NYERI

DEFINISI
• Nyeri adalah pengalaman sensorik dan
emosional yang tidak menyenangkan terkait
dengan kerusakan actual maupun yang
berpotensi merusak jaringan atau hal-hal yang
terkait dengan kerusakan tersebut
• Nyeri adalah pengalaman sensorik yang
berkaitan dengan aktivasi nociceptor dan
lintasan nyeri
• Nyeri adalah suatu pengalaman emosional
• Kerusakan jaringan tidak mesti ada
“Pain is alarm protection tell
us that something wrong in
our body”.
 Perception
Pain Perception
Pain

Medulation
Descending
modulation Dorsal Horn

Ascending Dorsal root

Conduction
input ganglion

Transduction
Spinothalamic Peripheral
tract nerve

Transmission Trauma
Peripheral
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
Modified by AHT
 NYERI BDS WAKTU
AKUT
Nyeri yang baru mulai dan kemungkinan jangka waktu yang
terbatas
Lama nyeri kurang dari 3 bulan

KRONIS
Nyeri bertahan melampaui penyembuhan cedera
Seringkali tidak ada penyebab yang dapat diketahui
Nyeri berlangsung lebih dari 3 bulan
 NYERI BDS PENYEBAB

 Nyeri Kanker
 Progresif
 Mungkin gabungan akut dan kronis

 Nyeri Non-Kanker
 Penyebabnya banyak yang berbeda
 Akut atau kronis
 Nosiseptif
 Jenis paling umum setelah terjadinya luka pada jaringan
 Nyeri “ fisiologis”
 Disebabkan olah stimulasi reseptor nyeri dalam jaringan
yang sudah cedera
 Terlokalisir

 Neuropatik
 Kerusakan atau kelainan system saraf
 Nyeri “Patologis”
 Cedera jaringan mungkin tidak jelas
 Tidak terlokalisir dengan tepat
 Pain Rating Scales

0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
Pain threshold
Pain tolerance
Under treatment of postop pain
have serious consequences…
Postop
Postop pain
pain
Inadequate
Inadequate
treatment
treatment
Physiologic
Physiologic and
and Decreased
Decreased
psychological
psychological changes
changes mobilisation
mobilisation
Induction
Induction of
of
chronic
chronic pain
pain
Increased
Increased risk
risk of
of
deep
deep vein
vein thrombosis,
thrombosis, pulmonary
pulmonary embolism,
embolism, myocardial
myocardial
infarction
infarction and
and coronary
coronary ischaemia
ischaemia

Mortality/morbidity,
Mortality/morbidity, longer
longer hospital
hospital stay,
stay, re-admission,
re-admission, decreased
decreased quality
quality of
of
life,
life, decreased
decreased patient
patient satisfaction
satisfaction and
and increased
increased health
health costs
costs

Ballantyne et al. Anesth Analg 1998;86:598;

Wu et al. Anesth Analg 2003;97:1078;
Pavlin et al. Anesth Analg 2002;95:627;
Anesthesiology 2004;100:1573;
Perkins et al. Anesthesiology 2000;93:1123
Main goals of Postop Pain Management
To provide sufficient analgesia that permits
pleasant, normal activities (PAIN FREE)

To prevent central sensitization that leads to

chronic pain (STRESS FREE)

To improve surgical outcome

• Early ambulation
• Early oral nutrition
• ↓ cardiopulmonary morbidity
• ↓ psychological stress, anxiety and
insomnia
Step Ladder
Perioperative of Multimodals
Multimodal Analgesia
Analgesia

Step 1 and Step 2 Strategies AND

Step 3 Severe
Local Anesthetic Peripheral Neural Blockade (With or Without
Postoperative Catheter)
Pain
Use of Sustained Release Opioid Analgesics

Step 2 Moderate
Postoperative Step 1 Strategy AND
Pain Intermittent Doses of Opioid Analgesics

Step 1 Mild Nonopioid Analgesic (Acetaminophen, NSAIDs, or COX-2 Specific

Postoperative Inhibitors)
Pain AND Local Anesthetic Infiltration
Bythe
By theLadder
Ladder
Pain
Acute Pain
Deminishing
Pain
Deminishing
Strong Opioid
Severe
+/- Non Opioid Weak Opioid
Pain +/- Adjuvants
Moderate
+/- Non Opioid Non-Opioid
Pain Mild
+/- Adjuvants
+/-
Pain Adjuvants

Or
Or

Strong Opioid
Pain Persisting Severe
+ / - Non Opioid
Or Increasing Pain +/- Adjuvants

Pain Persisting Weak Opioid

Moderate Or
Or // Par
Par
+/- Non-Opioid
Or Increasing
Pain +/- Adjuvants

Mild Non-Opioid
Chronic Pain
Pain +/- Adjuvants
WHO
Or
Or
 Choosing pain killer and its
combinations
10 Pain Intensity Scale

0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
paracetamol NSAID Strong opioid
or/+ ± ±
NSAID weak opioid NSAID
± ± ±
adjuvant adjuvant adjuvant
analgesic analgesic analgesic
RSUP Dr. Kariadi Semarang
 Less GI side effects

More GI side effects

Diclofenac Celecoxib
Acetosal Indomethacin Ibuprofen
Ketorolac Piroxicam Ketoprofen
Meloxicam
Nimesulide
COXIB
Rofecoxib
Valdecoxib

preferentially non- preferentially

COX-1 COX-1 COX-2 COX-2
selective
selective selective selective selective
COX
inhibitor inhibitor inhibitor inhibitor
inhibitor

analgesic anti-inflammatory
 Multimodal Analgesia
OPIOID
- Systemic
PERCEPTION - Epidural
- Subarachnoid
Pain Ketamin, Tramadol, 
agonist
ANESTHETIC
COX-2, COX-3? - Epidural
-Subarachnoid
MODULATION -Peripheral nerve block
Descending Dorsal Horn
modulation
Ascending
CONDUCTION/
input
TRANSMISSION
Steroids LA
COX-1
COX-2
Spinothalamic Peripheral
tract nerve TRANSDUCTION
TRANSMISSION

Trauma
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.
 Targets of Pain Therapies
Pharmacotherapy
Non-opioid analgesics
Opioid analgesics
Nerve Blocks
Adjuvant analgesics (neuropathic,
musculoskeletal)

Acetaminofen Electrical Stimulation

Transcutaneous electrical nerve
stimulation (TENS)
Percutaneous electrical nerve
stimulation (PENS)

Alternative methods
Acupuncture
(NSAID) Physical Therapy
Chiropractics
Gottschalk et al., 2001 Surgery
Methods of Postoperative Pain Relief

 Two standard methods of postoperative pain

relief in APS
1. Epidural Analgesia (EA)
2. Patient-Controlled analgesia (PCA)
 Continuous peripheral nerve block
 Intrathecal opioid
 Opioid
 NSAIDs (COX-1 & COX-2)
Nonpharmacologic Strategie
Used alone or in combination with pharmacologic strategies
and multidisciplinary

 Psychologicaltherapies  Physical therapies

 cognitive-behavioral therapy,  Exercise programs,
 relaxation,  assistive devices,
 biofeedback, and hypnosis  TENS,
 vibration,
 massage,
 manipulation,
 heat and cold, and
 acupuncture