Management of Acute Pain

ANLS 2012

JAKARTA, 1-2 DESEMBER 2012

Definition Pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage”

International Association for the Study of Pain,(IASP), 1986

Klasifikasi Sindroma Nyeri

Nociceptive

Duration Pathophysiology

mixed Neuropathic

Somatic Visceral Peripheral Central

-superficial -deep

-Acute : < 3-6 months, mostly nociceptive -Chronic : > 3-6 months, mostly neuropathic

Acute Chronic

idiopatik

Klasifikasi Nyeri • Nyeri sederhana/fisiologik

nyeri timbul oleh berbagai stimuli yang tidak menimbulkan kerusakan jaringan

• Nyeri patologis/klinis

1. nyeri inflamasi (nyeri akut/nyeri nosiseptik)

nyeri timbul oleh berbagai stimuli yang me-

nimbulkan kerusakan jaringan.

2. nyeri neuropatik : nyeri krn lesi primer atau

disfungsi sistem saraf perifer atau sentral

3. nyeri idiopatik/psikogenik : nyeri yg kausanya

tidak jelas

Nociceptive

Psy

cho

logi

cal

pain

a b

Haddox, 1990; Mariano, 2001

Physical state

Perception

nociceptor Reflex action

environment

Affect/mood

Evaluation

Memory & expectation Actions

Response

Symptoms & signs

Painful : Non-Painful :

Diagram Nyeri (Farrar.J.T)

BERDASARKAN INTENSITAS NYERI (Numeric Pain Rating Scale)

INTENSITAS NPRS

NYERI RINGAN 1 - 3 NYERI SEDANG 4 - 7 NYERI BERAT 7 - 10

Faces Pain Rating Scale (untuk anak)

VISUAL ANALOG SCALE (VAS)

NUMERIC PAIN RATING SCALE (NPRS)

• Post-operative Pain

• Traumatic injury-related Pain

• Burn Pain

• Acute Herpes Pain

• Acute Pain in Obstetrics

• Sickle Cell Pain

• Cancer-related Pain

Kausa Sindroma Nyeri

• Headache

– Musculoskeletal : muscle tension

– Vascular : migraine, aneurysm

– Complex : compound headache

• Musculoskeletal Pain (back pain)

• Ischemic Pain

• Chest Pain

– Angina/ischemia

– Esophagitis/reflux

– Pleuritic pain : effusion, pneumonia, inflammation

Kausa Sindroma Nyeri .. 2

• Abdominal Pain

– Acute exacerbation of Pancreatitis

– Acute abdomen : perforation, obstruction, aneurysm dissection/rupture

– Renal colic

• Neurogenic Pain

– Herniated disk

– Nerve compression

Kausa Sindroma Nyeri .. 3

Examples Peripheral

• Postherpetic neuralgia

• Trigeminal neuralgia

• Diabetic peripheral neuropathy

• Postsurgical neuropathy

• Posttraumatic neuropathy

Central

• Poststroke pain

Common descriptors2

• Burning

• Tingling

• Hypersensitivity to touch or cold

Examples

• Pain due to inflammation

• Limb pain after a fracture

• Joint pain in osteoarthritis

• Postoperative visceral pain

Common descriptors2

• Aching

• Sharp

• Throbbing

Examples

• Low back pain with

radiculopathy

• Cervical radiculopathy

• Cancer pain

• Carpal tunnel syndrom

Mixed Pain Pain with

neuropathic and

nociceptive

components

Neuropathic Pain Pain initiated or caused by a

primary lesion or dysfunction

in the nervous system

(either peripheral or

central nervous system)1

Nociceptive Pain Pain caused by injury to

body tissues

(musculoskeletal,

cutaneous or visceral)2

1. International Association for the Study of Pain. IASP Pain Terminology.

2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57

Kausa Nyeri (Patofisiologi)

Lumbar

vertebra

Disc herniation

Activation of peripheral nociceptors –

cause of nociceptive pain component

Compression and inflammation of nerve root –

cause of neuropathic pain component

LBP & Lumbal Radiculopati

karena HNP (mixed Pain)

Iskemik, Spasme Cedera, dll

Nosiseptor free nerve

ending

Histamine K*, bradikinin Prostaglandin

5-HT

Mekanisme Rasa Nyeri

NAP Cornu

dorsalis

A myelin/fast C unmyelin/slow

Substanse P

Platelet - serotonin Mass cell - histamin

1. Transduksi 2. Transmisi 3. Persepsi 4. Modulasi

GABA, Glycine Adenosine Bombesin Cholecystokinin Dynorphin Enkephalin Neuropeptide-Y

