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PENGELOLAAN NYERI

PERIOPERATIF
2
Topik yang akan dibahas
1. Apa itu nyeri? (definisi nyeri)
2. Mengapa nyeri harus dikelola?
3. Apa itu nyeri pascabedah?
4. Konsekwensi nyeri pascabedah
5. Prinsip dasar pengelolaan nyeri pasca
bedah
6. Analgesia multimodal
7. Strategi multimodal analgesia guna
meningkatkan outcome pembedahan
8. Penutup
Definisi Nyeri

Perasaan sensorik
dan pengalaman
emosional yg tidak
menyenangkan
- Akibat adanya kerusakan
jaringan yang nyata atau yang
berpotensi rusak,
- Atau digambarkan seperti
adanya kerusakan jaringan.

International Association for the


Study of Pain (1979)
2001: Global Day Against Pain
2004: Global Year Against Pain
European Federation of IASP Chapters (EFIC)
WHO
IASP
SLOGAN:

The Relief of Pain Should be a Human Right


* 2005 - 2006: Pain in Children * 2010 - 2011: Acute Pain
* 2006 - 2007: Pain in Older Persons * 2011 - 2012: Headache
* 2007 - 2008: Pain in Women * 2012 - 2013: Visceral Pain
* 2008 - 2009: Cancer Pain * 2013 - 2014: Orofacial Pain
* 2009 - 2010: Musculoskeletal Pain
ASA Task Force on Acute Pain Management

Acute pain:
Nyeri yang muncul pada pasien yang baru saja
menjalani prosedur bedah.
Bisa diakibatkan dari prosedur pembedahan
atau komplikasi yang berkaitan dgn prosedur
tsb.
Pain management in the perioperative setting:
Semua tindakan yg dilakukan sebelum, saat,
sesudah pembedahan yg bertujuan mengatasi
nyeri post operatif sebelum px dipulangkan.
Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated
Report by the ASA Task Force on Acute Pain Management, 2004.
Mekanisme Umum Nyeri
Poisons
mechanical , thermal , chemical

Tissue damage

Release of mediators
Hydrogen and potassium ions,
neurotransmitters, kinins,
prostaglandins

Stimulation of nociceptors

Transmission to CNS
via afferent pathways
7
Alur Nyeri Nosisepsi Neuron III Persepsion

SS

Transduction
Nociceptor
Mechanical Conduction/
Transmission
Transmission
Modulation
Neuron II
Thermal

Neuron I
Chemical
Nociceptor

Modified by AHT
Mengapa nyeri harus
dikelola atau diobati?
The Epidemiology and the Magnitude of
Postoperative Pain
Nyeri post operative adalah masalah medis yg utama,
ekonomi, sosial dan problem kemanusiaan , karena :

Pengalaman nyeri dirasakan jutaan orang setiap harinya.


Jutaan orang menjalani operasi tiap tahunnya.
> 75% pasien menderita nyeri setelah operasi:
30% severe pain.
40% moderate pain.
10% mild pain.
Tata laksana nyeri yg Inadequate lama rawat >>> biaya.

Karena nyeri post operative, banyak pasien tidak mau


dioperasi.
Cousins M. Postoperative pain. Proceeding of IASP, 1991.
Pain Relief is HUMAN RIGHT

Recently, pain relief is being viewed as


BASIC HUMAN RIGHT (ethical as well
as morally)
Unrelieved pain may adversely affect
the outcome of surgery ( morbidity
and mortality)
May lead to chronic pain ( financial
and social cost)
Pain should be viewed as the FIFTH
VITAL SIGN (recorded, assessed and
managed regularly)
What the patients want ?

If you ask patients what they want from


their surgery, the answers always are:
1. I WANT THE SURGERY TO BE SUCCESSFUL
2. I DONT WANT ANY COMPLICATIONS
3. I DONT WANT IT TO HURT
4. I DONT WANT ANY SIDE EFFECT OF
ANALGESIC DRUGS
What patients say to his/her
anesthesiologist?
In the past (before 90).

Im worried that
I wont wake up,
after the
surgery

Main Goal of Anesthesia is to Bring Back


Patients Alive
Now, patients say

Im worried to have
PAIN, after the
surgery

Save Anesthesia and Optimal Analgesia


Apa itu nyeri pasca bedah?
Nyeri Pasca Bedah adalah:
Nyeri Pasca Bedah

Dari semua macam nyeri yang kita


kenal, maka nyeri pasca bedahlah
yang paling kita ketahui:
We know what causes it
We know the mechanism
We know it is self limited
We know how to treat it
We know the best drug for it

Lema MJ. Department of Anesthesiology, Buffalo State University.


