Penatalaksanaan Nyeri

dr. Pangkuwijaya P, Sp.An

Affective component
Peripheral Sensitization

Pain
Pain is an unpleasant sensory and emotional experience associated with actual
or potential tissue damage or described in terms of such damage (IASP,
1979)
Adopted from Mersky, 1964
Pain can be manifested without actual tissue damage or organic pathology
Pain is very subjective
Prevention is better or more efficacious than treatment (pre-emptive Analgesia(
Nociception

The detection of tissue damage by transducers in the skin and other tissues
and the propagation of this information to the central nervous system by A-
and C fibersin the peripheral nerves

Pathological Pain

Normal Sensory Function

Modulation
Excitability in dorsal horn neurons is determined by balance between excitatory

inputs from primary afferents and inhibitory inputs (local and descending)

Modulation

Physiological Pain

Features of Physiological Pain

Pain (A and C fibers) can be differenttiated from touch (A fibers)
Pain as symptom
Pain serves a protective function
Pain acts as a warning of potential damage
Pain is transient
Pain is well localized
Pathology recognized
Stimulus-response pattern is the same as with other sensory modalities
Clinical Pain
Inflammatory response
Peripheral nerve injury
Peripheral sensitization
Central sensitization
Metabolic and endocrine changes

Features of Clinical Pain

Pain can be elicited by A and C as well as A fibers
Pain as disease
Occurs in the context of peripheral sensitization
Occurs in the context of central sensitization
Pain outlast the stimulus
Pain spread to non-damaged areas
No biologic usefullness
Pain is pathological
Associated with inflammation, neuropathy, etc
Types of Pain
Nociceptive
Neuropathic
Idiopathic
Pain Assessment
The cornerstone of pain management
Both on rest and with activity
Using a valid measurement tool
Taking the History
Comprehensive history
History of pain problem
Past medical history
Psychological and psychosocial history
Family history
Characteristic of the Pain
Provocating/palliating factors
Quality
Radiation: location and distribution
Severity/intensity
Temporal : duration and periodicity
Response to previous analgesic and disease-modifying agent
Effect of pain on activity of daily living
Quality of Pain
Nociceptive pain
Deep somatic /visceral
Dull
Diffuse
Poorly localized
Suferficial
Sharp
Well localized
Neuropathic pain
Pins and needles
burning
Location and Distribution
Localized Pain
Projected Pain
Referred Pain
Reflex sympathetic pain
Severity / Intensity

Number Needed to Treat (NNT)

Patients with 50% reduction in pain vs placebo

Post operative Pain Cycle with PRN Medications

History of the Pain

Pain at onset
Pain during the interval
Present pain
Physical Examination
General physical examination
Neurologic examination
Pain Assessment

Analgesic Agents
Paracetamol
NSAIDs
Tramadol
Opioids
Local anesthetics
Multimodal analgesia gamber

Profile of Plasma Drug Levels During PCA Therapy

Titrate Opioids to Effects

Analgesia Ladder for Post-operative Pain

Barriers to Adequate Pain Control

General Strategy for the Management of Acute Pain