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Erwin KresnoadiErwin Kresnoadi

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“an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage”.

Nyeri adalah rasa indrawi dan pengalaman emosional yang tidak menyenangkan akibat adanya kerusakan jaringan yang nyata atau yang berpotensi rusak, atau tergambarkan seperti itu.

DEFINISI NYERI

A Definitionof Painby John D.Loeser, M.D.

IASP (International Association for the Study of Pain) 1979 defined pain as :

H. Merskey

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NYERINYERI

AkutAkut

KronisKronis33

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Nyeri yang terjadi akibat adanya Nyeri yang terjadi akibat adanya

kerusakan jaringan yang nyata.kerusakan jaringan yang nyata.

(Pain with injury)(Pain with injury)

NYERI AKUTNYERI AKUT

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PENYEBABPENYEBABInflamasi / Kerusakan JaringanInflamasi / Kerusakan Jaringan

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MEKANISME NYERIMEKANISME NYERITRANSDUKSITRANSDUKSI

TRANSMISITRANSMISI

MODULASIMODULASI

PERSEPSIPERSEPSI66

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TRANSDUKSITRANSDUKSI

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TRANSMISITRANSMISIAction PotentialAction Potential

Electrical basis for signal Electrical basis for signal transmission within a nerve transmission within a nerve cell.cell.

Cell depolarizes due to a Cell depolarizes due to a change in internal ion change in internal ion concentration.concentration.

Depolarization travels down Depolarization travels down the axon away from cell the axon away from cell body.body.

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MODULASIMODULASI

Afferent Central Terminal

Glutamate

Sub P

Activity

NK1

mGluR

NMDA

AMPAAMPA

VGCCGABAA

AdensosineOpiateCB1

Dorsal Horn Neuron

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PERIPHERAL SENSITIZATIONPERIPHERAL SENSITIZATION

Innocuous/Noxiousstimulus

primary sensory neuron central neuron

Primary hyperalgesiaPrimary allodynia

Inflammation

Reduced Transduction Threshold

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CENTRAL SENSITIZATIONCENTRAL SENSITIZATION

Noxiousstimulus

primary sensory neuron central neuron

Secondary hyperalgesiaTactile allodynia

IrritantsTissue damageInflammation

Increased Pain Responsiveness

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13Descending pain pathway (Purves, 2001).

PERSEPSIPERSEPSIModulation of

Pain PerceptionThe Descending Pain Pathway – The Periaqueductal Grey is the major convergence point.

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PERCEPTION

MODULATION

TRANSMISSION

TRANSDUCTION

OPIOID- Systemic- Epidural- Subarachnoid

LOCAL ANESTHETIC- Epidural- Subarachnoid

NSAIDs

PENGELOLAAN NYERI

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TARGET OF PAIN THERAPIESTARGET OF PAIN THERAPIES

Gottschalk et al., 2001

Alternative methodsAlternative methodsAcupuncturePhysical TherapyChiropracticsSurgery

PharmacotherapyPharmacotherapyNon-opioid analgesicsOpioid analgesics Nerve Blocks Adjuvant analgesics (neurophatic, musculoskeletal)NSAID

Electrical StimulationElectrical StimulationTranscutaneous electrical nerve stimulation (TENS)Percutaneous electrical nerve stimulation (PENS)

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PERAN NSAIDsPERAN NSAIDs

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Normal Tissue Inflammation Site

Physiolgical ProstaglandinProduction

PathologicalProstaglandinProduction

COX-1Constitutive

COX-2Inducible

Arachidonic Acid

Normal Functions Inflammation, pain, fever

NSAIDs COX-2Inhibitors

+ CytokinesGrowth factors

Treatment pain cheklist• Understand the pain pathway• Understand the proposed procedure• Understand possible pain treatment options• Review previous records of pain treatment• Identify contraindications to treatments• Review the impact of coexisting disease

processes• Discuss options with the patient • Discuss options with the surgeon• Considere the risk/benefits for each option

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Recommendations Grade A :Recommendations Grade A :

NSAID are not sufficiently effective as the sole agent after major surgery in most patients

But are often effective after minor to moderate surgery

NSAID decrease opiod requirement ( decrease side effect of opioid)

Quality of opiod analgesia is often enhance by NSAID

In situation where there are no contraindications, NSAID are the drug of choice after many day case procedure

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1.1. Nyeri akut diobati secepat mungkin. Nyeri akut diobati secepat mungkin.

2.2. Pada nyeri berat, perlu kombinasi :Pada nyeri berat, perlu kombinasi :

NSAIDNSAID

OpiatOpiat

3.3. Perlu pendekatan psikologi. Perlu pendekatan psikologi.

KESIMPULANKESIMPULAN

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A close relationship between the surgeon & anesthesiologist