Dilemma Nyeri Pasca Bedah`

Tapi kenapa nyeri pasca bedah sampai


saat ini masih sub-optimal?
80 % nyeri pasca bedah masih merasa
nyeri mulai dari nyeri ringan, sedang
sampai amat berat.

Pain can be relieved effectively in 90%


of patients, but is not relieved
effectively in 80% of patients.
Walco et al. N Engl J Med 1994;331:8.
Beberapa Penyebab Sub-optimalnya
Pengelolaan Nyeri Pasca Bedah
Kurangnya pengetahuan farmakologi obat
analgesik bagi sebagian dokter dan
perawat
Pemberian obat yg uniform (umumnya
morfin)
Diberikan secara prn dengan i.m
Takut terhadap efek samping
Takut adiksi

Kehlet H. Postoperative pain. ACS Surgery, 2005.


Consequences of Postop Pain

Physiological Psychological/Emotional
Consequences Consequences
Sympathetic overactivity: Fear
Tachycardia, hypertension
Increased cardiac work
Anxiety
Increased oxygen Apprehension
consumption, etc
Respiratory dysfunction
GIT dysfunction ileus
Renal suppression Suffering
oligouria
Immunosuppression
Thromboembolic

Increases morbidity Pain behavior


and mortality (chronic pain)
SURGERY & PAIN

Surgery

Tissue damage Nociceptive PAIN


Inflamed tissue input

Surgery has a biphasic insults to the body


1. Trauma to tissue
2. Inflammatory response
ALLODYNIA
HYPERALGESIA
*SPONTAN PAIN
*PROLONGED PAIN

X
Nyeri Klinik Hilang Nyeri
(Nyeri Patofisiologis) Setelah sembuh kronik
(2-10%)
Kenapa hal ini dapat terjadi
Setelah pembedahan, setelah
kerusakan jaringan atau jaringan
mengalami inflamasi, terjadi
proses:

SENSITISASI PERIFER
SENSITISASI SENTERAL

MEMPENGARUHI SUSUNAN SYARAF


SENSITISASI
PERIFER
Sensitisasi Perifer

Tissue Damage Inflammation Sympathetic Terminals

Sensitizing Soup
Hydrogen ion Histamine Purines Leucotrine
Norepinephrine Potassium ion Cytokines Nerve Growth Factor
Bradykinin Prostaglandins 5-HT Neuropeptides

High Treshold Nociceptor

Transduction Sensitivity Primary Hyperalgesia

Low Treshold Nociceptor


SENSITISASI
SENTRAL
Sensitisasi Sentral
terjadi di kornu posterior medulla spinalis

Inhibitory
Interneuron

Nociceptor NE

Terminal ending MU

SP SP
Glu
Glu
Post Synaptic Membrane of SP

the Spinal Sensory Neuron Mg++


Glu SP
Glu
Glu NMDA
Receptor NK-1 MU
AMPA Receptor
Receptor
Kainate
Receptor Second Messenger
Fast Prime Formation, (cAMP,
Na+ Slow Prime
PKA)

NMDA Receptor: Requires voltage


mRNA synthesis, and
dependent priming for activation -
upregulation of inducible
enzymes/ protein
Spontaneous Allodynia
Tissue damage Hyperalgesia
pain

PERIPHERAL
ACTIVITY
CENTRAL
SENSITIZATION

Decreased Increased
Nerve damage threshold to spontaneous
peripheral Expansion of activity
stimuli receptive
field
Prinsip Dasar Pengelolaan
Nyeri Pasca Bedah
Pengelolaan Nyeri Perioperatif
Mencegah, menekan atau
meminimalisasi terjadinya proses
sensitisasi perifer maupun
sensitisasi sentral.

Mencegah terjadinya platisitas


susunan saraf.
Mempertahankan agar susunan
saraf tetap dalam keadaan
status fisiologis.
The Aim of Postoperative Pain Management

Subjective patient comfort (pain free)


Inhibiting stress response (stress free)
Enhance restoration of body function
by allowing patient to breathe, cough,
and move more easily

Note: pain free is not the synonym of stress free


G = General Anesthesia
S = Spinal Anesthesia
12 G & L = General Anesthesia + Local Anesthetic Infiltration
Time to first Analgesic (h)

