Nyeri Kanker

Nyeri Kanker
MANAJEMEN NYERI / PPKC
Nyeri Kanker
Nyeri merupakan :
utama pasien-pasien kanker :
selama terapi, dan juga pada
penyakit lanjut & terminal
Simptom untuk melalukan evaluasi terapi
Konsekuensi tersering yang sangat ditakutkan
pasien
Simptom
Bukti tentang nyeri kanker

Nyeri terjadi pada 30% pasien dari berbagai
tingkatan stadium.
stadium.
Nyeri bertambah seiring dengan progres penyakit
90%
90% pasien kanker stadium lanjut mengalami nyeri
hebat
Lebih dari 50% pasien kanker masalah nyeri tidak
tertangani dengan baik
Hambatan Penanganan Nyeri Yang Efektif

Petugas Medis Profesional
Tidak terlatih masalah manajemen nyeri
Ilmu yang kurang up to date
Takut dalam meresepkan obatobat-obat narkotik
Takut akan terjadi adiksi
Takut akan terjadi toleransi analgetik
Takut akan terjadi efek samping
Sifat subjektif nyeri
Gejala kanker stadium lanjut

Bruera.. Why Do We Care? Conference 1992; Memorial SloanBruera
Sloan-Kettering
Asthenia
Anorexia
Pain
Nausea
Constipation
Sedation/Confusion
Dyspnea
% Patients (n=275)
0
10
20
30
40
50
60
70
80
90
Prevalensi Nyeri Kanker

Portenoy.. Cancer 1989;63:2298.
Portenoy
All
All: Advanced
Bone
Pancreas
Stomach
Uterus/Cervix
Lung
Breast
Prostate
Colon
Lymphoma
% Patients
Leukemia
0
10
20
30
40
50
60
70
80
90
Keseluruhan
Mortalitas
Nyeri kanker
203,000-365,400 kasus kanker

baru setiap tahun
Penyebab kematian
terbanyak di dunia
nomor
Nyeri merupakan keluhan utama 89%

pasien-pasien pada unit Paliatif di Dr.
Soetomo Hospital
Nyeri yang tidak tertangani

Penanganan nyeri tidak optimal berhubungan:
Gangguan tidur
Tidak nafsu makan
Konsentrasi menurun
Cemas dan depresi
69% pasien kanker stadium lajut cenderung
melakukan bunuh diri
(Wisconsin 1985)
Definisi Nyeri (IASP 1979):

Pengalaman sensorik dan emosional yang
tidak menyenangkan akibat kerusakan
jaringan yang nyata atau potensial terjadi
atau digambarkan seperti terjadinya
kerusakan
tidak menyenangkan
(sensorik)
emotional expienced
Dimensi
Fisik
Nyeri Organik
Nyeri
Dimensi
Psikologis
Afek Motivasi
Evaluasi Kognitif
The meaning of pain
CANCER PAIN IS TOTAL PAIN

Nyeri kanker sangat COMPLEX and
COMPLICATED dan kumulasi antara :
Nyeri organik
Nyeri psikologis
socioeconomic, cultural and spiritual
TOTAL PAIN
BIOPSYCHOSOCIOCULTUROSPIRITUAL
WHO 1986
Symptoms of debility
Non-cancer pathology
Side-effects of therapy
Cancer
Loss of social position
SOMATIC SOURCE
Loss of job prestige and income

Loss of role in family
Friends who do not visit
TOTAL
DEPRESSION
Chronic fatigue and insomnia

