Acute Pain Management

Fransisca Dewi Kumala

RSUD Kebayoran Lama

November 3rd 2022
Introduction
• Pain is main subjective for patient to find help at health institution
• As a healthcare worker, one of our competencies is to manage pain,
especially acute pain
• Inadequate pain management can lead to prolonged recovery,
prolonged length of stay at hospital, more cost and more ultimately
lead to chronic pain
• Pain is the fifth vital sign
Definition
• Unpleasant sensory and emotional experience associated with actual
or potential damage, or describe in terms of such damage
• Essentialy a sensation, but has strong cognitive and emotional
components
• Associated with avoidance motor reflexes and alterations in
autonomic output

Merskey H, Bugduk N. Classification of Chronic Pain. Descriptions of Chronic Pain

Syndromes and Definitions of Pain Terms. 2nd ed. Seattle: IASP Press; 1994.
Pain Classification

Duration Patophysiology Clinical

Post
Acute Nociceptive
operative

Chronic Inflammatory Cancer

Neuropathic Degenerative

Functional
Pain and Disease
• Pain can be adaptive or maladaptive
• Adaptive pain contributes to survival by protecting from injury or promoting
healing when injury has occured
• Maladaptive pain is an expression of the pathologic of the nervous system; it
is a disease
Pain Mechanism
1. Transduction
2. Transmission
3. Modulation
4. Perception
Why manage pain?
• Pain management is human right → Pain is the fifth vital sign
•  suffering due to pain
•  patient satisfaction
•  recovery speed →  LOS →  cost
•  complication due to pain
•  evolve to chronic pain
•  productivity and QoL

Wu CL, Raja SN. Treatment of acute postoperative pain. 2011;377:2215-25.

 Pain Effect (Postoperative)

Metabolic Cardiovascu Musculoske Nerve

Respiratory Gastrointes
Endocrine lar letal system
tinal

Hormonal HR, SVR, BP, Muscle

secretion myokard spasm,
(ACTH, O2 Breathing mobility Neuroplasti
restriction
Gut motility
cortisol, demand, impairment city
catecholami Hyperckoag , muscle
ne, insulin) ulation breakdown

Sympatheti Atelectasis, CHRONI

Prolonged
c, stress Infarct, DVT hypoxemia, Weakness
recovery C PAIN
response hypercarbia
 Neuroplasticity
“ the capacity of neuron to change their structure, function,
or chemical profile”

SSP
Sensitisasi sentral Mediator inflamasi
Spinal “wind-up”
Histamine, Leukotrienes,
Norepinephrine, Cytokines,
Bradykinin, Neuropeptides,
Prostaglandins,
5-HT,Purines, H+/K+ions
Hiperalgesia
sekunder
(Area tidak inflamasi)

Hiperalgesia
Sensitisasi perifer primer
(Area inflamasi)
Modify by AHT
Sensitization
Pain Assessment
• Obtain history of pain:
• Ask about onset, pattern, duration, location, intensity, and characteristics of the pain
• Find out aggravating or palliating factors, and the impact on the patient
• Evaluate psychological state of patient
• Screen for depression
• Anxiety
• Assess social networks and family involvement
Pain Assessment (PQRST)
• P = Provokes/palliates
• What causes pain? What makes it better? Worse?
• Q = Quality
• What does it feel like? Is it sharp? Dull? Stabbing? Burning? Crushing? ( Try to let patient
describe the pain, sometimes they say what they think you would like to hear. )
• R = Radiates/region
• Where does the pain radiate? Is it in one place? Does it go anywhere else? Did it start
elsewhere and now localised to one spot?
• S = Severity
• How severe is the pain on a scale of 1 - 10? ( This is a difficult one as the rating will differ
from patient to patient. )
• T = Time/temporal
• Time pain started? How long did it last?
Pain Assessment
• Evaluate psychological state of patient
• Screen for depression
• Anxiety, Assess social networks and family involvement
• Any medication allergy?
• Renal and liver function
Pain Thermometer

Pain as bad as it could be

Extreme pain
Severe pain
Moderate pain
Mild pain
Slight pain

No pain
(Herr and Mobily, 1993)
Neonatal Infant Pain Scale (NIPS) (<1 tahun)
NIPS 0 1 2

Ekspresi wajah Relaks Kontraksi / meringis -

Menangis Tidak ada Mumbling / merengek Kuat

Bernapas Relaks Perubahan pola nafas -

Lengan Relaks / tidak kaku Fleksi/extensi -

Tungkai Relaks / tidak kaku Fleksi/extensi -
Allertness Tidur/tenang Tidak nyaman, gelisah, rewel -

 Nilai 0-2 = tidak nyeri atau nyeri ringan,

 Nilai 3-4 = nyeri ringan – sedang,
 Nilai >4 = nyeri berat.
FLACC (Anak)
Kriteria 0 1 2
Face (wajah) Tidak ada ekspresi Sesekali meringis, Sering mengerutkan dahi,
tertentu / tersenyum mengerutkan dahi, tidak rahang terkatup, dagu
tertarik gemetar
Legs ( Kaki) Normal/santai Cemas, gelisah, tegang Menendang, menarik kaki