Kortek Talamus

1

2 3 4

Jenis-jenis Serabut Saraf Fiber type Function Ø fiber

(mm) Conduction

velocity (m/s) Hypoxia Pressure LA

Aα Propriception somatic motor

12-20 70-120 ++ +++ +

Aβ Touch, pressure 2-12 30-70

Aγ Motor to muscle spindle

3-6 15-30

Aδ Pain,cold, touch 2-5 12-30

B Preganglionic otonomic

<3 3-15 +++ ++ +

C dorsal root Pain, temperature mechanoreception, reflex response

0.4-1.2 0.5-2 ++ ++ +++

C simpatetik

Postganglionic sympathetic

0.3-1.3 0.7-2.3

A and B fibers are myelinated, C : fibers unmyelinated, LA : local anesthetic +: least susceptible, ++ : intermediated susceptibility, +++ : most susceptible

Dorsal Horn Dorsal root

ganglion

Peripheral sensory

Nerve fibers

A

A

C

Large

fibers

Small

fibers

Sensory Afferent Neurons 1. Large myelinated Aβ fibers, very fast conduction velocity, respond to innocuous stimuli. 2. Small myelinated Aδ & C unmyelinated fibers, have slow conduction velocity, respond to noxious stimuli

Dapat dibagi menjadi 4 tahap yaitu :

1. Tranduksi : proses timbulnya aktivitas listrik krn stimulasi noksius pd reseptor “nerve ending”

2. Transmisi : menjalarnya impul nyeri dr nosiseptor aferen primer(NAP) ke kornu dorsalis med spinalis

3. Persepsi : Impul rasa nyeri diterima talamus kmd diproyeksikan ke kortek somatosensorik & kortek asosiasi timbul kesadaran rasa nyeri

Mekanisme Rasa Nyeri

4. Modulasi : aktivitas selektif sel saraf untuk meng-hambat transmisi rasa nyeri via serabut saraf Aδ, medula spinalis, medula oblongata & midbrain. Ada 2 teori modulasi,

a. Gate control hypothese - modulasi nyeri saraf asenden yaitu jika serat saraf C di aktivasi terjadi inhibisi inter-neuron pintu nyeri akan terbuka, jika serat saraf Aδ di aktivasi terjadi eksitasi interneuron pintu nyeri akan tertutup

b. Sistem opioid endogen - modulasi nyeri saraf desenden berasal dari :

Mekanisme Rasa Nyeri .. 2

midbrain

med.obl

(a)

(b)

(b)

med.spin (c)

a. Midbrain : periaquaduct gray-matter (PAG) mengandung μ reseptor yg dpt mengaktivasi opioid endogen.

b. Medula oblongata, di : - nucleus raphe magnus (NRM)

melepas serotonin. - NPRG (nucl reticularis para

giganto cellularis) melepas noradrenalin

c. Cornu dorsalis Med spinalis, dapat menghambat trasmisi nosiseptor.

Rasa nyeri ↓ atau menghilang.

2: Nosiseptor melepas substance P pemb drh

melebar & dilepas media- tor inflamasi yi Bradykinin

(redness and heat)

3: Substance P juga me- rangsang degranulasi mass

cells, dilepas zat histamin (swelling)

Pain-sensitive tissue

Painful stimulus

Prostaglandin

Substance P

Histamine

Mast cell

Blood vessel

Bradykinin

Nociceptor

Substance P

2 3

1

1: cedera jaringan merang- sang pembentukan prosta-

glandin sensitivitas no- siseptor ↑ (pain)

Mekanisme Rasa Nyeri

S

P C

I O

N R

A D

L

Lateral

thalamus

kortek

somasensorik

ACTH

associative

cortex

medial

thalamus reticular

formation

hypothalamus

Mediator Humoral

Perifer

Interleukin 1 & 2

TNF/tumor necr F

Bradykinin

α interferon

PGE1,PGE2, etc

Pituitary. gl

sympatic

Nerv syst

adrenal

gland

pancreas

spinothalamic

neospinothalamic

spinoreticular paramedian

propiomelano-

cortin

growth horm

prolactin

vasopressin

Nor-eph

Epineph

Enkephalins

Aldosterone

cortisol

glucagon

β endorphin

Affect

Sensation

Corticotropin-releasing factor

Vasoactive-intestinal peptide

Post-Injury Stress Response

Metabolic and Endocrine responses to injury

↑ ACTH, cortisol , ADH, growth H, Catecholamine, angiotensin II, aldosterone, glocagons, IL-1, TNF, IL-6

↑catabolic hormons Endocrine

↓insulin, testosterone ↓anabolic hormons

Metabolic

↑glycogenolisis, gluconeogenesis (cortisol, glucagon, growth H, adrenalin, free fatty acid). ↓insulin secretion/activation.