Sense of helplessness
PAIN
ANGER
Delay in diagnosis
Unavailable doctors
Irritability
ANXIETY
Disfigurement
Bureaucratic bungling
Therapeutic failure
Fear of hospital or nursing home
Fear of pain
Worry about family
Family finances
Fear of death
Loss of dignity and bodily control
Spiritual unrest
Uncertainty about future
A cancer is not only a

physical disease, it is a
state of mind.
M. Baden, New York Times, 1979
Nyeri Kanker
Dapat dibagi 2 kategori :
1. Nyeri organik
2. Nyeri psikologis
Nyeri organik
A. Nyeri Nociceptif :
Nyeri somatik
(kulit, otot, jaringan ikat)
Nyeri visceral
(organ dalam torak dan abdomen)
B. Nyeri non nociceptif:
Nyeri neuropatik(nyeri deaferensiasi) /
kerusakan saraf perifer atau saraf pusat
NYERI NOSISEPTIF
NOSISEPTIF
dapat di bagi :
NYERI SOMATIK
NYERI VISCERAL
1. NYERI SOMATIK
konstan
tajam, perih
lokasi dapat ditunjuk
Mekanisme:
aktivasi nosiseptor
pelepasan mediator nyeri ( terutama PG)
Contoh:
metastasis tulang
tumor jaringan lunak
Penanganan:
Aspirin
Acetaminophen
NSAID (COX1 or COX2 inhibitor)
Nyeri Nocicepti
Nociceptiff
Nyeri Somatik
2. NYERI VISCERAL
konstan
nyeri dalam atau tumpul
lokasi sulit di tunjuk
diikuti mual dan muntah
kadang nyeri di alihkan ke kulit
kolik & kram
Mekanisme:
Aktivasi nosiseptor
Contoh:
kanker pankreas
metastasis kanker hati/paru ke tulang bahu
Manajemen:
Opioid (MS contin)
Blok saraf (e.g celiac plexus block)
Nyeri Nociceptif
Nyeri Visceral
Penyebab stimulus nyeri visceral :

1.
2.
3.
4.
Iritasi
Iritasi permukaan mukosa dan serosa
organ viscera
Torsi dan tertarikya mesenterium
organ viscera
Distensi atau kontraksi rongga usus
usus..
Tertekannya organ viscera
B. Nyeri non nosiseptif

Nyeri neuropatik (nyeri deaferensiasi)
nyeri luka bakar
nyeri tersetrum & nyeri tertembak
(panas)
Mekanisme:
kerusakan langsung sistem saraf perifer & saraf
sentral
hilangnya hambatan sentral
Contoh:
metastasis brachial or lumbosacral plexopathies
post herpetic neuralgia (PHN)
Penanganan:
obat antidepressant or anticonvulsant
Blok saraf
etc
Nyeri Neuropatik
Neuropatik
Kerusakan jalur saraf
Respon tidak normal pada stimulus
yang normal
Akibat kerusakan saraf perifer & sentral
Allodynia: Nerve Injury Leads to Central

Reorganization in the Spinal Dorsal Horn
Normal terminations of primary afferents in the dorsal horn
After Nerve Injury
Klasifikasi nyeri kanker

TEMPORAL
2. TOPOGRAP
TOPOGRAPII
3. ETIOLOGI
4. PAT
PATOFI
OFISIOLOGI
SIOLOGI
Nyeri yang berhubungan dengan
tumor langsung
Nyeri yang berhubungan dengan
terapi kanker
Nyeri yang tidak berhubungan
dengan kanker
1.
1.
2.
3.
Various Schemes for Classifying Cancer Pain

Etiologic classification:
- Primarily caused by cancer

- Treatment of malignancy
- Debility
- Concurrent pathology
Pathophysiologic classification:
- Nociceptive (somatic, visceral)

- Neuropathic
- Mixed pathophysiology
- Psychogenic
Location of cancer pain syndromes:
- Head and neck pain

- Chest wall syndromes
- Vertebral and radicular pain
- Abdominal or pelvic pain
- Extremity pain (e.g., brachial plexopathy
or bony spread)
Temporal classification:
- Acute
- Breakthrough
- Chronic
Severity-based classification:
- Mild
- Moderate
- Severe
Clinical Characteristics of the Pathophysiologic