Activity Berbaring tenang, Menggeliat, tegang Melengkung, kaku,

(aktifitas) posisi normal, bergerak menyentak
mudah
Cry (tangis) Tidak ada teriakan, Mengerang, merintih, Menangis terus, terisak,
tenang mengeluh mengeluh terus-terusan
Consolability puas, tenang, santai Sesekali dihibur, Sulit untuk dihibur dan
dialihkan, diyakinkan dibuat nyaman
dengan sentuhan

 0 = tidak nyeri;
 7-9 = nyeri berat;
 1-3 = nyeri ringan;
 10 = nyeri sangat berat.
 4-6 = nyeri sedang;
The Pain Assessment in Advanced Dementia
(PAINAD) scale
Pain assessment in nonverbal patients

Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs. 2000 Mar; 1(1):13-21.
McGill Pain Questionnaire
• Multidimensional scales evaluate
pain in multiple domains
• to evaluate a person
experiencing significant
pain
• can be used to monitor the
pain over time and to
determine the effectiveness of
any intervention
Assess & Re-assess
• Before and after therapy given
• Based on patients words
• Asses non verbal signs
• Special needs for patient with cognitive impairment
• Use the right pain scale
• Documentation
Pain Management
• Non Pharmacological
• Electric stimulation (TENS / Transcutaneous Electrical Nerve Stimulation)
• Psychological : relaxation with serene environment, right positionin, deep
breath technique
• Distraction technique : distract attention to other stimulation for example,
watching, reading, listening to music
• Interventional Techniques
• Pharmacological
• Analgesic: Non opioid, opioid, adjuvant (antidepressant, anticonvulsant)
WHO Analgesic Ladder

WHO 1996
 Analgesic Ladder Modification

Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Can Fam Physician
2010;56:514-7.
Multimodal Analgesia

Is a combination of two or more

analgesics that act at different
mechanisms, produce additive or
synergistic analgesia

Vadivelu N, Mitra S, Schermer E, Kodumudi V, Kaye AD, Urman RD. Preventive analgesia
for postoperative pain control: a broader concept. Local and Regional Anethesia
2014;7:17-22.
 Analgesic Agents

NONOPIOID OPIOID ADJUVANT

•Weak Opioid • Steroid
• Paracetamol
•NMDA antagonist(Ketamine)
• NSAID (nonselektive) ( codeine, tramadol )
•Alfa-2 agonist(Clonidine)
• Coxib (selective NSAID) •Strong Opioid •Gabapentinoid
( Morfin, Fentanyl )
 Paracetamol
Acetaminophen/PAAP

Route
❖ Oral ❖Safe for almost all patients
❖ Rectal ❖ Dose 15-25 mg/kg every 6
❖ Intravena jam, max 4 gram/day
❖ Intravena
 Non-Steroidal Anti-Inflammatory Drugs
Arachidonic Acid Glucocorticoids
(fatty acid) (-) (block mRNA expression)

(-) (-)
NSAID
COX-1 COX-2

sCOXIB
Normal Normal
Induction
constituent constituent

⚫ Gastric cytoprotection ⚫ Inflammation ⚫ brain

⚫ Sodium balance / water and kidney ⚫ kidney
⚫ Pain
⚫ Platelet aggregation ⚫ ovarium
⚫ Fever ⚫ uterus
Prostaglandin
Opioid Dose

Butterworth JF, Mackey DC, Wasnick JD, eds. Analgesic agents In: Morgan & Mikhail’s
clinical anesthesiology. 6th ed. New York: McGraw-Hills. 2018.
 Opioid Adverse Effects
Frequent Rarely
1. Nausea and 1. Tolerance
vomitingmuntah 2. Respiratory depression
2. Sedatioin 3. Addiction
3. Urtica
4. Constipation

Adverse effect is dose-related

Adjuvant
Antihyperalgesia and antiallodynia
• NMDA receptor inhibitor (Ketamine, dextrometorphan)
• Anti depressant (SSRI : duloxetine, TCA: amitriptyline)
• Anti convulsant (calsium channel inhibitor: gabapentinoid)
• Alfa-2 agonist (clonidine, dexmedetomidine)
Regional Anesthesia and Intervention Techniques
• Continuous local anesthetic regiment through epidural catheter,
intraarticular, peripheral nerve block
• Steroid injection
• Adhesiolysis
• Nerve stimulation
Take Home Messages
• Goal of acute pain management is not only optimal analgesia but also
to prevent chronic pain
• Use the right pain scale to asses individual needs
• Analgesic therapy given to relieve pain score based on WHO step
ladder and the use multimodal analgesia to lessen adverse effects
Thank You