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Penanganan Nyeri

Akut Membandel
Ardi Pramono

Pain ??
An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.(The International
Association for the Study of Pain)
Involved:
Transduction: Change of noxious stimulus to
electrical modalities

Transmision: along sensory nerve fiber A


and C
Modulation: Complex processing in
substantia gelatinosa. Interaction
between excitatory or inhibitory
neurotransmitter
Perception: in central somatosensory
cortex

CLINICAL PAIN
Inflammatory response
surgery, cancer & chronic pain

Peripheral nerve injury


surgical section, invasion, trauma

Peripheral Sensitisation
Central sensitisation
Metabolic & endocrine changes
An affective component

Categorized
1) acute pain, which is primarily due to
nociception
Somatic pain
Visceral pain

2) chronic pain, which may be due to


nociception but in which psychological
and behavioral factors often play a major
role (1-6 month)

TREATMENT OF PAIN
GOALS OF THERAPY

Decrease the frequency and / or severity


of the pain
General sense of feeling better
Increased level of activity
Return to work
Decreased health care utilization
Elimination or reduction in medication
usage

Copyright 2003 American Society of Anesthesiologists. All rights reserved

Pathophysiology
Pain arises when nociceptors become sufficiently
stimulated/damaged (i.e. by strength and/or duration of
exposure)
or when visceral nociceptors are sufficiently
deformed/damaged to generate humoral and/or cellular
responses.
Parallel ascending pathways detect the affective
(unpleasantness) and sensory (discriminative)
components to convey to the CNS the information about
damage in the tissue served.
Resultant activation of descending pathways leads to
modulation/inhibition of the nociceptive input.

Pathophysiology
stimulation also produces altered gene
expression in the spinal cord & brain
leaving behind a physical memory of
nociception & pain.
In the periphery, immune cells activated
by neural & humoral events respond by
releasing cytokines, as well as
endogenous opioids.

Term

Allodynia: Perception of an ordinarily

nonnoxious stimulus as pain


Analgesia: Absence of pain perception
Anesthesia: Absence of all sensation
Anesthesia dolorosa:Pain in an area that lacks
sensation
Dysesthesia: Unpleasant or abnormal
sensation with or without a stimulus
Hypalgesia (hypoalgesia):Diminished
response to noxious stimulation (eg, pinprick)

Hyperalgesia: Increased response to noxious


stimulation
Hyperesthesia:Increased response to mild
stimulation
Hyperpathia:Presence of hyperesthesia,
allodynia, and hyperalgesia usually associated
with overreaction, and persistence of the
sensation after the stimulus
Hypesthesia (hypoesthesia): Reduced
cutaneous sensation (eg, light touch, pressure,
or temperature)

Neuralgia:Pain in the distribution of a


nerve or a group of nerves
Paresthesia:Abnormal sensation
perceived without an apparent stimulus
Radiculopathy:Functional abnormality of
one or more nerve roots

Chemical Mediators of Pain

Neurotransmitter

Receptor1

Substance P

Calcitonin gene-related peptide

Glutamate

NMDA, AMPA, kainite, quisqualate

Excitatory

Aspartate

NMDA, AMPA, kainite, quisqualate

Excitatory

Adenosine triphosphate (ATP)

Somatostatin

Inhibitory

Acetylcholine

Muscarinic

Inhibitory

Enkephalins

Inhibitory

-Endorphin
-Endorphin

Inhibitory

Norepinephrine

Inhibitory

Adenosine

A1

Inhibitory

Serotonin

5-HT1 (5-HT3)

-Aminobutyric acid (GABA)

Glycine Inhibitory

1NMDA, N-methyl-D-aspartate; AMPA, 2-(aminomethyl)phenylacetic acid; 5-HT, 5-hydroxytryptamine.

NK1

Effect on Nociception

Excitatory
Excitatory

P1, P2

A, B

Excitatory

Inhibitory
Inhibitory

Systemic Responses to
Acute Pain
Efferent limb is mediated by the sympathetic
nervous and endocrine system
cathecolamine release:
Cardiovascular effects
Respiratory effects
Gastrointestinal and urinary effects
Endocrine effects cathecolamine, cortisol,
glucagon increase
Immune effects: depress the reticuloendothelial
system

Management
Pain measurement:
Visual analog scale (VAS)
McGill pain questionnaire (MPQ)

Perioperatif Preemptif therapy


Balanced analgesia
Neural blockade
Pharmacologic intervention:
COX inhibitor,Opioids, Antidepresant, anticonvulsant,
neuroleptic, corticosteroid, local anesthetics

Post surgery rehabilitation

Multimodal analgesia
Low-tech

Intermittent opioid bolus: SC, IM,


IV, Oral

High-tech

Epidural or Nerve Plexus


Infusion
PCA to deliver opioid

PAIN
INTENSITY

Oral NSAID and /or


Tramadol +/- Paracetamol
Oral Paracetamol
+/- NSAID

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