Prinsip Dasar

Pengelolaan Nyeri
Faisal Sommeng
1. Kenapa nyeri harus dikelola?
2. Siapa yang berhak mengelola nyeri?
3. Kapan sebaiknya dikelola?
4. Bagaimana Manajemen Nyeri yang
baik?
5. Bagaimana menilai nyeri.
 Beecher (ahli bedah PD II)

Pain is just like any enemy. You keep

moving around and the enemy can not
hit you. Same way with pain. The
quicker you break away from the pain,
the quicker you will drive the pain out of
your system. You sit too long and you
will not able to move.
 Mengapa nyeri harus diobati?
Nyeri akut
• Merupakan penderitaan (suffering)
• Menurunkan kualitas hidup manusia
• pengelolaan nyeri pascabedah not for comfort only.
Nyeri - imunitas 
- komsumsi oksigen 
- mudah atelaktasis, emboli dll

• Tanpa mengelola nyeri pascabedah

MORBIDITAS DAN MORTALITAS   

 Kehlet 1995
Accelerated surgical stay program

1. Prabedah : Psychological cognitive treatment

2. Durante bedah : Minimise surgical stress
(combine GA + epidural)
3. Pasca bedah : Balance analgesia

AGGRESSIVE MOBILITATION
EARLY ORAL NUTRITION

Outcome penderita bedah 

 Mengapa nyeri harus diobati?
Nyeri kronik

• Menderitakan penderita
• Menurunkan kualitas hidup
• Merupakan masalah sosial-ekonomi
• hilangnya pekerjaan (PHK)
• biaya kompensasi
– di AS 70 milyar dollar/tahun
– di Australia, 1/3 biaya kesehatan
• biaya sosial socially death
 Mengapa nyeri harus diobati?
Nyeri kanker

• Menderitakan penderita
• Menurunkan kualitas hidupnya
• Merupakan masalah:
BIOPSIKO-SOSEK-KULTUROSPIRITUAL
• yang termahal adalah KULTUROSPIRITUAL
bagaimana mengantar penderita menghadap
penciptaNya tanpa rasa nyeri dengan iman
 Pain Relief is HUMAN RIGHT
• BASIC HUMAN RIGHT (ETIKA MORAL)
• APABILA TIDAK DIHILANGKAN MEMPENGARUHI
OUTCOME ( MENINGKATKAN MORBIDITAS DAN
MORTALITAS )
• MAY LEAD TO CHRONIC PAIN ( FINANCIAL AND

 SOCIAL COST)
• PAIN SHOULD BE VIEWED AS THE FIFTH VITAL SIGN
 Pain: The Fifth Vital Sign™

• Pulse
Pain:
• Blood pressure
•
The Fifth
Temperature
• Respiratory rate
Vital Sign™

• American Pain Society (APS) has redefined PAIN as the 5th vital sign
•Health care professional has to assess patients for pain every time
 Siapa yg harus mengelola nyeri
• Semua dokter memiliki hak, Oleh karena
itu, harus mampu:
• knowledge
• affective dalam mengelola nyeri
• skill
• Dokter spesialis anestesiologi
• Konsultan nyeri
 Kapan nyeri harus dikelola?

• Sebelum terjadi (preemptive analgesia)

• As early as possible
• as comprehensive as possible
mencegah

• persistent pain
• minimise longterm sequalae
mencegah

PLASTISITAS
 Prinsip Dasar Manajemen Nyeri
1. Kenali dulu jenis nyeri (nosisepsi atau
neuropatik).
2. Lakukan assesment (penilaian) nyeri.
3. Segera tangani nyerinya, tidak menunda
pengobatan.
4. Memahami dengan baik farmakologi obat-
obat analgetik dan adjuvannya.
5. Sebisa mungkin diberikan secara oral.
 Prinsip Dasar Manajemen Nyeri

6 . Memberikan obat secara teratur sesuai

dengan durasi efek analgetik.
7. Memberikan analgetik yang sesuai dengan
beratnya nyeri.
8. Selalu mempertimbangkan modalitas
adjuvan pada tiap pasien.
9. Memberikan prevensi terhadap efek samping
pengobatan.
 Sebelum terapi nyeri lakukan
Assessment
Ada dua hal yang harus dinilai sebelum pengobatan
nyeri.
1. Jenis nyeri ( kualitas nyeri )
 Nyeri Somatik
 Nyeri viseral
 Nyeri Neuropatik
2. Intensitas nyeri (kuantitas nyeri )
 Mild pain 1 – 3
 Moderate pain 4 – 7
 Severe pain 8 – 10
 Initial Pain Assessment

• Detailed history, including an assessment of

the pain, location, character and intensity
• Conduct a physical examination, emphasizing
the neurologic examination
• Obtain a psychosocial assessment
• Provide an appropriate diagnostic workup to
determine the cause of the pain
 Assessment of Pain
using VAS is !

