OAINS (menit-jam)
Efek antiinflamasi (1-2 minggu)

Indikasi dan kegunaan:

Nyeri akut atau kronik.
Lebih efektif tipe nyeri somatik.

Lanjutan..
Sediaan dan dosis:
Oral, rectal, topikal dan parenteral.
Beberapa OAINS hanya dapat diberikan

1 kali sehari.

Efek Samping:
Gangguan traktus gastrointestinal

(dispepsia, ulkus, ), perdarahan (efek

antiplatelet) inhibisi terhadap COX-1.

Generic Name

Indications

Usual Oral Dosing

Interval or
Frequency
q 4-6 h

Dosage Forms and

Routes of
Administration
Multiple oral (e.g.,
tablets, caplets, powder,
elixir, suspension,
liquid); rectal
suppositories

Acetaminophen

Mild to moderate pain due

to multiple causes including
headache, toothache,
muscular aches, backache,
menstrual cramps, arthritis,
common cold and flu; fever
reduction

Aspirin (ASA)
Diflunisal
CMT (Choline
Magnesium
Trisalicylates)

Mild to moderate pain due

to multiple causes including
headache, toothache, sinus
pain, muscular aches,
bursitis, backache, sprains,
arthritis, pain due to fever,
cold, flu

ASA: q 4-6 h;
Diflunisal: q 8-12 h;
CMT: once per day
(QD), twice daily
(BID) or three times
daily (TID)

Multiple oral (e.g.,

NSAID class effects
tablets, gelcap, caplets, Diflunisal hypersensitivity: life-threatening
effervescent tablet, gum, reaction that may involve multiple organs
liquid); rectal
suppositories

Ibuprofen

Mild to moderate pain due q 4-6 h

to multiple causes including
headache, toothache,
muscular aches, backache,
menstrual cramps, arthritis,
common cold and flu; fever
reduction

Oral (tablets, caplets,

geltabs, suspension);
rectal suppositories

Naproxen

Reumatoid arthritis (RA),

Osteoarthritis (OA),
Ankylosing spondylitis
(AS), Juvenile arthritis;
tendonitis, bursitis, gout,
primary dismenorrhea

Tablets, oral suspension, NSAID class effects; Pseudoporphyria

delayed-release tablets

Ketoprofen

Signs and symptoms of OA q 6-8 h; q 24 h for

and RA, pain and primary extended release

q 6-12 h

Capsules, ER capsules

Major Side Effects

Acute overdose: hepatic necrosis (liver

damage)
Chronic overdose: liver toxicity,
nephrotoxicity, trombocytopenia

NSAID class effects;

Toxic amblyopia

NSAID class effects

Flurbipofen

OA, RA

BID, TID, QID

(four times daily)

Tablets

NSAID class effects

Oxaprozin

Acute and long-term

q 24 h
management of OA and RA

Caplets

NSAID class effects.

Other: Photosensitivity rash

Indomethacin

Moderate to severe OA,

RA, AS; acute painful
shoulder (bursitis and/or
tendonitis)

Piroxicam

Acute and long-term

q 24 h
management of OA and RA

Meloxicam
Diclofenac

OA
OA, RA, AS, primary
dismenorrhea

q 24 h
Tablets
BID, TID, QID (four Tablets, ER tablets
times daily), ER
form q 24 h

NSAID class effects

NSAID class effects.
Other: acute hemolytic anemia, aseptic
meningitis, rash. Avoid use in patient with
porphyria. Combination with misoprostol
contraindicated in pregnant women

Ketorolac

Short-term (<5 days)

treatment of moderately
severe acute pain that
requires analgesia at the
opioid level (e.g.,
postoperative pain)

Varies for parenteral Oral (tablets), IV

therapy, q 4-6 h oral (injector, sterile
form
cartridges

NSAID class effects.

Warning indicating potential for serious
NSAID side effects if used inappropriately
not recommended for minor or chronic
pain

Rofecoxib

OA, acute pain in adults,

primary dysmenorrhea

q 24 h

Tablets, oral suspension

Most common: Upper Respiratory

Infection, nausea, hypertension.
NSAID class effects less likely, rare
aphylactoid reactions

Celecoxib

OA, RA, Familial

Adenomatous, Polyposis

q 12 or 24 h

Capsules

Most common: Upper Respiratory

Infection, nausea, hypertension.
NSAID class effects less likely, rare
aphylactoid reactions

BID, TID, QID (four Oral (capsules,

times daily)
suspension slow-release
capsules) rectal
suppositories
Capsules, ER capsules

NSAID class effects.