Hyperglycemia, glucose intolenrance, insulin resistence

carbohydrate

↑cortisol, adrenalin, glucagon, IL-1, IL-6 dan TNF.

Muscle prot catabolism ↑synthesis of acute phase proteins

Protein

↑catecholamine, cortisol, glucagon, growth H.

↑lypolysis & oxidation Lipid

Metabolic and Endocrine responses to injury .. 2

↑catecholamine, aldosterone, ADH, cortisol, angiotensin II, prostaglandin and othersfactors.

retention of water and sodium. ↑ excretion of potassium, ↓functional ECF with shifts to ICF

water and electrolyte flux

Note: ICF - intracellular fluid, EC F- extracellular fluid, TNF - tumor necrosis factor

Source: acute pain management; the scientific evidence (NHMRC, 1999)

Gejala klinik Nyeri Nosiseptif Akut

• Onset mendadak • kualitasnya tajam, tertikam, tertusuk • Lokalisasi • Self-limiting • mungkin ada manifestasi fisiologis dgn berbagai

sistem organ yg lain. • Response Autonom: palpitasi, ↑tekanan darah,

berkeringat , etc • Biasanya kausa jelas • Dipengaruhi keadaan fisiologis

Karakteristik Nyeri Somatik Dalam

• kualitas nyeri : tumpul dan sakit

• kurang terlokalisir dibanding nyeri superfisial

• berhubungan dgn hiperalgesia kutaneus, allodinia, lemas, reflek otot spasme , hiper-aktivitas simpatis.

Tatalaksana Nyeri Akut

• Tujuan : mencegah nyeri akut menjadi kronik

– Terapi nyeri akut harus adekuat

– Cegah “yellow flags”

• Terapi

– Kausal : merawat luka, reposisi dan fiksasi fraktur, operasi.

– Farmakologik : analgetik opioid, non-opioid, analgetik ajuvan (AED, antidepresan, dll)

– Non Farmakologik : terapi fisik, psikologis, dll

Cegah Nyeri Akut Jadi Kronik

Acute (nociceptive)

Chronic (neuropathic)

Biological function (+)

Biological function (-)

Avoid tissue damage

disadvantage

Psychological *triad :

Physical *impairment *disablity

Pain

Mood Sleep

> Dysfunction ↓QoL > Socioeconomic loss

Advantage *health *well being

Terapi adekuat : -Cegah nyeri kronik -Cegah Yellow Flag

Kausal :

• Medis

– Antibiotika

– Kemoterapi

– radioterapi

• Surgical

– Perawatan luka

– Operasi/mengangkat tumor

– Fiksasi/operasi fraktur

Tatalaksana Sindroma Nyeri

• Terapi farmakologik :

– Analgetik non opioid

– Analgetik opioid

– Antikonvulsan

– antidepresan

• Terapi non-farmakologik :

– neurostimulasi (TENS),

– psikologis (kognitif behavior, relaksi, hipnosis).

• Terapi invasif/operasi

– Perawatan luka

– Fiksasi/operasi fraktur

Tatalaksana Sindroma Nyeri .. 2

Prinsip Terapi Nyeri Akut & Berat Beri analgesik dosis maksimal

Alur Terapi Nyeri Kronik (WHO ANALGESIC LADDER 1996)

Non opioid +/- Adjuvant

Opioid for mild to moderate pain +/- Non opioid , +/- Adjuvant

Opioid for moderate to severe pain +/- Adjuvant

Step 1

Step 2

Step 3

Persisting Pain

Persisting Pain

Freedom from pain

Farmako Terapi Nyeri Inflamasi

NYERI RINGAN

FARMAKOTERAPI TINGKAT I

Nama Obat Dosis Jadwal

Aspirin 325-650 mg, mak 4 g/hr 4 jam sekali

Asetaminofen 325-650mg 4-6 jam sekali

FARMAKOTERAPI TINGKAT II

Ibuprofen 200mg 4-6 jam sekali

Sodium Naproxen Awal 440mg, selanjutnya 220mg 8-12 jam sekali

Ketoprofen 12,5mg 4-6jam sekali

Farmako Terapi Nyeri Inflamasi .. 2

NYERI SEDANG

FARMAKOTERAPI TINGKAT III

Nama Obat Dosis Jadwal

Asetaminofen Penyesuaian dosisi misal

Aspirin 1000mg

4 jam sekali

Ibuprofen 4-6 jam sekali

Sodium naproxen 8-12 jam sekali

Ketoprofen 4-6 jam sekali

FARMAKOTERAPI TINGKAT IV

Jika terapi tk. III, OAINS yg dipilih dapat diganti, pilihan OAINS ke-2 sebaiknya dr kelompok kimia yg berbeda (lihat tabel analgesik non-opioid yg sering digunakan