0 1 2 3 4 5 6 7 8 9 10

No distress Unbearable
distress
a 10-cm baseline is recommended for VAS
( Visual Analogue and Numeric Scale )
ABCDE Mnemonic for Pain Assessment and
Management

Ask about pain regularly

Believe the patient and family reports of pain
Choose pain control options appropriate
Deliver interventions in a timely, logical and
coordinated
Empower patients and family
SOMATIC PAIN
 constant
 aching, gnawing
 well localized
• Example :  bone metastasis.
 tumor of the soft tissue
• Mechanisms :
 activation of nociceptors
 release algesic substances
(spesially prostaglandins)
• Management :  Aspirin
 Acetaminophen
 NSAID
 VISCERAL PAIN

 constant
 deep or dull aching
 poorly localized
 usually with nausea and vomit
 often referred to cuttaneous sites
 occational colicky or cramp
• Mechanisms :  activation of nociceptors
 pancreatic cancer
• Example :
 liver/lung metastasis with shoulder pain
 NSID,Opioid (MS contin ®)
• Management :  Nerve block (e.g celiac plexus block)
NEUROPHATIC PAIN

 burning pain
 paroxysmal shooting or
electrical shock-like pain
• Mechanisms :  spontaneus discharges of
peripheral or central n.s.
 loss of central inhibition
• Example :  metastasis brachial or
lumbosacral plexopathies
 post herpetic neuralgia
• Management :  antidepressant or anticonvulsant
 nerve block
 etc
CAUSE OF CANCER PAIN can be
classified into 3 categories:

1. Pain associated with direct tumor

(tumour infiltration, bone metastases)
2. Pain associated with cancer therapy
(chemotherapy, surgery or radiation)
3. Pain unrelated to cancer
(RA, OA, headache or herpes zoster)
* Due to cancer debility
(decubitus)
 We have only three kinds
ANALGESIC DRUGS

NONOPIOIDS OPIOIDS ADJUVANTS

• Mild Opioid • Steroid (dexamethason)
• Paracetamol
• Ketamine
• NSAID (nonselective) ( codeine & tramadol )
• Clonidine
• Coxib (selective NSAID) • Strong Opioid • Pregabaline & gabapentine
( Morphine & Fetanyl )
WHO Three Step Ladder of WHO.

2 3
1
Nyeri Berat (VAS 8-10)

Nyeri Sedang (VAS 4-7) Strong Opioid

± nonopioid
Nyeri ringan VAS 1-3 Mild Opioid ± adjuvant
± nonopioid
Nonopioid ± adjuvant  Morphine
± adjuvant - Rapid relies; tab or
 Codein or Tramadol liquid
 Acetaminophen ± Paracetamol - Slow relies MST
 Ibuprofen or
 Celecoxibe
 Fentanyl Patch
± NSAID or Coxib

Modify AHT
 Intramuscular Morphine

Respiratory
Serum Drug Concentration

Depression

Sedation

Analgesia

Pain

0 1 2 3 4 5 6 7 8

Time (hrs)
 Analgetik Non-Opioid

Analgesik biasa Analgesik AINS

• Paracetamol • Yang tidak

selektif, disebut
AINS (Cox-1)
• Yang selektif
disebut  Coxib
(Cox-2)
1. Paracetamol (Acetaminophen)
known since 100 years

Para-aminophenol

Analgesic Effects Antipyretic Effect

No Anti inflammation Effects

Route of Administration
 Orally
 Rectally
 Intravenously  available in Indonesia since 2009
PARACETAMOL : NEW VISTAS OF AN OLD
DRUG
 Paracetamol
Paracetamol adalah obat yang sangat aman selama
diberikan dalam dosis yang direkomendasikan
(Dewasa < 4 gr/ hari, bayi dan anak 20-40 mg/kgBB

1. Semua usia – dari bayi sampai orang tua

2. Dari wanita hamil sampai menyusui
3. Dapat diberikan pada pasien dengan
gangguan ginjal dan hati
 Mechanism Of Action
Central Antinociceptive Effect

1 Central COX (Cyclooxygenase) Inhibition

Activation of the endocannabinoid system

2 and serotonergic pathways)

3 prevent prostaglandin
production at the
cellular level.

