CURRICULUM VITAENama : dr. I Putu Pramana Suarjaya, SpAn, KMN, KNATempat/Tanggal Lahir : Denpasar, 8 Juni 1969Alamat : Jalan Tukad Yeh Penet 11A, Renon, DenpasarIstri : dr. Ni Made Puspa Dewi AstawaAnak-anak : I Putu Krisna Murti Made Kartika Dewi Nyoman Ira Sayani Saraswati I KetutAgama : Hindu Riwayat Pendidikan SD 3 Saraswati Denpasar 1976-1982SMP N 3 Denpasar 1982-1985SMAN 1 Denpasar 1985-1988Fakultas Kedokteran Universitas Udayana Denpasar 1988-1995Pendidikan Dokter Spesialis Anestesi 1999-2003Fakultas Kedokteran Universitas Padjadjaran, BandungPendidikan Magister Kesehatan 2001-2003 Fakultas Kedokteran Universitas Padjadjaran, Bandung7. Pendidikan Konsultan NeuroAnesthesia dan Neuro Critical Care 2009-2012 Kolegium Anestesiologi dan Terapi Intensif, Fakultas Kedokteran Universitas Padjadjaran, Bandung

 Pendidikan TambahanDalam Negeri

ESPEN LLL (Bali, 2012)

LuarNegeri Asia Pasific Parenteral Nutrition Workshop (Kuala Lumpur 2010) Medical Observership di Department of Anesthesiology and Intensive Care, Tan Tock Seng Hospital, Singapore (Singapore 2011)Pengalaman KerjaDokter di kapal MV. Illiria, (1996)Dokter PTT di Puskesmas Ubud I, Gianyar Bali (1996-1999)Dokter Asisten di Bagian Anestesiologi RS Sanglah, Denpasar Bali (1999)Dokter Spesialis Anestesi RS Zainul Abidin, Banda Aceh (2004)Dokter Spesialis Anestesi RS Korpri Puri Raharja Denpasar (2004- sekarang)  Dokter Spesialis Anestesi RS Sanglah Denpasar (2004-sekarang)Keanggotaan Profesi

Ikatan Dokter Spesialis Anestesiologi Indonesia ( IDSAI) BaliIndonesian Society of Anesthesiology for Pain Management (ISAPM)Perhimpunan Manajemen Nyeri Indonesia (PMNI)Indonesian Society of Neuro Anesthesia and Critical Care ( ISNACC)Asian Society of Neuro Anesthesia and Critical Care (ASNACC)Anggota IDI Wilayah BaliAnggota IDI DenpasarAnggota PKDGI

  

ACUTE PAIN SERVICE

in DENPASAR I Putu Pramana Suarjaya

IGN Mahaalit Aribawa

Department of Anesthesiology and Intensive CareSanglah General Hospital

Denpasar

1. Pulse 2. Blood

pressure3. Temperature4. Respiratory

rate

05/02/2023BROS 4

Pain:The Fifth

Vital Sign™

*by now health care professional asses patient for pain every time we check for other vital sign

June 2005

Anesthesiology-Based APS• Introduced in US, 1988

Nurse-Based APS• Introduced in Sweden, 1991

The Organization Structure of APS

• ANESTHESIA RESIDENT BASE

Developed in teaching hospital

Non teaching -Private Hospital

APS IN DENPASAR

Despite of advanced knowledge & techniques in acute pain management

Postoperative pain

MORE than 50% patients do not receive adequate postoperative pain relief

Filos,KS: lehman, KA, Eur Surg Des 2002

1.Confusion about who is responsible for postoperative pain management ?

2.Inadequate knowledge of analgesics (opioid & non-opioid analgesics).

3.Administration of analgesic is too late, when the patient complain of pain.

4.Using single modality and similar to every surgery.

Why postop pain continue to be undermanaged ?

1.PATIENT BARRIERS :

• ANXIETY AND PAIN

2. PROFESSIONAL BARRIERS

• ATTITUDE : UNWILLINGNESS TO RAISE THE PRIORITY OF PAIN• LACK OF ASSESMENT AND DOCUMENTATION• LACK OF KNOWLEDGE ABOUT PAIN AND PAIN KILLER

BARRIER TO APS

3. ORGANISATIONAL BARRIERS

• ACCOUNTABILITY WHO??• LOCAL POLICIES RULES AND REGULATION??• LOCAL RESOURCES• GLOBAL BARRIERS AND NATIONAL POLICIES

BARRIER TO APS……..

MULTIMODAL ANALGESIA

IV kontinyu : syringe pump

Oral analgesia

Epidural analgesia :

intermitten dan kontinyu

Intratekal opioid

MULTIMODAL Bolus IV

Patch percutaneus

Peripheral Nerve Block : continuous

Patient Controlled Analgesia ( PCA) : IV and

Epidural

12

GRANDFATHER OF PCA….

13

PCA + TCI

PCA PORTABLE

15

PERBANDINGAN PCA IV : IM : BOLUS IV

APS IN PRIVATE HOSPITAL ( BALI ROYAL HOSPITAL / BROS )

1. PATIENT BARRIERS

• PATIENT’S REQUEST PAIN FREE HIGHER SOCIAL CLASS

SOME BARRIERS RESOLVE

2. PROFESIONAL BARRIERS :

• SURGEON LACK OF PAIN AWARENESS BUT WILLING TO SET PAIN FREE FOR PATIENT CONSULT TO ANESTHETIS

• ASSESMENT AND DOCUMENTATION START AS PART OF MED RECORD

• NURSE GET CONTINUING PAIN UP GRADE SESSION

AT BROS HOSPITAL…………

ACCOUNTABILITY WHO?

