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
1Cousins M et al. Textbook of Pain. 1999:447-491.
2European Federation of IASP Chapters. Europe Against Pain Web site. Available at: http://www.efic.org/eap.htm. Accessed October 31, 2003.
3Phillips 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)
1999 (n=250)
70%

60%
Patients

49% 47%
50%

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
Average Pain: Moderate to Severe
60%

50% 45%
Patients (%)

40%
40%

30%
24% 26%

20%
13%
10%

0%
24 hours 48 hours Day 7
Time After Discharge

1Beauregard 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
1
Pain Management
• 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-1β 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
1Samad TA et al. Nature. 2001;410:471-475.
2Smith 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
Zidomethacin Benoxaprofen
Metizinic
Etodolac Fenoprofen
Indoprofen
Ketoprofen
Pirprofen
Tiaprofenic Acid

Enolic Acid Alkanos Sulphonanilide Coxib

Pyrazolones Oxicams
Naphtylalkanone Methan
Nabumetone Sulphonanilide Celexocib
Refexocib
Oxyphenbutazone Piroxicam
Phenylbutazone Tenoxicam Acid 6 MNA
Nimesulide
Valdecoxib
Feprazone Parecoxib
Eterocoxib
 Commonly Used Pain Medications:
Nonspecific NSAIDs
Mechanism of Action Benefits
• Inhibition of COX-1 and • Anti-inflammatory
COX-2 isoenzymes analgesic1
inhibits prostaglandin • Non-narcotic safety
synthesis1 profile1
• Effective relief of pain
on movement1
• Multimodal efficacy1
– Enhanced
analgesic effect
Prescribing
Considerations
• Risk of GI and
antiplatelet adverse
events1
• Ceiling effect2
• Use with caution in
patients with impaired
renal function and/or
considerable
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
1,2
• Peptic ulceration; gastrointestinal hemorrhages
Gastrointestinal • Esophagitis and strictures
• Small and large bowel erosive disease

Hematologic3 • Inhibition of platelet aggregation

• Increased risk of bleeding

• Reversible acute renal failure

Cardiorenal1 • Fluid and electrolyte disturbance/edema
• Chronic renal failure and interstitial fibrosis
• Interstitial nephritis
• Nephrotic syndrome
• Exacerbation of
– Hypertension
– Congestive heart failure
– Angina
1Brooks P. Am J Med. 1998;104(suppl 3a):9S-13S.
2GirgisL et al. Drugs Aging. 1994;4(2):101-112.
3Atcheson 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
Adverse • Respiratory depression
• 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

1Needleman P et al. J Rheumatol. 1997;24(Suppl 49):6-8.

2Power I et al. Surg Clin North Am. 1999;79(2):275-295.
3Noveck RJ et al. Clin Drug Invest. 2001;21(7):465-476.
4Atcheson 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.
 1-3
COX-1 vs COX-2
COX-1 COX-2
• Constitutive in many • Inducible (in most
tissues tissues)
• Present in most tissues • Induced mainly at sites
• Synthesizes PGs of inflammation by
that regulate physiologic cytokines
processes • Synthesizes PGs that
• Especially important in mediate inflammation,
– Gastric mucosa pain, and fever
– Kidneys • Constitutive expression
– Platelets primarily in
– Vascular endothelium – CNS
– Kidneys
1Needleman P et al. J Rheumatol. 1997;24(suppl 49):6-8.
2DuBois RN et al. FASEB J. 1998;12:1063-1073.
3Samad TA, Moore KA, Saperstein A, et al. Interleukin-1β-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

1Noveck 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 ).