Classes of Cancer Pain
Nociceptive Pain
Somatic Pain:
- Character of somatic pain is aching, stabbing,

and throbbing
- Pain is usually well localized
Visceral Pain:
- Character of pain usually gnawing or cramping

when due to obstruction of hollow viscus
- Pain typically described as aching, sharp, throbbing
when due to tumor involvement of organ capsule
- Usually diffuse and difficult to localize
- Visceral pain
may be referred to somatic
structures
Clinical Characteristics of the Pathophysiologic

Classes of Cancer Pain
Neuropathic Pain
Nerve Compression:
- Character of pain often described as burning, pricking, electric-like

- Pain usually located in the area innervated by the compressed
peripheral nerve, plexus or nerve root
- Radiographic imaging may show the malignancy compressing the
neuronal structure
Deafferentation
Nerve Injury:
- Character of pain similar to that of nerve compression may also be

shooting or stabbing in nature
- Dysesthesia or allodynia may be present
- Often associated with loss of afferent sensory function in the
painful region
- Superficial burning pain with allodynia, may also have deep
aching component
Sympathetically
Mediated:
- Associated symptoms include cutaneous vasodilation, increased

skin temperature, abnormal pattern of sweating, trophic changes
and allodynia
- Hallmark is nondermatomal pattern of pain
- Confirmed withMANAJEMEN
diagnostic
block
NYERIsympathetic
/ PPKC
Penyebab nyeri kanker

1. Nyeri yang berhubungan dengan kanker
langsung ::
Invasi ke tulang
Invasi ke saraf
Invasi ke organ visceral
Invasi ke pembuluh darah
Invasi ke membran mukosa

Tumor itu sendiri
2. Nyeri yang berhubungan dengan

terapi kanker
Sindrom Pasca torakotomi
Sindrom Pasca masektomi
Sindrom Pasca Radical neck disection (RND)
Sindrom Pasca amputasi
Kemoterapi:
Polineuropati
Nekrosis tulang
Pseudorhematoid steroid
Mucositis
Radiasi:
Fibrosis akibat radiasi pleksus brachial dan pleksus
lumbosacral
Mielopati akibat radiasi
Radiasi yang mencetuskan tumor saraf perifer
Mucositis
Nekrosis tulang akibat radiasi
Penyebab Nyeri Kanker

Dari Kemoterapi
Penyebab Nyeri Kanker

Berhubungan dg terapi
COBALT RADIATION BURN

3.Nyeri yang tidak berhubungan

dengan kanker
Nyeri miofasial
Osteoporosis
Postherpetic neuralgia
Debiliting (ulcus decubitus)
Etc

faktor--faktor lain
faktor
Acute Herpes ZosterMANAJEMEN NYERI / PPKC

Faktor-faktor lain
FaktorStatus Immunocompromised
MANAJEMEN PASIEN DENGAN

MANAJEMEN
NYERI KANKER
PALLIATIVE CARE
CARE (memperbaiki
kualitas hidup )
Palliative care dalam bentuk :
Pembedahan
Radiasi
Rad
iasi
Kemoterapi
Manajemen Nyeri
PALLIATIVE CARE
World Health Organization Definition:
Palliative care is an approach that improves the
quality of life of patients and their families facing the
problem
associated
with
life-threatening
illness,
through the prevention and relief of suffering by means

of early identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
PRINSIP DASAR
Analgetik
Analge
tik diberikan regularly
Ada akses untuk obat analgetik
Eskalasi potensi analgesic
analgesic sesuai dengan
analgesic ladder
Obat yang sesuai untuk breakthrough pain
Obat untuk mengatasi efek samping
Monitoring pasien secara berkala
Opioids
Infrequent dosing
Toxicity
Effect
Analgesia
Pain
Time
Opioids
Adequate dosing
Toxicity
Analgesia
Pain
Time
Analgesia Monitoring Guidelines

Baseline assessment:
- Obtain RR, HR, BP, O2 saturation, sedation score, and pain score before administering a single or
intermittent dose or initiating continuous infusion.
Intermittent intravenous administration:

