8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Dr. dr. Sudadi, Sp.An, KNA, KAR
Acute Pain Management in Emergency Setting
Single vs Multi Modal Analgetics
Bagian Anestesi dan Reanimasi FK UGM/RSUP Dr. Sardjito Yogyakarta
Simposium 2
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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TANDA VITAL
1. Tensi
2. Nadi
3. Respirasi
4. Suhu
5. NYERI
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
International Association for Study of Pain :
“Nyeri merupakan perasaan indrawi danpengalaman emosional yang tidak menyenangkanakibat kerusakan jaringan yang nyata atau yang
berpotensi rusak atau yang tergambar seperti itu”
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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NYERI AKUT
✤ Disebabkan rangsangan noksius akibat trauma
atau proses penyakit atau abnormalitas fungsiotot atau organ dalam
✤ Selalu disebabkan oleh nosiseptis
✤ Mudah dideteksi, lokasi jelas, kerusakan jaringanterbatas, intensitas proporsional dan self limited
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Nyeri AkutNyeri akut : nyeri pasca bedah, trauma, lukabakar, melahirkan
Merupakan problem sosial ekonomi :
Kejadian meningkat seirama jumlahpembedahan
Jika tidak dikelola dengan baik meningkatkan morbiditas dan mortalitas,memperpanjang perawatan, meningkatkanbiaya perawatan
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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AKIBAT PENANGANAN YANG
TIDAK SEMPURNA✤ PENYEMBUHAN LUKA YANG LAMA
✤ RESIKO TROMBOSIS
✤ GANGGUAN TIDUR
✤ KECEMASAN
✤ PENGURANGAN KUALITAS HIDUP
✤ MEMPERPANJANG LAMA RAWAT
✤ PENINGKATAN KOMPLIKASI
✤ RESIKO MENJADI “NYERI KRONIS”
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MEKANISME NYERI
• Nociception – nociceptor
• Tranduksi : stimuli (kimia, mekanik,panas) diubah menjadi aktifitas listrik
• Transmisi : penyaluran rangsang nyerinociceptor melalui saraf aferen ke tingkatlebih tinggi.
• Modulasi : kontrol dan modulasi sebelum sampai pusat persepsi.
• Persepsi : persepsi nyeri bersifat
subyektif
Si i K d kt N i l Cli i l U d t 2015|14 15 M t 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
TATALAKSANA
Si i K d kt N i l Cli i l U d t 2015|14 15 M t 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Simposium Kedokteran Nasional Clinical Updates 2015|14 15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Simposium Kedokteran Nasional Clinical Updates 2015|14 15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Simposium Kedokteran Nasional Clinical Updates 2015|14 15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Activation
External
Stimuli
Heat
Mechanical
Chemical
VR1Ca2+
mDEG
P2X3
Generator potentials
action potentials
Voltage gated sodium channels
Pain and auto-sensitization
Woolf & Mitchel, 2001
TRANDUKSI - TRANSMISI
ATP
Na+
PAINPAIN
Simposium Kedokteran Nasional Clinical Updates 2015|14 15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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OPIOIDS NEURAXIAL BLOCKS PERIPHERALNERVE BLOCKS
NON-OPIOIDANALGESICS
ADJUVANTS
MULTIMODALANALGESIA
Multimodal Analgesia
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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BALANS ANAGESIA
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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PRE-EMPTIVE ANALGESIA
Pemberian analgesia sebelum stimulasi nyeri
terjadi.
Hipereksitabilitas neuron kornu dorsalis dapat
dieliminasi/dikurangi sebelum impuls aferen
mencapai SSP
Mengurangi kebutuhan analgesia durante dan
pasca operasi
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Balans AnalgesiaSuatu teknik pengelolaan nyeri yang
menggunakan pendekatan MULTI
MODAL pada proses NOSISEPSI,
dimana proses TRANDUKSI ditekan
dengan NSAID, proses TRANSMISI
dengan obat anestesi lokal, dan prosesMODULASI dengan opioid
Sinergis – dosis kecil – analgesia optimal
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Simposium Kedokteran Nasional Clinical Updates 2015|14 15 Maret 2015|FK UGM 1983 & 2009
SINERGIS TERAPI
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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MULTI MODAL ANALGESIA
Konsep analgesia multimodal dikenalsebagai teknik untuk memperbaiki analgesiadan mengurangi efek samping opioiddengan penambahan efek sinergis antaraobat analgesi dari golongan yang berbedasehingga efek samping lebih rendah olehkarena pengurangan terhadap dosis padamasing-masing obat (Buvanendran danKroin 2009) .