Bertolini et al, 2006; Botting, 2006; Pickering et al, 2006; Mallet et al, 2008; Pickering et al, 2008; Mancini et al, 2003
 Mechanism of Cox-1, 1971
2. NSAID (AINS) Invention of Cox-2, 1999

PGI2 PGI2

PGE2

TXA2
 NSAIDS Arachidonic
Acid
5-
LOX
COX

COX- -3

1 COX-2
Leukotrienes
•GI Ulcers
•DJD

Inhibition undesirable Inhibition desirable

Prostaglandins for homeostatic Prostaglandins in

unctions inflammation
• Integrity of GI mucosa •Pain
• Modulate renal blood flow •Edema
• Regulate platelet function •Fever
Efek samping yang berat AINS
1. Perdarahan GI
2. Gagal ginjal akut
3. Memicu serangan asma
4. Perdarahan intraoperatif
5. Reaksi alergi
6. Hipertensi

REVIEW ARTICLE WHITE ANESTH ANALG

NON-OPIOID ANALGESICS AND ACUTE POSTOPERATIVE PAIN 2005;101:S5–
 AINS harus berhati – hati

• Resiko tinggi perdarahan intraoperatif eg.

Operasi mayor cardio vaskuler, op hepatobilier
• Penurunan fungsi hati, diabetes, kelainan
perdarahan dan koagulasi, penyakit vaskuler.
• Wanita hamil dan menyusui
• Anak-anak < 16 atau usia lanjut
• Sedang menggunakan NSAID lain.
Kontraindikasi NSAID (AINS)

• Gangguan ginjal
• Gagal jantung
• Disfungsi hati berat
• Hipertensi yang tidak terkontrol
• Penderita asthma
• Riwayat perdarahan GI
 2. NSAIDs
COX 1 & COX 2 inhibitors Selective COX 2 inhibitors

• ibuprofen (Motrin, Advil) • celocoxib (Celebrex)

• naproxen (Aleve) • rofecoxib (Vioxx)
• diclofenac (Voltaren) • valdecoxib (Bextra)
• indomethacin (Indocin)
• ketorolac (Toradol)
• sulindac (Clinoril)
• mefanamic (Ponstel)
• piroxicam (Feldene)
• flurbiprofen (Ansaid)
• ketoprofen (Orudis)

NSAIDs had many advantages but also many

disadvantages
 Ketorolac
• AINS injeksi pertama (AINS non selektif).
• Potensi analgetiknya tinggi mendekati morphine.
• Sehingga , digunakan secara luas untuk nyeri pasca
bedah.
• Sayangnya, pemakaian lama meningkatkan efek
samping.
• Banyak laporan kasus melaporkan masalah dalam
penggunaannya.
• Paling mahal diantara AINS.
 Efek Samping Ketorolak
Efek samping yang paling sering dan serius:
• Perdarahan G I
• Perdarahan pasca bedah
• Disfungsi ginjal
• Semua itu berhubungan dengan dosisnya
Note
• Dosis tunggal maksimum 60mg
• Dosis ulangan maksimum 30mg
• Waktu maksimum pemberian adalah 72 jam
• Pada usia lanjut maksimal 48 jam
COX-1 vs Cox-2 Selective Inhibitor
(COXIB)

Selective COX-2 more safety than Non-

selective COX inhibitor

But, it still had disadvantages such as :

Cardiovascular Problem
 Cox-1 Selective Inhibitor vs Cox-2
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

anti-inflammatory
analgesic
 Yang penting diperhatikan dalam
penggunaan analgetik Non-opioid
• Gunakan dosis penuh. Hati-hati pada pasien
dengan gagal ginjal dan lambung.
• Semua AINS memiliki sifat ceiling effect (dosis
di atas dosis maksimum tidak lagi memiliki efek analgetik).
• AINS nonselektif dapat menyebabkan
prdarahan Saluran Cerna
• Sedang yang selektif inhibitors dapat
menyebabkan efek samping kardivaskuler.
WHO Three Step Ladder of WHO.

2 3
1
Nyeri Berat (VAS 8-10)

Nyeri Sedang (VAS 4-7) Combination of

Strong Opioid with
Nyeri ringan VAS 1-3 Combination of ± nonopioid
Mild Opioid with
± adjuvant
Nonopioid ± nonopioid
 Morphine
± adjuvant ± adjuvant
- Rapid relies; tab or
 Codein or Tramadol liquid
 Acetaminophen ± Paracetamol - Slow relies MST
 Ibuprofen or  Fentanyl Patch
 Celecoxibe ± NSAID or Coxib

This is called multimodal analgesia

Modify AHT
What is multimodal analgesia?

Is a combination of two or more

analgesics that act at different
mechanisms, produce additive or
synergistic analgesia

Main goals of Multimodal Analgsia is to reduce the amount of Opioid

 Philosophy of Multimodal Analgesia
Not only just giving 2 or more drugs which different
mechanism, but;

• One drug should be effective at peripheral

sensitization and other at central sensitization.