10

G S G&L
Tverskoy et al. Postoperative pain after inguinal herniorrhaphy with
different types of methods. Anesth Analg 1990;70:29-35.
Berbagai Cara Pengelolaan
Nyeri Pasca Bedah.
Berbagai Teknik Pengelolaan Nyeri
Pascabedah
PCA (Patient Controlled Analgesia)
Epidural/Intratekal dgn opioid
Epidural/Intratekal dgn anestetik lokal
Blokade saraf (infiltrasi, interkostal, intrapleural
dll)
Opioid
NSAID COX-1 atau COX-2 inhibitor)
Paracetamol (COX-3 inhibitor)
Gabapentanoid (gabapentin, pregabalin)
Tramadol
Ketamin
MULTIMODAL ANALGESIA
Dll.
Apa itu Analgesia Multimodal?
(Balanced Analgesia)
Mengkombinasikan 2 atau lebih analgesik
yang memiliki mekanisme kerja yang
berbeda, menghasilkan analgesia yang
sinergik dengan efek samping yang kurang

Jadi merupakan tindakan


polifarmakologik yg dapat bekerja
pada:
Transduction NSAIDs (COX1 &
COX2 inhibitor)
Transmission Local anesthetics
Modulation Opioid or NMDA
antagonist
Multimodal or Balanced Analgesia

Opioid doses of each analgesic

Optimal analgesia
due to synergistic/additive
Potentiation effects

May side-effects of each


drug
- Paracetamol
- NSAIDs
- COXIBs
- Nerve blocks
- Gabapentinoids

Kehlet & Dahl. Anesth Analg 1993;77:1048


Playford et al. Digestion. 1991;49:198
Multimodal Analgesia
OPIOID:
- Systemic
PERCEPTION - Epidural
- Subarach

Pain Ketamin, Tramadol,


agonist

COX2, COX3 inhibitor LOCAL ANESTHETIC:


- Epidural
MODULATION - Subarachnoid
Descending
modulation Dorsal Horn - Peripheral nerve block
Ascending Dorsal root
input ganglion
- LA
TRANSMISSION - COX1 inhibitor
- COX2 inhibitor
- Steroids
Spinothalamic
Peripheral
tract TRANSDUCTION
nerve

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.
Effect Magnitude
Blood loss or 30%
transfusion
requirements
Pulmonary 40%
complications
Thromboembolic 50%
complications
Ileus (abdominal 2 days
procedures)
Mortality (acute hip 25%
surgery)
= Reduced.
Beda Pembedahan Beda Intensitas
Nyeri

Different Different
types pain
of pain intensity

Different
procedures

Different risks
and benefits of Different
analgesic location
techniques of pain
Perioperative Multimodal Analgesia
Parecoxib
Ketamine
Ibuprofen
ivNMDA
COX2 inhibitor antagonists
iv

NSAIDs
iv Better analgesia:
synergy
Multimodal additivity

Paracetamol Reduced 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
NSAID

COXIB

Tramadol
OPIOID

Ketamine
PARACETAMOL
Gabapentanoid
(Morphine, Fentanyl)

(Gabapentin, Pregabalin)
Choice of Analgesic Technique
(Analgesic Ladder of WFSA)

Opiate Oral route available give orally

Pain And
NSAID Oral route unavailable
Intensity and Rectal paracetamol & NSAID Opiate:
High Tech: PCA
Paracetamol Low tech: IM algorithm Epidural
infusion analgesia

NSAID
and
Paracetamol

Pain Paracetamol
decreases as
time passes
Fast Track Surgery
Wilmore and Kehlet (BMJ 2001; 322: 437-476)
Surgery is undergoing revolutionary
change due to newer approaches to
pain control
Regional anesthesia (epidural, spinal or
nerve blocks)
Minimal invasive surgery
Optimal pain control
Aggressive postoperative rehabilitation
Early mobilization
Early oral nutrition
Minimal use of tubes, drains and catheters

Increased Outcome of Surgical Patient


Kesimpulan
1. Pathophysiology and mechanism of
postoperative pain is the occurrence of:
1. Peripheral sensitization
2. Central sensitization
2. Basic principle pain management is treating.
1. Peripheral sensitization:
Local anesthetic
NSAIDs (COX1 or COX2 inhibitor)
2. Central sensitization:
Opioids
Ketamine low dose
Kesimpulan

3. Balanced analgesia (multimodals) is the


best regiment.
4. Optimal postoperative pain relief, not only
decrease morbidity and mortality but also
reduce the cost, prevent the developing
of chronic pain and humanity.
5. Multifaceted interventions is needed to
increase the outcome.
A close relationship between
the surgeon & Anesthesiologist