PAIN

MANAGEMENT
Wilesing Gumelar
 Is All Pain “Bad?”

The Gift of Pain by Dr. Paul Brand

• “The Beloved Enemy”
• Pain is evolutionarily necessary for survival
– Acute pain is protective
 The “Gift” of Pain--an Example
• Mycobacterium leprae
– Disfigurement
• Infectious processes or
painlessness?
• The Cat Test
– Sensory Neuropathy

http://bhavanajagat.files.wordpress.com/
 Classification of Pain

Acute Chronic
• Generally protective • Generally no useful fnctn.
• Relieved when healing • Persists after healing
complete complete
• Short duration • Long duration
• Predictable pathology • Unpredictable Pathology
• Predictable • Unpredictable
• prognosis Tx with • prognosis Tx
analgesics multidisciplinary
 Chronic Pain Conditions

Neuropathic Pain: Nocioceptive Pain:

•CRPS 1 and CRPS 2 • Osteoarthritis
•Chronic abdominal pain
•Chronic pelvic pain
Mixed Pain:
•Diabetic neuropathy
•Malignant pain
•HIV neuropathy
•Chronic headache
•Phantom limb pain
•Fibromyalgia
•Arachnoiditis
•Failed back surgery syndrome
•Post herpetic neuralgia
•Post thoracotomy pain
•Trigeminal neuralgia
•Degenerative disc disease
 Factors Contributing to
ChronicPain

“Chronic Pain Load”

• Intensity of injury
• Duration of injury
• Repetitiveness of injury
• Chronicity of underlying disease
• Genetic predisposition
– BH4 enzyme production
•
Other factors:
- Psychological
- Socioeconomic
- Cultural
 Mechanisms of Pain: Neuroplasticity
How does a Chronic Pain State Develop?

• Peripheral Sensitization
- Injury causes release of
“sensitizing soup”
- Reduction in threshold and
increase response of nocioceptors

• Central Sensitization
- Membrane excitability,
synaptic recruitment and
decreased inhibition
-
Uncoupling of pain from
peripheral stimuli
http://www.aafp.org/afp/200
1
Treatment: Multiple Options
 Traditional Step Approach

http://www.nationalpainfoundation.org/images/Impla
ntableTherapy
Multimodal Pain Management
 Goals of Treatment
• Reduce pain
• Increase activity level
• Improve quality of life
• Pre-emptive analgesia
• Stay within “Therapeutic
Window”
– Avoid undertreatment
– Avoid toxicity
• How?
– Synergism with Meds
• Morphine + Gabapentin
– Apply multimodal pain
strategies when possible
 Pain Relief is HUMAN RIGHT

• Recently, pain relief is being viewed as

BASIC HUMAN RIGHT (ethical as well
as morally)
• Unrelieved pain may adversely affect
the outcome of surgery (  morbidity
and mortality)
• May lead to chronic pain (  financial
and social cost)
 Preemptive Analgesia
Preemptive Began in early of 1920’s by Crile &
Lower
Incision
(Noxious signal)

Before incision Surgery Post operative

Central nervous system (CNS) protection until post operative

period
Note :
Preemptiv Pain modulation by CNS takes a place before perception
e
Analgesia
Duration of the agents (ex : 2 hrs)
PREVENTIVE ANALGESIA
Broader definition of preemptive
Incision
(Noxious signal )

Pre - Incision Surgery Post operative

or

Preventiv Preventiv
e e
Preventiv Analgesiaof action from the agent
Duration Analgesia
covering
e the entire perioperative period
Analgesia
Duration of action from the agent is longer than preemptive target
 SURGERY & PAIN

Surgery

• Tissue damage Nociceptive PAI

• Inflamed tissue input N

Surgery has a biphasic insults to the

body
1. Trauma to tissue
2. Inflammatory response
 Peripheral and Central Sensitization in
Inflammatory Pain
Central sensitization

Spinal “wind-up”

Histamine, Leukotrienes,
Norepinephrine, Cytokines,
Bradykinin,
Prostaglandins,
Neuropeptides, 5-HT,
Purines, H+/K+ions
Secondary
hyperalgesia

Peripheral sensitization Primary hyperalgesia

After the injury the NS will changed → neuro-

plasticity
 Nyeri Pasca Bedah

• HYPERALGESIA

• ALLODYNI
A
Pengelolaan Nyeri Perioperatif
Mencegah, menekan atau
meminimalisasi terjadinya proses
“sensitisasi perifer maupun
sensitisasi sentral

 Mencegah terjadinya
plastisitas susunan saraf.
 Mempertahankan agar
susunan saraf tetap dalam
keadaan status fisiologis.
 MENILAI NYERI
• Anamnesa
• Pemeriksaan Fisik
• Riwayat Penyakit Lain
• Faktor Lain
• Terapi yang sudah didapat (non-
farmakologis/farmakologis)
• Derajat nyeri (dengan “tools”)

28
Nyeri bila
WBFS >
4

29
30
31
Nyeri
bila
BPS > 5

32
Nyeri bila
CPOT ≥ 3

33
What is multimodal analgesia?

Is a combination of two or more

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

Main goals of Multimodal Analgesia is to reduce the amount of Opioid

Why we need multimodal analgesia
for postoperative pain?

Most of the pain is a multifaceted

and multiple-sources.

No single analgesic is perfect and no

single analgesic can treat all types of pain.

Multimodal Analgesia is potentiating in

efficacy, reduced doses, minimal adverse
effect. Improve the outcome.
 Philosophy of Multimodal Analgesia
Not only just giving 2 or more drugs which different
mechanism, but;

• One drug should be effective at peripheral

sensitization and other at central sensitization.

• Combine drugs must be synergetic or addictive.

• Must be proven by laboratory or clinical data.

• Some drugs may act at several point at nociceptive

pathway.
Benefits of Multimodal
Analgesia
Opioids • REDUCED DOSES
of each analgesic
• IMPROVED EFFECACY
due to synergistic or
additive effects
• REDUCE SIDE
EFFECTS
of each drug

1 Kehlet H et al. Anesth Analog. 1993;77:1048-1056

 Target Point of Analgesic Agents
Ketamin
Paracetamol
Gabapentin
Perception
Opioids
Gabapentinoid
s Clonidine
Dexamethasone
Ketorolac
Corticosteroid
s NSAID
Modulation Transduction COXIB
Local Anesthetic

Transduction
DRG

Transmission
Modulation
Local anesthetics
Cryotherapy
COXIBs
 NSAID
PARACETAMOL

COXI
B

(Morphine,
Fentanyl)

OPIOID
Tramado
l
Ketamine

Gabapentanoid
(Gabapentin,
Pregabalin)