Mengenal nyeri untuk peserta ipm ke dua 7 nov 2017 di makassar
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Transcript of Mengenal nyeri untuk peserta ipm ke dua 7 nov 2017 di makassar
Mengenal Nyeri
Andi Husni TanraKetua Program Studi Sp2 Ilmu anestesi
Fakultas Kedokteran Universitas HasanuddinMakassar
Kuliah perdana bagi peserta IPM ke-dua 7 Nov 2017 di Makassar
Pembahasan meliputi:
1. Sejarah singkat Anestesi dan IPM
2. Klasifikasi Nyeri
3. Apa itu Nyeri ? Pain perception?
4. Penutup
Anesthesia was the first
applied science in the world
Before Eva was created from Adam’s rib,
Adam was put into sleep by Jibril
Drawn by Prof. HyodoLeader of pain clinic in Japan
First Ether Anesthesia in 1846 at Massachusetts HospitalWilliam T, Morton (left) holding globe inhalerJohn C Warren the SurgeonGilber Abbot the Patient
Di batu nisan Thomas, William G. Morton
di Massachusetts, Amerika Serikat
tertulis, disinlah berbaring:
• Penemu anestetik inhalasi.
• Atas jasanya, nyeri pembedahan dapat diatasi
• Sejak itu ilmu-pengetahuan telah mengontrolnyeri.
• Sebelum dia, pembedahan sebagai penderitaanyang luar biasa.
Charles Darwin pernah ditanyak, penemuan apa yang terbesar diabad 19?“Painless surgery” jauh lebih bermanfaat dari mesin uap atau telegaram yg ditemukan pd abad yg sama
What is Anesthesiology?
Anesthesiology is the practice of medicine dedicated to the pain relief and total care of the surgical patient before, during and after surgery.
Who is Anesthesiologist?
Anesthesiologists is a physician who focus on surgical patient and pain relief.
( perioperative pain management doctor)
History of Pain Management
John Bonica (1917-1994)Founding Father of Pain Management from Seattle
2010
First edition 1953
“Brian Ready “ pencetus Acute Pain Service dari
“Washington University” ,
Seattle USA 1988
He is Anesthesiologist from Washington University’s Hospital in Seattle
First Anesthesiologist who practice pain management in US. In 1990 Founder the Society for Pain Practice Management (SPPM). One of the leader of Intervention Pain Management.
Steven D. WALDMAN
ANESTHESIOLOGIST is a superman DoctorIS NOT JUST IN THE OPERATING ROOM
• Operating roomhospital
surgical center
• Labor & delivery suite
• Other procedural areas
• Intensive care unit (ICU)
• PACU
• Pain management
acute pain
chronic/ cancer pain
o Emergency Medicine
• “Code Blue” team
• Respiratory therapy
• Administration
operating room
hospital
medical school
• Education
health professionals
public
• Research
• ManagersCopyright © 2003 American Society of Anesthesiologists. All rights reserved
PERDATIN
Perhimpunan dokter spesialisAnestesi dan terapi intensif
Perhimpunan dokter spesialis Anestesi, Terapi Intensif dan Menejemen Nyeri
Pain
Tissue damage - inflammationor nociceptive pain
Nerve damage - neuropathyHeadache/periodCentral painCancer pain
Co-existence
AcuteChronic
Most accepted classification:1. Nociceptive pain (Acute pain)2. Inflammation Pain 3. Patological Pain
According to neuropathology, pain can be devided into 3 type
(by Cliford Woolf 2010)
PAIN
NociceptivePain
Inflammatory Pain
Pathological Pain
Neuropathic Pain Dysfunctional Pain
1.Nociceptive Pain
According to Neuropathology Pain can be Divided into 3 type
• Due to potential tissue damage
• To protect further damage
• E.g. touching something to hot, cold or sharp
• Also called physiological pain withdrawal reflex
• Activation of nociceptor by noxious stimulus nociceptive pain
• Adaptive and protective pain
According to Neuropatology Pain can be Devided into 3 type
2. Inflammatory Pain
• Due to tissue damage and infiltration of immune calls.
• To pro more healing by causing pain hypersensitivity until healing occurs.
• Pain is one of the coordinal features of inflammatory.
