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Acute Pain Management

an introduction

Noroyono Wibowo
Fetomaternal Division
Department Obstetrics & Gynecology
FMUI - Dr CMGH
Jakarta
Pain: The Fifth Vital Sign

1.Pulse
Pain:
2.Blood pressure The Fifth
Vital Sign *
1

3.Temperature
4.Respiratory rate

*Trademarks are the property of their respective owners.

1
American Pain Society Web site.
Treatment of Pain: an Unmet Medical Need

Inadequately treated pain can have many negative effects


on patients1
There is an urgent need for patient education about
pain management
Pain management is moving toward new treatments to
meet physician and patient needs
New guidelines from associations such as Europe Against
Pain (EAP) and the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) underscore the need
for better pain management2,3
1
Cousins M et al. Textbook of Pain. 1999:447-491.
2
European Federation of IASP Chapters. Europe Against Pain Web site. Available at: http://www.efic.org/eap.htm. Accessed October 31, 2003.
3
Phillips DM. JAMA. 2000;284:428-429.
Pain Continues to be Undertreated
Postoperative pain U.S., 1996 and 19991,2

100%

90%
82%
80% 77%
1993 (n=135)
70% 1999 (n=250)

60%
Patients

50%
49% 47%

40%
.
30%
23%
19% 21%
20% 18%
13%
10% 8%

0%
Any Slight Moderate Severe Extreme
Pain Pain Pain Pain Pain

Adapted from Apfelbaum J et al. Anesth Analg. 2003;97:534-540.


Potential Consequences of Poor
Pain Management
Decreased motion1
Prolonged rehabilitation
Muscle atrophy
Pneumonia
Prolonged hospitalization1,2
Increased cost1,2
Greater hospital resource utilization
Psychological impact1
Poor patient satisfaction1

1
Cousins et al. Textbook of Pain. 1999:447-491.
2
Zimberg SE. Manag Care Q. 2003;11:34-36.
Incidence of Postoperative Pain:
Outpatient Surgery1
70% 65%
Worst Pain: Moderate to Severe
60% Average Pain: Moderate to Severe

50% 45%
Patients (%)

40%
40%

30% 26%
24%
20%
13%
10%

0%
24 hours 48 hours Day 7
Time After Discharge

1
Beauregard L et al. Can J Anaesth. 1998;45:304-311.
Clinical Significance
of the Basic Science of Pain

Not all pains are the same


Not all patients have the same pain sensitivities
Not all patients have the same pain relief from opioids
Not all patients have the same side effects of opioids
Not all opioids are the same
Not all opioid receptors are the same
Not all mu opioid receptors are the same

Pasternak, 2001
The Goals of Emergency Medicine
Pain Management1
Meet the humanitarian need for pain
relief
Provide rapid diagnosis for immediate
intervention
Provide rapid relief without complicating
diagnosis or limiting further treatment
options

1
Cousins N, Power I. Acute and postoperative pain. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed. Edinburgh,
UK: Churchill Livingstone; 1999:447-491.
Pain Sensitization
10
Hyperalgesia Normal
8 Pain
Response
Pain Intensity

6 Injury
Hyperalgesia
4 heightened sense of
Allodynia pain in response to
noxious stimuli
2 Allodynia pain
resulting from normally
painless stimuli
0
Stimulus Intensity

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1980.


Pain Mechanisms: Peripherally and
Centrally Induced COX-21,2
Peripheral Central
Trauma / inflammation Pathophysiologic conditions
(eg, hypoxia, ischemia) or
PLA2 IL-1 inflammatory stimuli
IL-6?

Release of arachidonic acid


Induction of COX-2
induction of COX-2

Prostaglandins
Prostaglandins
Central sensitization

Sensitivity of
peripheral nociceptors Abnormal pain sensitivity

Pain
1
Samad TA et al. Nature. 2001;410:471-475.
2
Smith CJ, Zhang Y, Koboldt CM, et al. Pharmacological analysis of cyclooxygenase-1 in inflammation. Proc Natl Acad Sci USA. 1998; 95:13313-13318.
Pain Transmission
Pain

COX-2
Descending
modulation Dorsal Horn

Ascending Dorsal root


input ganglion

COX-2
Spinothalamic
Peripheral
tract
nerve

Trauma
Peripheral
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
Treatment Options for Acute
and Chronic Pain

NSAIDS
Nonspecific
COX-2 specific
Opioids
Local anesthesia
Adjunctive therapy
Other
1

Klasifikasi NSAIDs berdasarkan Struktur Kimia

Carboxylic acid

Salicilic and Phenylacetic Indolacetic Propionic Acid Phenamic


Ester Acids Acid Acid Acid

Aspirin Diclofenac Indomethacin Ibuprofen Flufenamic Acid


Diflunisal Aceclofenac Sulindac Naproxen Mefenamic Acid
Fenclofenac Tolmetin Flurbiprofen Meclofenamate
Ionacolac Acemethacin Fenbrufen
Metizinic Zidomethacin Benoxaprofen
Etodolac Fenoprofen
Indoprofen
Ketoprofen
Pirprofen
Tiaprofenic Acid

Enolic Acid Alkanos Sulphonanilide Coxib

Pyrazolones Oxicams Naphtylalkanone Methan


Nabumetone Sulphonanilide Celexocib
Refexocib
Oxyphenbutazone Piroxicam Acid 6 MNA Valdecoxib
Phenylbutazone Tenoxicam
Feprazone Nimesulide Parecoxib
Eterocoxib
Commonly Used Pain Medications:
Nonspecific NSAIDs
Mechanism of Action Benefits Prescribing
Considerations
Inhibition of COX-1 and Anti-inflammatory Risk of GI and
COX-2 isoenzymes analgesic1 antiplatelet adverse
inhibits prostaglandin Non-narcotic safety events1
synthesis1 profile1 Ceiling effect2
Effective relief of pain Use with caution in
on movement1 patients with impaired
Multimodal efficacy1 renal function and/or
Enhanced considerable
analgesic effect dehydration2

