Professional Documents
Culture Documents
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
1
American Pain Society Web site.
Treatment of Pain: an Unmet Medical Need
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
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
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
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
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
Carboxylic acid
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
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
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
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
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
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 ).