Secuil Catatan Tentang

NYERI

Dr Yosie Arief Sanjaya, SpAn

RS Amal Sehat Wonogiri
 PAIN DEFINITION

IASP ( International Association for the

Study of Pain ) 1979
defined pain as :

“ an unpleasant sensory and emotional experience

associated with actual or potential tissue damage
or described in term of such damage”.H. Merskey, 1979
Trauma (tekanan, suhu, kimia)
Atau Pasca bedah

MSR
(Metabolic Stress Response)

Seluruh Memperberat
Sistem Tubuh Kondisi

Perubahan Fisiologi
& Psikologi
 Kognitif

Perubahan
Neuroendokrin Fisiologis & Neurohumoral
Psikologi

Simpatosdrenal
 Perception
PAIN PATHWAY
Pain

Modulation
Descending
modulation Dorsal Horn

Ascending
input
Dorsal root
ganglion
Transmission

Transduction
Spinothalamic
Peripheral
tract
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.
Instrumen
Mengukur Nyeri
Principles of pain treatment:
Multimodal Approach

Pain is complex and multifactorial, thus

appropriate management requires a “balanced”
therapeutic approach.
Benefits of multimodal approach:
◦ higher effectiveness due to synergism;
◦ lower side effects due to lower doses used;
◦ flexibility.
Preventive Multimodal Analgesia

 Significant improvement in
◦ Pain reduction
◦ Opioid use
◦ Recovery or day ward length of stay
◦ Unplanned admission to the hospital

Reuben et al. Acute Pain. 2004;6:87-93.

Multimodal Analgesia
OPIOID
- Systemic
PERCEPTION
- Epidural
- Subarach
Pain Ketamin,Tramadol

COX-2, COX-3
LOCAL ANESTHETIC
MODULATION - Epidural
Descending
modulation Dorsal - Subarachnoid
Horn
Ascending Dorsal root
input ganglion

TRANSMISSION LA
COX-1
COX-2
Spinothalamic
Peripheral
tract TRANSDUCTION
nerve

Peripheral Trauma
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.
Benefits of Multimodal Analgesia

Opioids

• Reduced doses of each

analgesic
Potentiation • Improved pain relief due
to synergistic or
additive effects
• May reduce severity of
NSAIDs, side effects of each
acetaminophen, drug
nerve blocks
1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.
Multimodal Analgesia
Ketamine
Deksketoprofe
n ivNMDA
iv
Cox-2 agents antagonists

NSAIDs Better analgesia

iv
– Synergy
Multimodal – Additivity
Paracetamol Reduce side effects
iv

NorAdr & iv Local Anaesthesia

Opioids 5HT antagonists
iv Jin et al. J Clin Anesth;13:524, 2001
Tramadol Kehlet et al. Anesth Analg;77:1048. 1998
Woolf CJ, Science, 288:1765-1768, 2000
tep Ladder of Multimodals Analgesia
Step 3 Severe Postoperative Pain
Step 1 and Step 2 Strategies
AND
Local Anesthetic Peripheral Neural Blockade
(With or Without Catheter)
Use of Sustained Release Opioid Analgesics

Step 2 Moderate Postoperative Pain

Step 1 Strategy
AND
Intermittent Doses of Opioid Analgesics

Step 1 Mild Postoperative Pain

Nonopioid Analgesic
Acetaminophen, NSAIDs, or COX-2 Specific Inhibitors
AND
Local Anesthetic Infiltration

Modification of WFSA analgesic ladder

Crews JC, JAMA 2002;288:629-32
PRE-EMPTIVE ANALGESIA

– Analgesics is given PRIOR to procedures

- Using LA, opioids and NSAIDs

– An attractive working hypothesis

– 93 RCTs failed to demonstrate benefits
Some Drugs Are Superior to Others

Dexketoprofen

• Potent analgesia
• Higher therapeutic index
• Less pharmacokinetic variability
• Less long term side effects
CLINICAL STUDIES
Double blind, randomised, parallel group study of the safety, efficacy and influence on morphine
usage of intravenous dexketoprofen trometamol (50 mg) in comparison to intravenous tramadol
(100 mg) or placebo in the relief of pain following orthopaedic surgery
Hanna, et al. Br J Clin Pharmacol. 2003 Feb;55(2):126-33

60

50
intensitas nyeri , VAS (mm)
Mean VAS pain intensity score (mm)

40
Rata-rata skor

30

20

10

0
0,5 1 2 4 6 8 10 12
Waktu (jam)
placebo+ morfin
PLASEBO + MO RFIN
tramadol + morfin
TRAMADO L 100 mg IV + MO RFIN
dexketoprofen + morfin
KETESSE IV 50mg + MO RFIN
CLINICAL STUDIES
Double blind, randomised, parallel group study of the safety, efficacy and influence on
morphine usage of intravenous dexketoprofen trometamol (50 mg) in comparison to
intravenous tramadol (100 mg) or placebo in the relief of pain following orthopaedic
surgery
Hanna, et al. Br J Clin Pharmacol. 2003 Feb;55(2):126-33

2.5
p<0.001 2.24
5
2
1.73 57,6
Morphine (mg/hr)

1.6 Kebutuhan morfin per-

1.5 jam pasca operasi
antara ke-2 kelompok
1 obat tidak berbeda
bermakna
0.5

0
Dexketoprofen Tramadol Placebo
50 mg 100 mg
CLINICAL STUDIES
Efficacy and Tolerability of Intramuscular Dexketoprofen in
Postoperative Pain Management following Hernia Repair Surgery
Jamdade, et al, 2011, Anesthesiology Research and Practice

Single dose of
dexketoprofen trometamol
50 mg given intramusculary
provided faster, better, and
longer duration of
analgesia in postoperative
CLINICAL STUDIES
PERBEDAAN SKOR VISUAL ANALOGUE SCALE ANTARA
KETOROLAK DAN DEKSKETOPROFEN PADA PASIEN PASCA
BEDAH
Pritaningrum, Harahap, Hardian, 2010
6

3 Ketorolak
2 Dexketoprofen
1

0
VAS 1 VAS 2 VAS 3 VAS 4 VAS 5 VAS 6
Grafik perbedaan skor VAS tiap 8 jam selama 48 jam antar kelompok
perlakuan.
CLINICAL STUDIES

Perbandingan perubahan prersentase agregasi trombosit antara

sebelum dan sesudah perlakuan pada kelompok deksketoprofen dan
ketorolak. Ratry, Harahap, 2009

Penurunan agregasi trombosit lebih besar sesudah

pemberian ketorolak dibanding sesudah pemberian
deksketoprofen.
 Jazakumullah
khairan katsiran