1
Power I et al. Surg Clin North Am. 1999;79(2):275-295.
2
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.
Further Considerations in Prescribing
Nonspecific NSAIDs
Peptic ulceration; gastrointestinal hemorrhages
Gastrointestinal 1,2 Esophagitis and strictures
Small and large bowel erosive disease

Inhibition of platelet aggregation


Hematologic3 Increased risk of bleeding

Reversible acute renal failure


Fluid and electrolyte disturbance/edema
Chronic renal failure and interstitial fibrosis
Cardiorenal1 Interstitial nephritis
Nephrotic syndrome
Exacerbation of
Hypertension
Congestive heart failure
Angina

1
Brooks P. Am J Med. 1998;104(suppl 3a):9S-13S.
2
Girgis L et al. Drugs Aging. 1994;4(2):101-112.
3
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.
Commonly Used Pain Medications: Opioids
Mechanism of Action Benefits Prescribing
Considerations

Bind to opioid Effective in severe pain1 Serious risks


receptors, producing Not associated with GI associated with
agonist action that bleeding1 opioid side effects2,3
inhibits pain impulses1 Generally, no Risk of tolerance
ceiling effect2 and dependency3

1
Moreland LW, St. Clair EW. The use of analgesics in the management of pain in rheumatic diseases. Rheum Dis Clin North Am. 1999;25:153-191.
2
Atcheson R, Rowbotham DJ. Pharmacology of acute and chronic pain. In: Rawal N, ed. Management of Acute and Chronic Pain. London, England: BMJ Books;
1998:23-50.
3
Power I, Barratt S. Analgesic agents for the postoperative period. Nonopioids. Surg Clin North Am. 1999;79:275-295.
Further Considerations in Prescribing
Opioid Analgesics1-3
Respiratory depression
Adverse Nausea, vomiting, and constipation
Effects Sedation and cognitive impairment
Urinary retention
Pruritus
Urticaria

Special Issues Chronic use can lead to development of physical


dependence and tolerance
Less able to control pain on movement
Can produce withdrawal syndrome with abrupt cessation
Many single and combination opioid agents are
short-acting, requiring multiple daily doses
Increased utilization of hospital resources

1
Moreland LW et al. Rheum Dis Clin North Am. 1999;25:153-191.
2
Power I et al. Surg Clin North Am. 1999;79:275-295.
3
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.
Commonly Used Pain Medications:
COX-2 Specific Inhibitors

Mechanism of Action Benefits Prescribing


Considerations
Selective for COX-2 Anti-inflammatory analgesic2 Ceiling effect4
isoenzyme inhibition1 No effect on platelet Use with caution in
aggregation 3
patients with impaired
Non-narcotic safety profile2 renal function or
Effective relief of pain considerable
on movement2 dehydration4
Multimodal efficacy2
Enhanced analgesic effect
Lower risk of GI side effects1

1
Needleman P et al. J Rheumatol. 1997;24(Suppl 49):6-8.
2
Power I et al. Surg Clin North Am. 1999;79(2):275-295.
3
Noveck RJ et al. Clin Drug Invest. 2001;21(7):465-476.
4
Atcheson R, Rowbotham DJ. Pharmacology of acute and chronic pain. In: Rawal N, ed. Management of Acute and Chronic Pain. London, England: BMJ
Books; 1998:23-50.
COX-1 vs COX-2 1-3

COX-1 COX-2
Constitutive in many tissues Inducible (in most tissues)
Present in most tissues Induced mainly at sites of
Synthesizes PGs inflammation by cytokines
that regulate physiologic Synthesizes PGs that
processes mediate inflammation,
Especially important in pain, and fever
Gastric mucosa Constitutive expression
Kidneys primarily in
Platelets CNS
Vascular endothelium Kidneys

1
Needleman P et al. J Rheumatol. 1997;24(suppl 49):6-8.
2DuBois RN et al. FASEB J. 1998;12:1063-1073.
3
Samad TA, Moore KA, Saperstein A, et al. Interleukin-1-mediated induction of COX-2 in the CNS contributes to inflammatory pain hypersensitivity.
Nature. 2001;410:471-475.
Cyclooxygenase (COX) in Platelets1

Platelet (Cox)-1 Inhibitors of


COX-1
(-)

Thromboxane A2
Increased
bleeding

Platelet
aggregation

1
Noveck RJ et al. Clin Drug Invest. 2001;21(7):465-476.
MEKANISME TIMBULNYA
NYERI PERSALINAN
DAMPAK NYERI
PERSALINAN
THD AKTIFITAS RAHIM DAN
KEMAJUAN PERSALINAN
Kontraksi tidak teratur / menurun
mempengaruhi lama persalinan.
THD JANIN
Mengurangi transfer oksigen dari ibu ke
janin.
Pola detak jantung janin abnormal.
BERBAGAI POSISI SAAT
KALA I
BERBAGAI POSISI SAAT
KALA II
PENDAMPINGAN
PERSALINAN
1. Pendampingan persalinan oleh suami
dapat menurunkan tingkat kecemasan
secara bermakna ( p = 0,000 ).
2. Skor nyeri VAS pada kala I fase aktif
menurun bermakna ( p = 0,028 ),
sedangkan pada kala II menurun tidak
bermakna ( p = 0,054 ).
PENDAMPINGAN
PERSALINAN
3. Pendampingan persalinan oleh suami
dapat menurunkan secara bermakna
sekresi hormon kortisol ( p = 0,025 ).