• Adaptive and protective pain
2. INFLAMMATION PAIN
Clinical Signs:• Calor (heat)• Dolor (pain)• Rubor (redness)• Tumor (swelling)• Functio laesa (loss of function) Bimolecular changes
in inflammation
Pain may occur without noxious stimuli
Prostaglandin threshold nyeri
EP
receptor PKA
PKC
Increased
neuronal
membrane
excitability
PGE2
NaV1.8
TTx-resistant
sodium channel
Neuron
firing threshold
decreases
Tissue injury
COX-2 expressed
P
Spinal cord
Adaptive, high-threshold painEarly warning system ((protective))
Adaptive, low-threshold painTenderness promotes repair (protective)
PeripheralInflammationPositivesymptoms
NociceptionrSensory neuron
HeatColdIntense mechanical forceChemical irritants
MacrophageMast cellNeutrophilGranulocyte
Inflammation
Tissue damage
Noxious stimuli
Inflammatory pain
Nociceptive painA
B
Pain Autonomic response
Withdrawal reflex
Spontaneous painPain hypersensitivity
Modify by: AHT
Pathological Pain
According to Patophysiology Pain can be Devided into 3 type
• Maladaptive pain and non protective pain
• This is not a symptom or protective pain but a disease state
Due to damage of nervus system
Neuropathic Pain Dysfunctional Pain
No damage of the NS
• Panthom pain• Herpetic neuralgesia• Trigemeanial neuralgesic• Diabetic neurophatic
• Fibromyolgia• IBS tension• Head achl• TMJ disease
Pathological Pain
Neuropathic Pain
• After damaging of the nervous system
Post limb amputation
Post herpetic neuralgia
Trigeminal neuralgia
Diabetic neuropathic
etc
Dysfunctional Pain
• No such damaging of the nervous system
Fibromyalgia
Irritable bowel synd.
Tension headache
TMJD, Interstitial cystitis
etc.
WRAMC Feb1, 2005
Is not a symptom but a disease of the nervous system
AbnormalCentral processing
Maladaptive, low-threshold painDisease state of nervous system
PeripheralNerve damage
Neural lesionPositive and negativesymptoms
Neuropathic pain
Spontaneous painPain hypersensitivity
Injury
Stroke
Modified by AHT
. Nyeri neuropatik;
Adalah nyeri yang terjadi akibat adanya kerusakanpada saraf, baik saraf perifer atau saraf sentral.Jadi nyeri akibat terjadinya disfungsi saraf baikperifer maupun sentral.
3. Nyeri Neuropatik
Burning, feeling like the feet are on fire
Stabbing, like sharp knives Lancinating, like electric shocks
Freezing, like the feet are on ice,
although they feel warm to touch
Modified by Meliala 2006
Gejala nyeri nya laindari biasanya
Stimulus-Response dari ke 3 jenis nyeri
Nociceptivepain
Inflammatorypain
Neuropathicpain
No stimulus
No stimulus
No stimulus
Responseduration
Responseduration
Responseduration
Pain
Pain
Pain
touch
touch
touch
Klasifikasi Nyeri
• 1. Menuru neurobiologinya dibagia atas
1.1. Nyeri nosisptif
1.2. Nyeri inflamasi
1.3. Nyeri patologik
- Nyeri neuropatik
- Nyeri disfungtional
• 2. Menurut durasinya dibagi; Akut dan Kronik
CJ. Woolf, J Clin Invest. 2010
Kesimpulan akademiknya
Dalam klinik nyeri hanya dibagi atas :
1. Menuru Jenisnya (Type nyeri)
1. Nyeri nosisptif
2. Nyeri neuropatik
2. Menurut durasinya dibagi; Akut dan Kronik
3. Menurut intensitasnya :
1. Nyeri ringan (mild pain)
2. Nyeri sedang (moderate)
3. Nyeri berat (seveare pain)
Kesimpulan klinik
Apakah orang ini merasa nyeri?
• Ada Rangsang kuat
• Ada Kerusakan jaringan
• wajahnya tidakmemperlihatkan kalau dianyeri. Tidak nyeri.
Bagm. menerangkannya?
Nociception without pain,There is a nociception but no Pain
Apakah pasien ini merasa nyeri?Tanpa suatu stimulus
Pain without nociception no nociception but pain
CRPS. (Complex RegionalPain Syndrome)
AllodyniaHiperlagesia
Bagaimana dengan pasien ini?
Wajahnya sangat nyeriTak ada lagi jaringan rusak. Sudah sembuh.
PHN Post Herpetic NeuralgiaVery painful, allodynia & Hiperalgesia
Pentingnya Nyeri Nosisepsi
• Pentingnya nyerinosiseptif dalamkehidupan manusiasebagai alat proteksidapat kita bayangkandengan melihatpenderta ini. Hidupnyatidak bisa panjangkarena tidak bisamerasa nyeri.
Congenital insensitivity to pain( chennelopathy)
Nyeri adalah suatu rahmat, tanpa sensasi nyeri,kita mudah mencederai diri kita tanpa sadar.