• ANESTHETIS RESPONSIBLE FOR PAIN MANAGEMENT, MIN 3 DAYS

LOCAL POLICIES RULES AND REGULATION

• DEVELOPMENT AND IMPLEMENTATION OF SOP• SET UP PAIN MANAGEMENT TEAM INCL NURSE & GP ON DUTY • ANESTHETIS CONSULTANT VISITE DAILY & READY 24 H

3. ORGANISATIONAL BARRIERS

AT BROS HOSPITAL…………

LOCAL RESOURCES • MEDICAL STAFF TRAINING @ 1 MONTH• PAIN MANAGEMENT EQUIPMENT SUPPLY:

• SYRINGE PUMP BY HOSPITAL• PERIPHERAL BLOCK CATHETER• PATIENT CONTROLLED ANALGESIA MACHINE : 11 PCA MACHINE

IN BROS HOSPITAL (BY ANESTHETIS)• USG (BY ANESTHETIS)

GLOBAL BARRIERS AND NATIONAL POLICIES COMMON PROBLEM

ORGANISATIONAL BARRIERS……..

AT BROS HOSPITAL…………

JAN FEB MRT APR MEI JUN JUL AUG SEP OKT0.00%

10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

PCAEPIDURALSYRINGE PUMP

ANALGESIA METHODE BROS HOSPITAL 2012

SYRINGE PUMP; 63.29%

PCA; 18.50%

EPIDURAL; 5.78%

BOLUS IV / ORAL; 10.72%

PERIPHERAL BLOCK; 2.00%

SYRINGE PUMPPCAEPIDURALBOLUS IV / ORALPERIPHERAL BLOCK

PAIN MANAGEMENT MODALITY JANUARY-OCTOBER 2012 BROS HOSPITAL

BARRIERS TO APS NOT YET CLEARED JCI ACRREDITATION ENCOURAGE

APS IN TEACHING HOSPITAL-RS SANGLAH DENPASAR

1. PATIENT BARRIER

• WIDE PATIENT VARIETY• PATIENT LESS DEMANDING

2. PROFESIONAL BARRIER

• OPERATOR STILL UNWILLINGNES TO TREAT PAIN• ASSESMENT & DOCUMENTATION ONLY DONE BY ANESTHETIST AND NURSE,

SURGEON DO NOT

ORGANISATIONAL BARRIERS

• SOP• IF VAS <5 SURGEON RESPONSIBLE FOR PAIN MANAGEMENT POST OP• IF VAS ≥ 5 ANESTHETIST RESPONSIBLE• RULES DAN REGULATION NOT WELL ESTABLISHED YET• LACK OF HOSPITAL UNDERSTANDING OF PAIN MANAGEMENT MODALITY

BANNED NEW TECHNIQUE BY MANAGEMENT• EQUIPMENT SUPPLY FOR PAIN MANAGEMENT

ANALGESIA MODALITY RS SANGLAH

STARTING MAY 2012, DRIP NOT USED ANYMORE JCI

SISTEMIC IV :1.SYRINGE

PUMP2.PCA

PATIENT CONTROLLED ANALGESIA

CONTINOUS INFUSION

EPIDURAL ANALGESIA

CONTINUOUS SUPRACLAVICULAR BLOCK

CONTINUOUS SCIATIC BLOCK

“DUAL EPIDURAL THORAKAL-LUMBAL CONTINUOUS

PATIENT CONTROLLED ANALGESIA

POST THORAKOTOMY + FR CLAVICULA BY PCA

CONT. INFRACLAVICULAR BLOCK

CONTINUOUS FEMORAL BLOCK

CONTINUOUS INTERSCALENI BLOCK

THANK YOU

05/02/2023 38

BULAN PEMAKAIAN PCA

TOTAL PASIEN OPERASI

PERSENTASE PEMAKAIAN

JANUARI 11 108 10.18FEBRUARI 14 108 12.96MARET 15 161 9.3APRIL 19 133 14.28MEI 24 175 13.71JUNI 21 172 12.20JULI 19 133 14.29AGUSTUS 37 147 25.17SEPTEMBER 48 158 30.38OKTOBER 64 160 40TOTAL 272 1455 18.69

PEMAKAIAN PCA DI BROS 2012

PEMAKAIAN EPIDURAL BROS 2012

BULAN PEMAKAIAN EPIDURAL

TOTAL PASIEN OPERASI

PERSENTASE PEMAKAIAN

JANUARI 6 108 5.55FEBRUARI 5 108 4.63MARET 8 161 4.96APRIL 10 133 7.51MEI 9 175 5.14JUNI 8 172 4.65JULI 7 133 5.26AGUSTUS 11 147 7.48SEPTEMBER 12 158 7.59OKTOBER 9 160 5.62TOTAL 85 1455 5.84

PEMAKAIAN SYRINGE PUMP DI BROS 2012

BULAN PEMAKAIAN S.P.

PCA EPIDURAL

ORAL-BOLUS IV

BLOK PERIFER

TOTAL PASIEN OPERASI

PERSENTASE PEMAKAIAN SP

JANUARI

87 11 6 10 4 108 82.07

FEBRUARI

74 14 5 11 4 108 68.51

MARET 116 15 8 19 3 161 72.04APRIL 87 19 10 15 2 133 65.41MEI 119 24 9 20 2 175 68JUNI 122 21 8 18 3 172 70.93JULI 93 19 7 12 2 133 69.92AGUSTUS

82 37 11 14 3 147 55.78

SEPTEMBER

80 48 12 15 3 158 50.63

OKTOBER

61 64 9 22 4 160 38.12

921 272 85 156 (10.72)

30 (2.06%)

1455 63.29