- RR, HR, BP, and sedation score every 5 min X 4, then every 30 min X 2, and then as per patients
condition/preexisting orders
- Pain score every 20-30 min
- Continuously monitor O2 saturation only for children whose underlying condition predisposes
them to respiratory depression.
Intravenous additive (to run over 15-20 min):

- RR, HR, BP, and sedation score every 10 min X 2, then every 30 min X 2, and then as per
patients condition
- Pain score at completion of the flush, then every 30 min X 2, and then as per patients
condition/preexisting orders
- Continuously monitor O2 saturation only for children whose underlying condition predisposes
them to respiratory depression.
Analgesia Monitoring Guidelines

Continuous IV infusion/PCA:
- RR, HR, BP, pain score, and sedation score every 1 h X 4, then RR and sedation score every 1 h,
and then HR, BP, and pain score every 4 h
- Continuously monitor O2 saturation and document reading every 1 h
Intermittent epidural administration:

- RR, HR, and BP every 5 min for the first 20 min following a bolus dose,and then RR and sedation
score every 1 h
- HR, BP, pain score, and motor block score every 4 h
- Continuously monitor only for children whose underlying condition predisposes them to
respiratory depression
Continuous epidural infusion:

- RR, HR, BP, sedation score, pain score, and motor block score every 1 h X 4 h, then RR and
sedation score every 1 h, and HR, BP, pain score, and motor block score every 4 h.
- Continuously monitor O2 saturation and document reading every 1 h
CANCER PAIN ASSESMENT

Many ways to asses the level of pain
Most popular is VAS (Visual Analog Scale)
from 0 to 10
0
10
0 = No pain, 10 = Very severe pain

1-3 : Mild Pain
4-6 : Moderate pain
7-10 : Severe pain
Assessment of Pain Intensity

Visual Analog Scale
Verbal Pain Intensity Scale

No
pain
Mild Moderate Severe Very

Worst
pain
pain
pain severe possible
pain
pain
Worst
possible
pain
No
pain
010 Numeric Pain Intensity Scale
0
No
pain
2
Mild
pain
Moderate
pain
Faces Scale
10
Worst
possible pain
WHO Analgesic Ladder
How to apply
THREE STEP LADDER ANALGESIC
As much as possible, depend on patients
condition, drugs should be given by
by::
the patients him/herself
the mouth/oral
the clock (06, 10, 14, 18, 22, 02)
the ladder
Started with step one, two than three
April 19-21, 2008
WHO 33-Step Analgesic Ladder

3.Severe
Morphine*
2.Moderate
Codeine*
1.Mild
Hydrocodone
Oxycodone
ASA*
Acetaminophen*
NSAIDs*
Adjuvants*
Dihydrocodeine
Tramadol*
Adjuvants*
Hydromorphone
Methadone
Levorphanol
Fentanyl*
Oxycodone
Adjuvants*
Level I Analgesics
Paracetamol::
Paracetamol
Simplest and safest analgesic
Mechanism of action not fully elucidated
Central effect
(chemotherapy
(chemotherapy--induced) neuropathy
Non-steroidal antiNonanti-inflammatory
drugs:
Very diverse group
Main mechanism of action:
Reduction PG synthesis
Malignant bone pain
Ceiling analgesic effect
Opioid dosedose-sparing MANAJEMEN
effectNYERI / PPKC
No reduction in side effects
Level II Analgesics
Codeine:
10
Weak analgesic
K i (M )
Combination with paracetamol

0,1
Tramadol:
0,01
Weak opioid activity

Noradrenaline + Serotonin uptake
0,001
ol
ad
in
am
Tr
e
in
Verbale Beoordelingsschaal
Ti
l id
Co
de
Pr
op
ir a
e
in
yfe
Pe
ox
De
xt
ro
p
ro
p
th
id
cin
ne
zo
do
nt
a
Pe
fi n
e
ha
M
et
em
to
b
or
ne
yl
i do
an
nt
Fe
Ke
Bu
pr
e
no
r fi
ne
0,0001
Tilidine::
Tilidine
Weak opioidopioid-like activity
Buprenorphine:
morfine 4,3 g/kg IT
buprenorfine 1,3 g/kg IV
No ceiling effect for analgesia