Kita tidak mengenal lagi istilahRangsang nyeri
• Yang ada hanyalah:
Rangsang kuat (Noxious Stimulus) dan
Rangsang lemah (innocuous Stimulus)
Cortex
Thalamus
MidbrainProjectionTo PGA
BrainstemReticularformation
Spinothalamic tract
Spinoreticular tract
Dorsal hornOf spinal cord
Cell body in DRG
Noxious stimulus
Sensory Location, intensity
Nociceptors
C fiber
A fiber
Nyeri Memiliki dua dimensi (inderawidan psikologis).
Pain perception Limbic System
EmotionalFear, anxiety
Nyeri Merupakan Output dari Otak
• Pain does not exist until the brain determines it does.
• Nyeri tidak akan dirasakan hingga otakmempersepsi bahwa ada nyeri Otak menggunakan peta virtual untuk mengarahkan
output nyeri ke daerah yang dicurigai dalam bahaya.
Proses ini merupakan komunikasi antara otak danjaringan tubuh sebagai pertahanan terhadap kerusakan
So far what we know is :
• We know that pain is processed in the Brain.
• How it processes, not clear yet.
• Do we have pain center in the Brain?
also not clear.
• Brain areas and structures that are involved in pain processing
What happen in the brain?
(Dillworth et al., 2012)
SomatoSensoryCortices (SSC1&2)
InsularCortex (IC)
PreFrontalCortex (PFC)
AnteriorCingulate
Cortex (ACC)
Thalamus
Hippocampu
s
Amygdala
Pain is Integrating of Sensory and Emotional experiences
Thalamus
Pre Frontal cortex
(PFC)
Hippocampus
Insular cortex(IC)
SomatosensoryCortex (S1 & S2)
Anterior Cingulated
Cortex (ACC)
Amygdala
SomatosensoryCortices
InsularCortex
PrefrontalCortex
AnteriorCingulate
Cortex
Thalamus
Signals from periphery and spinal cord
Hippocampus
Amygdala
SomatosensoryCortices
InsularCortex
PrefrontalCortex
AnteriorCingulate
Cortex
Thalamus
• Thalamus
– Primary relay center for transmission to somato-sensory and emotional signals
Hippocampu
s
AmygdalaSignals from periphery and spinal cord
• Anterior Cingulate Cortex (ACC)
– Affective/ emotional component • (e.g. sense of suffering)
SomatosensoryCortices
InsularCortex
PrefrontalCortex
AnteriorCingulate
Cortex
Thalamus
Hippocampus
AmygdalaSignals from periphery and spinal cord
• Prefrontal Cortex– Cognitive aspects of pain
• Meaning of pain, what to do about the pain
SomatosensoryCortices
InsularCortex
PrefrontalCortex
AnteriorCingulate
Cortex
Thalamus
Hippocampu
s
AmygdalaSignals from periphery and spinal cord
• Somatosensory Cortices– Primary (S1): Location of pain– Secondary (S2): intensity of pain
SomatosensoryCortices
InsularCortex
PrefrontalCortex
AnteriorCingulate
Cortex
Thalamus
Hippocampu
s
AmygdalaSignals from periphery and spinal cord
S1
S2
• Insular Cortex– Survival instinct– Active with the presence of threat
• Lack of oxygen, pain, low blood sugar
SomatosensoryCortices
InsularCortex
PrefrontalCortex
AnteriorCingulate
Cortex
Thalamus
Hippocampus
AmygdalaSignals from periphery and spinal cord
• Hippocampus (kuda Laut)
– Aversive input pain memory, menyimpan emosional
memory.
SomatosensoryCortices
InsularCortex
PrefrontalCortex
AnteriorCingulate
Cortex
Thalamus
Hippocampus
AmygdalaSignals from periphery and spinal cord
• Amygdala (almon) (penjaga emosi, perintahnya membuat kita tidak rasional, membajak
otak)
– Excecution decision, what to do due to pain
– Emotional reaction to pain
SomatosensoryCortices
InsularCortex
PrefrontalCortex
AnteriorCingulate
Cortex
Thalamus
Hippocampus
AmygdalaSignals from periphery and spinal cord
Pain : From simplicity to complexity
Rene Descartes 1649
EmotionalSensory
Cognitive
Tracey & Mantyh 2007
16th Century
21st Century
Prior experiences
Attention Mood (Psychological
state)
Ecpectation
The meaning
of pain
PainExperience
Noxiousstimulus
Penutup
• Nyeri adalah penggabungan perasaan sensorikdan emosional yang dipengaruhi olehberbagai faktor.
• Nyeri memiliki dua dimensi yg jelas, dimensiinderawi dan emosional
• Peran dimensi emosional lebih dominandibanding inderawi utamanya pada nyerikronik.