Ocular effects (corneal diposits, retinal
disturbances) Excacerbatiom of
Parkinson's disease, epilepsy, or psychiatric
disorders
NSAID class effects.
Insomnia

Opioid
Opioid

dikenal dengan narkotik

Analgesik nyeri sedang-berat
Mekanisme semakin jelas sejak
penemuan reseptor opioid (sistem
limbik, talamus, substansia
gelatinosa, kornus dorsalis dan usus)

Reseptor Opioid
Distimulasi

oleh peptida endogen

(endorphrin,enkepalis dan
dynorphin)
Terletak di presinaps dari serabut C
nosiseptif dan serabut A delta.
Mu () (morfin agonis), Kappa ()
(Ketosiklazosin agonis), Delta ()
(delta-alanin-delta-leucineenkephalin agonis, Sigma () (Nallylnormetazocine agonis)

Kategori Opioid
Drug Enforcement Agency (DEA):
1. Phenanthrenes: Morfin, codeine,
2.
3.
4.
5.

hydromorphone.
Benzomorphan: Pentazocine.
Phenylpiperidines: Fentanyl, alfentanil,
sufentanil, dan meperidine.
Diphenylheptanes: Methadone.
Tramadol

Lanjutan..
Antagonis opioid:
Nalokson
Mengikat resptor opioid dan

menghambat pengaktifannya.

Kombinasi agonis dan antagonis:

Pentazosin dan butofanol
Efek samping depresi pernapasan.

Generic Name

Indications

Usual Dosing Interval

Routes of Administration
Potential Side Effects
and Dosage Forms
PO (IR and CR), PR, IV,
Mu agonist class side
SC, EA, IA, SL
effects, precautions,
warnings, and
contraindications
Metabolite can accumulate
in setting of RF or hepatic
dysfunction

Morphine

Severe acute pain (e.g.,

trauma, postoperative pain,
MI), cancer pain, chronic
pain

Varies with IR and CR

Hydromorphone

Oral : management of pain

where opioid therapy is
appropriate
Parenteral : moderate to
severe pain (e.g., trauma,
MI, surgery, burns, renal
colic, biliary colic, cancer)

4-6 h for oral and parenteral PO, PR, IV, SC, EA, IA
6-8 h for rectal

Mu agonist class side

effects, precautions,
warnings, and
contraindications

Fentanyl

Severe acute pain, cancer

pain, CNCP
TD fentanyl is only
indicated for treatment of
chronic pain that requires
continuous administration
and cannot be manage by
lesser means

Varies with ROA and form

72 h for TD fentanyl

Mu agonist class side

effects, precautions,
warnings, and
contraindications
TD fentanyl is
contraindicated for
acute pain,
postoperative pain,
mild or intermittent
pain responsive to
PRN or nonopioid
therapy, and at doses
above 25 mcg/h at the
initation of opioid
therapy

IV, EA, IA, TD, OTFC

Oxycodone
Meperidine

Moderate to severe pain

(e.g., migraine, trauma,
postoperative pain, acute
abdominal pain

3-4 h

PO, IV, SC, EA, IA

Hydrocodone

Moderate to severe pain

4-6 h
(e.g., trauma, back pain,
postoperative pain,
abdominal pain, dental pain)

PO

Codeine

Mild to moderately severe

pain

4h

PO, SC

Mu agonist class side

effects, precautions,
warnings, and
contraindications
High doses may cause
agitation, muscle
jerking, and seizures or
hypotension
Use with care in
patients with renal
insufficiency,
convulsive disorders,
cardiac arrhytmias
Mu agonist class side
effects, precautions,
warnings, and
contraindications
Combination
hydrocodone +
ibuprofen NR for OA
or RA or for patients
with NSAID
hypersensitivity or
other to NSAIDs
Mu agonist class side
effects, precautions,
warnings, and
contraindications
Most common side
effects are
lightheadness,

Endogenous Peptides
Enkephalins

Agonist

Agonist

-Endorphin

Agonist

Agonist

Dynorphin A

Agonist

Agonist
Morphine
Codein

Agonist
Weak Agonist

Fentanyl

Agonist

Meperidine

Agonist

Methadone

Agonist

Weak Agonist

Agonist

Antagonist
Naloxone

Antagonist

Weak Agonist

Naltrexone

Antagonist

Weak Agonist

Kesimpulan

Daftar Pustaka

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