Ceiling effects for sideside-effects
No restriction for future opioid use
MANAJEMEN
NYERI / PPKC
Additive
effect when cocomorfine 4,3 g/kg IT +
administered
buprenorfine 1,3 g/kg IV
Level III Analgesics

Morphine:
Still standard of care
Hydromorphone:
5x potent as morphine
Fentanyl:
Hydromorphone
Morphine
Oxycodone
Fentanyl
High potency (100x)

High lipid solubility
Oxycodone:
-opioid receptor
Methadon:
Racemic mix
NMDA-antagonist
NMDA-receptor agonist

HalfHalf-life: up to 190 hours
Steady state: 6 - 12 hours of analgesia
Nonopioid Drugs of Cancer Pain Relief

Drug
Dosage
Comments
Acetaminophen
10-15 mg/kg PO, every 4-6 h

Dose limit of 65 mg/kg/day or
4 g/day, whichever is less
Lacks gastrointestinal and hematologic

side effects; lacks anti-inflammatory
effects (may mask infection associated
fever).
Ibuprofen
5-10 mg/kg PO, every 6-8 h

Dose limit of 40 mg/kg/day;
max dose of 2400 mg/day
Anti-inflammatory activity. Use with

caution in patients with hepatic or renal
impairment, compromised cardiac
function or hypertension (may cause fluid
retention, edema), history of GI bleeding
or ulcers, may inhibit platelet
aggregation.
Naproxen
10-20 mg/kg/day PO, divided

every 12 h
Dose limit of 1 g/day
Anti-inflammatory activity. Use with

caution and monitor closely in patients
with impaired renal function. Avoid in
patients with severe renal impairment.
Diclofenac
1 mg/kg PO, every 8-12 h

Dose limit of 50 mg/dose
Anti-inflammatory activity. Similar GI

renal and hepatic precautions as noted
above for ibuprofen and
Naproxen.
MANAJEMEN
NYERI / PPKC
Note: Increasing the dose of nonopioids beyond the
recommended
therapeutic level produces a ceiling effect
(i.e., there is no additional analgesia but there are major increases in toxicity and side effects).
Common Adjuvant Analgesics

Drugs
Symptom control
Tricyclic antidepressants
Antiepileptics
Ketamine
Neuropathic pain
Corticosteroids
Reduce pain associated

with tumour oedema
Benzodiazepines
Baclofen
Buscopan
Muscle spasm
Bisphosphonates
Bone pain
Adjuvant Analgesic Drugs

Drug Category
Antidepressants
Drug, Dosage
Indications
Amitriptyline:
- Initial dose 0.2-0.5 mg/kg PO
- Titrate upward by 0.25 mg/kg
every 2-3 days
- Maintenance: 0.2-3 mg/kg
Alternatives: nortriptyline,
doxepin, or imipramine
Anticonvulsants
Gabapentin:
- Initial dose 5 mg/kg/day PO
- Titrate upward over 3-7 days
- Maintenance: 15-50 mg/kg/day
PO divided TID
Neuropathic pain (i.e.,

vincristine-induced,
radiation plexopathy,
tumor invasion,
CRPS-1), insomnia
Monitor for hematologic,

hepatic, and allergic
reactions. Side effects
include gastrointestinal
upset, ataxia, dizziness,
disorientation, and
somnolence
- Initial dose 10 mg/kg/day PO

divided OD or BID
- Maintenance: up to 20-30 mg/
kg/day PO divided every 8 h.
Increase dose gradually over 24 weeks
Alternatives: clonazepam
Hydroxyzine: 0.5 mg/kg PO

every 6 h
Diphenhydramine: 0.5-1 mg/

kg PO/IV every 6 h
Usually improved sleep and

pain relief within 35 days.
Anticholinergic side effects
are dose-limiting. Use with
caution for children with
increased risk for cardiac
dysfunction.
Neuropathic pain,
especially shooting,
stabbing pain.
Carbamazepine:
Antihistamines
Comments
Opioid-induced
pruritus, anxiety,
nausea
Sedative side effects may be

helpful
Adjuvant Analgesic Drugs

Drug Category
Drug, Dosage
Sedatives,
hypnotics,
anxiolytics
- Diazepam: 0.025-0.2 mg/kg