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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MULTI MODAL ANALGESIA
Keuntungan yang ditunjukkan dari penggunaan
analgesi multimodal, antara lain adalah: efek
samping rendah, efek analgesia lebih baik, dapat
memperpendek rawat inap, memperbaiki waktu
pemulihan dan fungsi, serta kemungkinan dapat
menurunkan biaya kesehatan (Buvanendran dan
Kroin, 2009).
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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p p | |
OPIOID - NSAID
• Salah satu penerapan multimodal
analgesia adalah penggunaan opioidintravena yang dikombinasi dengan anti
inflamasi non steroid (AINS) yang
bertujuan untuk mengurangi dosis
sistemik opioid (Rawal, 2005).
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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p p | |
OPIOID - NSAID
• Beberapa penelitian telah dilakukan untuk
mengetahui efektivitas pemberian analgesi
multimodal dengan penambahan ketorolak
(AINS) intravena secara bolus intermiten ataukontinu pada penatalaksanaan nyeri pasca
operasi dengan fentanyl (Opioid). Menurut
Scholes (2011), kombinasi dua obat ini
kompatibel dalam larutan, sehinggadiharapkan tidak mempengaruhi farmasetika
dari masing-masing obat
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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p p | |
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8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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p p | |
OPIOID - NSAID
Kim, et al. (2011) Penambahan
ketorolak dengan pemberian kontinuintravena secara PCI pada fentanyl
kontinu intravena memberikan hasil
nilai Visual Analog Scale (VAS) kurangdari 2 (6 & 12 jam pasca operasi
histerektomi).
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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OPIOID - NSAID
Seung, et al. (2008) Penambahan
bolus ketorolak intravena padafentanyl kontinu intravena memberikan
hasil nilai Visual Analog Scale (VAS)
antara 2-4 (6 & 24 jam pasca operasi
histerektomi).
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Hierarchy of Pain Assessment In Order of Most Reliable to Least Reliable Measures
1. Patient’s self-report is the most valid and reliable measure of painexistence and intensity.
2. Pathologic conditions or procedures that usually cause pain
3. Observe Behaviors (e.g. facial expression, body movements,crying)
4. Proxy ratings. Report of pain from parent/family/others close topatient.
5. Physiologic measures: Least sensitive measure of pain existenceand intensity. Conclusion: inappropriate to rely solely on physiologicdata to measure pain.
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Selected Pain Assessment Tools
1. Numerical Rating Scale (NRS)
0 – 10 where 0 is no pain and 10 is the worst pain imaginable
2. Word Scale: “no pain, mild, moderate, severe”
3. Faces Scale
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WHO STEP LEADER
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Medical Consumption of Morphine (2005)
Sources: International Narcotics Control Board; United Nations population data; CIA World Factbook
1. Austria: 121.4
2. Canada: 70.9
4. Australia: 54.7
32. Japan: 3.99
34. HK: 3.38
61. Singapore: 0.99
64. Malaysia: 0.92
70. Thailand: 0.62
87. Korea: 0.36
88. China: 0.35
89. Philippines: 0.25
109. Viet Nam: 0.14
129. Indonesia: 0.02
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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Medical Consumption of Fentanyl (2005)
Sources: International Narcotics Control Board; United Nations population data; CIA World Factbook
1. USA: 1.8
2. Germany: 1.72
29. Australia: 2.23
36. Japan: 0.11
64. HK: 0.0087
48. Singapore: 0.02
55. Malaysia: 0.012
84. Thailand: 0.0045
40. Korea: 0.08
78. China: 0.0049
128. Philippines: 0.0002
106. Viet Nam: 0.0013
119. Indonesia: 0.0003
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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PRINSIP PENGELOLAAN
✤ Mengandung unsur indrawi (sistem saraf) dan Emosional
(kejiwaan/ psikologis)
✤ Tidak ada intervensi tunggal mengingat banyaknyaneurotransmitter yang terlibat
✤ Terapi bersifat individual dan tidak dapat digeneralisasir untuk
semua pasien trauma
✤ Pendekatan multimodal : menghambat secara sinergismenghambat proses transduksi, transmisi dan modulasi
✤ Teknik multimodal dosis tiap obat menjadi <<
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8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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FAKTOR-FAKTOR PENENTU
✤ Lingkungan pasien dirawat dan opsi terapi yangada
✤ Berat dan lokasi anatomi dari trauma
✤ Komplikasi serius yang mungkin timbul
✤ Riwayat penyakit terdahulu
✤ Apakah akan direncanakan tindakan operasi
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
8/18/2019 Simpo 8 - Acute Pain Management in Emergency Setting Single vs Multimodal - dr Sudadi SpAn.pdf
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SimpulanNyeri : pengalaman individual,banyak faktor yang mempengaruhi
Mekanisme : tranduksi, transmisi,
modulasi, persepsiPenatalaksanaan : tergantungpenilaian derajat nyeri
Balans Analgesia
Pre-emptive analgesiaPain Free – Stress Free
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