• Combine drugs must be synergetic or addictive.
• Must be proven by laboratory or clinical data.
• Some drugs may act at several point at nociceptive
pathway.
 Target Point of Analgesic Drugs
Ketamin
Paracetamol

Perception
Opioids
CNS Gabapentinoids
Clonidine

Corticosteroids
NSAIDs
Modulation Transduction COXIBs
Local Anesthetic

Transduction
DRG

Transmission
Modulation
Local anesthetics
COXIBs
Modify by AHT
 WHAT IS THE MOST REGIMENTS
There are many regiments for multimodal analgesia, but
the most popular are:

Paracetamol
NSAIDs and Coxibs
Opioid Local Anesthetic

2 (subunit of Ca
NMDA Antagonist -2 antagonist
Channel) agonist
(Ketamin) (Clonidine)
(Gabapentinoid)
Multimodal Analgesia
Kombinasi dua atau lebih obat yang mekanisme
kerjanya berbeda.

Paracetamol
325 mg

• DOSIS RENDAH untuk tiap obat

analgesik
sinergisme
• DAYA ANALGESIK MENINGKAT,
akibat sinergik atau potensiasi.
• EFEK SAMPING berkurang untuk
Tramadol setiap obat.
37.5 mg

1
Kehlet H et al. Anesth Analog. 1993;77:1048-1056.
COMBINE DRUGS MAY HAVE
3 EFFECTS

1. Synergetic ............. 2+2>4

2. Additive ................ 2+2=4
3. Subadditive ........... 2+2=3
 Kombinasi

Paracetamol
Analgesik bisa
325 mg
• DOSIS RENDAH
sinergisme • DAYA ANALGESIK MENINGKAT,
• EFEK SAMPING

Tramadol
37.5 mg Opioid lemah

.
 Rationale use of multimodal
Hasil kombinasinya:
Paracetamol
peak = 30 min – Onset cepat
T1/2 = 2 hrs – Lama kerja panjang
Drug Effect

TRAMADOL
peak = 2-3 hrs
T1/2 = 6 hrs

TIME
Kombinasi kedua obat ini, T1/2 meningkat lebih dari 7-9 jam Jadi
pemberiannya bisa setiap 12 jam (2x sehari)
Sediaan ini tersdia dalam berbagai merek.

»Tramaset ( Farenheit)
» Ultracet ( Janssen)
– Pemberiannya Cukup 2x/ sehari

Sangat aman untuk penggunaan jangka panjang dan

pada penderita orang tua atau yang beresiko tinggi.
Terima Kasih
 3. Nyeri Neurophatic
Spontaneous pain
Pain hypersensitivity
Peripheral
Nerve damage
Neuropathic pain
Neural lesion
Positive and negative Injury
symptoms Stroke

Abnormal Maladaptive, low-threshold pain

Central processing Disease state of nervous system

No neural lesion
No inflammation
Positive symptoms

Modify by AHT
 By Analogy
 If pain were a fire alarm,
 Nociceptive pain  would be activated
only by the presence of intense heat,
 Non- Nociceptive Pain  would be a
false alarm. (terjadi sambungan pendek)
caused by malfunction of the system et
self.
 Nyeri nosisepsi (nyeri akut)
Acute Pain is the normal predicted physiological
response to an adverse mechanical stimulus,
chemical, thermal or …., associated with
surgery, trauma and acute illness.”
Nyeri Akut (nyeri akibat adanya stimulus kuat misl adanya kerusakan jaringan)
Nyeri akut adalah respons fisiologis yang dapat
diprediksi akibat adanya stimulus mekanik, kimiawi,
termal atau akibat suatu pembedahan, trauma dan
penyakit akut.
( Federation of State Medical Boards of US )
 Yang penting diperhatikan dalam
penggunaan analgetik Non-opioid

• 1. Gunakan dosis penuh. Hati-hati pada

pasien dengan gagal ginjal dan mag.
• 2. Semua AINS bersifat ceiling effect ( dosis di
atas dosis maksimum tidak lagi memiliki efek analgetik).
• 3. Coxib (COX-2 inhibitors) dapat
menyebabkan efek samping kardivaskuler.
 Ion Fluxes TissueINJURY
TISSUE Injury
(H+, K+)
Transmission via
spinothalamic tract to brain Prostaglandins
Prostaglandins
Bradykinin
Bradykinin
Dorsal Horn

Leukotrienes
Leukotriens
Spinal Cord Substance P

PAIN Histamine
Histamine
To Brain Mast Cell Sensitized
Nociceptor

NSAID
Substance P, Aspartate, (Cox1 or Cox2)
Neurotensin, Glutamate