IASP
Pain (Nyeri) adalah suatu Nyeri adalah
pengalaman sensorik dan pengalaman sensorik
emosional yang berkaitan yang berkaitan dengan
dengan kerusakan aktivasi nociceptor dan
jaringan atau diduga ada lintasan nyeri
kerusakan jaringan Nyeri adalah suatu
pengalaman emosional
Kerusakan jaringan
tidak mesti ada
JENIS NYERI
Neuropathic Pain Inflammatory Pain
Mixed Pain
Pain initiated or caused by a Pain with Pain caused by injury to
primary lesion or dysfunction neuropathic and body tissues
in the nervous system nociceptive (musculoskeletal,
(either peripheral or components
cutaneous or visceral)2
central nervous system)1
Examples Examples
Peripheral Examples
Post herpetic neuralgia Pain due to inflammation
Trigeminal neuralgia Low back pain with
radiculopathy
Limb pain after a fracture
Diabetic peripheral neuropathy Joint pain in osteoarthritis
Postsurgical neuropathy Cervical
radiculopathy
Postoperative visceral pain
Posttraumatic neuropathy
Central Cancer pain
Common descriptors2
Posts troke pain Carpal tunnel
syndrome
Aching
Common descriptors2 Sharp
Burning Throbbing
Tingling
Hypersensitivity to touch or cold
Alternative methods
Acupuncture
(NSAID) Physical Therapy
Chiropractics
Gottschalketal.,2001 Surgery
Thick, myelinated, fast
conducting neurons Very thin, unmyelinated, slow-
conducting
Mediate the feeling of initial
fast, sharp, highly localized Mediate slow, dull, more
pain. diffuse, often burning pain.
Rabaan
Tekanan
Nerve Fibers
Class Velocity Function
A- Fast Motor
A- Fast Touch,
pressure
A- Intermediate Muscle tone
A- Intermediate Pain,
temperature
B Small Motor
C Small Pain
Chemical mediators are released from damaged tissue and
inflammatory cells. Some inflammatory mediators directly activate
nociceptors, while others act together to sensitize the pain
pathway.
Inflammation
biologicalresponse to injury or
foreign substances
acute and chronic
inflammation
components:
cellular response
biochemical mediators
Mechanisms of Inflammation
Cellular Mechanisms:
Acute inflammation
PMN
Chronic inflammation
lymphocytes
monocytes
Mechanisms of
Inflammation Biochemical
Mediators
vasoactive amines
plasma proteases (complement, kinins)
arachidonic acid metabolites (PG, LT)
lysosomal constituents
oxygen derived free radicals
cytokines
growth factors
Mediators of
Inflammation
Arachidonic Acid Metabolites
Prostaglandins
Leukotrienes
Generation of
Eicosonoids
Phospholipids
Phospholipase
Arachidonic Acid
5-lipoxygenase cyclooxygenase
5-HPTE PGG2
peroxidase
LTB4 LTC4
PGH2
Arachidonic acid
COX-1
COX-2
Constitutive
PGs
PGs Inducible Constitutive
Celecoxib
Rofecoxib
Valdecoxib
Meloxicam (Movi-cox)*
*[less COX-2 selective]
Golongan Coxib resiko kardiovaskuler
+ stroke
Physicians prescribing celecoxib or valdecoxib should
consider the emerging cautionary data "when weighing the
benefits against risks for individual patients." The most
appropriate candidates for coxib therapy are patients at a
high risk of GI bleeding or who have a history of intolerance
to "or are not doing well on" nonselective NSAIDs.
"Individual patient risk for cardiovascular events and other
risks commonly associated with NSAIDs should be taken
into account for each prescribing situation."
Consumers should use all over-the-counter analgesics,
"including NSAIDs," strictly according to the label
instructions and consult a physician if using them for longer
than 10 days.
Justification for the Development of
COX-2 Selective Inhibitors
COX-2 Selectivity:
Molecular Basis
NSAID Binding Clefts
COX-1 COX-2
Chemical Structures of Oxicams and
OXICAMS COXIBS
Coxibs
Linear, enolic acid Y-shaped, Tricyclic
NH2
CH3
O S Celecoxib
Meloxicam OH O S O
N
N N N
H CF3
S N
CH3
O O
H3C
CH3 O
Piroxicam OH O S Rofecoxib
O
N N
H O
S N
CH3
O O O
COX-2 Selectivity
Rofecoxib .013
Celecoxib .080
Meloxicam .200
Diclofenac .170
Indomethacin 1.500
Efficacy as an emerging concern of
NSAID used
Potency (strong)
Onset of action (rapid)
Duration of action (long)
Bronchospam CHF
Hepatotoxic Perdarahan
UGIB GI
Bleeding Nephrotoxic
Allergy Tocolytic
Mechanism of = Mechanism of
therapeutic effects adverse effects
Table IV. Incidence of gastrointestinal (GI) adverse events
Pain
Opioid Perception
Adjuvants
NSAIDs? Local block
Nociception
Acetaminophene NSAIDs (Movicox )
Neural augmentation Surgery
Ablative surgery Physical modalities
1. Looser JD, Cousins MJ. Med J aust 1990;216: 153-208; 2. van den Hout JH, et al. Clin J Pain. 2003;19:87-96.; 3.
Mynors-Wallis L, et al. Br J Psychiatry. 1997;170:113-119.; 4. Morley S, et al. Pain. 1999;80:1-13.
Anamnesa nyeri secara sistematik dan
teratur
Berprasangka baik (percaya) terhadap
keluhan pasien atau keluarga
Carilah metode kontrol nyeri yang nyaman
untuk pasien dan keluarga
Dilakukan intervensi yang tepat
waktunya, logis dan terkoordinasi
Edukasi pasien dan keluarga untuk
mengatasi nyeri sekuat mungkin