FARMAKOTERAPI TINGKAT V

Opioid (misal : codein)

FARMAKOTERAPI TINGKAT VI

Tramadol 50-100mg 4-6 jam

Farmako Terapi Nyeri Inflamasi .. 3 NYERI BERAT

FARMAKOTERAPI TINGKAT VII

Nama Obat Indikasi Mekanisme

Morfin Bila th/ non-narkotik tdk efektif dan terdapat riwayat th/ narkotik untuk nyeri

4 jam sekali

Campuran agonis -antagonis pentazosin

Blok aktivasi komponen mμ komplek reseptor

Agonis parsial idem

Analgetik Non Opioid yang Paling Sering Digunakan

Nama Obat Dosis Jadwal

Aspirin 325-1000mg 4-6 jam sekali

Kalium diklofenak 50-200 mg 8 jam sekali

Natrium diklofenak 50 mg 8 jam sekali

Ibuprofen 200-800 mg 4-8 jam sekali

indometasin 25-50 mg 8-12 jam sekali

Ketoprofen 25-75 mg 6-12 jam sekali

Asam Mefenamat 250 mg 6 jam sekali

naproxen 250-500 mg 12 jam sekali

Nama Obat Dosis Jadwal

Piroxicam 10-20 mg 12-24 jam sekali

Tenoxsicam 20-40 mg 24 jam sekali

Meloxicam 75 mg 24 jam sekali

Celecoxib 100 mg 12 jam sekali

Nimesulfid 100 mg 12 jam sekali

Ketoralax 10-30 mg 4-6 jam sekali

Asetaminofen 500 mg 6-8 jam sekali

Tramadol 50-100 mg 8 jam sekali

Analgetik Non Opioid yang Paling Sering Digunakan .. 2

Jenis Obat Pot Equal-analgesic Keterangan

Oral parenteral

Morphine 30mg 10mg Long acting oral 8-12 jam yg dpt diberikan rektal, hati-hati pd pts CRF dpt myoclonus

hydromorphone 7.5mg 1.5mg Opioid poten, bisa utk pts disfungsi renal

Oxycodone 20mg - Long acting diberikan o/rectal/8-12jam

Methadone 5mg ** Waktu paruh >24jam, penyesuaian dosis harus hati2, diberikan 6-8 jam utk th/ nyeri, dipakai utk nyeri neuropatik, ratio equal analgesik berubah dg dosis morphin oral >100mg, konsul spesialis

Derby, 1998 American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pai, 5th edition, 2003

Analgesik Opioid

Jenis Obat Pot Equal-analgesic Keterangan

Oral parenteral

Levorphanol 4mg 2mg Poten opioid dgn bbrp aktivitas NMDA antagonis

Meperidine 300mg 75mg Metabolisme normoperidine, stimulan CNS, dpt menimbulkan kejang pd pts dgn gagal ginjal.

Fentanyl *** - 100mcg Short-acting, bisa patch transdermal dan buccal

Codein 200mg 130mg 5-10% ras kaukusia tdk bisa merubah codein ke morphin, SE nausea dan konstipasi > dp opioid lain, efek narkose pd pts gagal ginjal

Hydrocodone 30mg - Sering dikombinasi dgn analgesik non-opioid,

Derby, 1998 American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pai, 5th edition, 2003

Analgesik Opioid .. 2

Non Farmakologi

1.Physical treatment

- Heat: diathermy, ultrasonic.

- Cold: compress, ice massage, vapo-coolant spray.

- Massage

- Exercise

- Ortosis.

- TENS, accupuncture.

2. Psychological therapy

Relaxation, biofeedback, education, hypnosis.

Spinal Cord Stimulator

SCS - equipment

Kesimpulan

1. Nyeri akut adalah respon fisiologis atas stimulasi noksius (mengancam/merusak jaringan atau tubuh). 2. Persepsi nyeri bersifat individual, dasar mekanisme fisiologisnya sangat komplek 3. Tatalaksana nyeri kronik/neuropatik ber- sifat multidisiplin meliputi terapi farmasi non farmasi, dan terapi bedah.

www.physiologyonline.org

• Nyeri akut: mekanisme tubuh utk melindungi & mencegah, supaya jaring-an yang cedera tdk ber-tambah parah, jaringan tsb dibatasi kemampuan gerak/mobilitasnya.

• Waktu berkisar 1-3 bulan

• Th/ jika tidak adekuat CHRONIC PAIN

Nyeri Nosiseptive (Akut)