PO every 6 h
- Lorazepam: 0.05 mg/kg/dose
SL
- Midazolam: 0.5 mg/kg/dose
PO administered 15-30 min
prior to procedure; 0.05 mg/
kg/dose IV for sedation
Acute anxiety, muscle

spasm; premedication
for painful procedures
Sedative effect may limit

opioid use. Other side effects
include depression and
dependence with prolonged
use
Prednisone, prednisolone,
and dexamethasone dosage
Headache from
increased intracranial
pressure, spinal, or
nerve compression;
widespread metastases
Side effects include edema,

dyspeptic symptoms, and
occasional gastrointestinal
bleeding
Opioid-induced
somnolence
Potentiation of opioid
analgesia
Side effects include agitation,

sleep disturbance, and
anorexia.
Administer second dose in
the afternoon to avoid sleep
disturbances
Corticosteroids
Indications
depend son clinical situation.
Dexamethasone:
- Initial dose: 0.2 mg/kg IV.
- Dose limit 10 mg.
- Subsequent dose: 0.3 mg/kg/
day IV divided every 6 h
Psychostimulants
Dextroamphetamine,Methyl
phenidate: 0.1-0.2 mg/kg BID.
Escalate to 0.3-0.5 mg/kg as
needed
Comments
Starting Doses of Opioid Analgesics for Cancer Pain Relief

Drug
Equianalgesic
dosage
(parenteral)
Starting dosage IV
IV:PO
ratio
Starting dosage
PO/Transdermal
Duration of
Action
Morphine
10 mg
- Bolus dose = 0.05-0.1

mg/kg every 2-4 h
- Continuous infusion
= 0.01-0.04 mg/kg/h
1:3
0.15-0.3 mg/kg/dose every

4h
3-4 h
Hydromorphone
1.5 mg
0.015-0.02 mg/kg every

4h
1:5
0.06 mg/kg every 3-4 h
2-4 h
Codeine
120 mg
Not recommended
1 mg/kg every 4 h (dose

limit
1.5 mg/kg/dose)
3-4 h
Oxycodone
5-10 mg
Not recommended
0.1-0.2 mg/kg every 3-4 h
3-4 h
Meperidine
75 mg
0.5-1 mg/kg every 3-4 h
1-2 mg/kg every 3-4 h

(dose
limit 150 mg)
1-3 h
Fentanyl
100 g
1-2 g/kg/h as
continuous infusion
Methadone
10 mg
1:4
1:2
25 g patch
72 h (patch)
12-50 h
Starting Doses of Opioid Analgesics for Cancer Pain Relief

Drug
Equianalgesic
dosage
(parenteral)
Starting dosage IV
IV:PO
ratio
Controlledrelease
morphine
0.6 mg/kg every 8 h

or 0.9 mg/kg every 12 h
Controlledrelease
hydromorpho
ne
0.18 mg/kg every 12 h
Controlledrelease
codeine
3 mg/kg every 12 h
Controlledrelease
oxycodone
0.30.6 mg/kg every 12 h
Starting dosage
PO/Transdermal
Duration of
Action
STRONG OPIOIDS
Most commonly use:
Morphine*
Hydromorphone
Transdermal fentanyl (Duragesic
(Duragesic)*
)*
Oxycodone
Methadone
DO NOT use Meperidine (Demerol) longlong-term
active metabolite normeperidine seizures
Long Acting Opioids

Drug
Morphine
Brand
Dosing Interval
MS Contin
8-12 hrs
Oramorph-SR
8-12 hrs
Kadian
12-24 hrs
Avinza
24 hrs
Oxycodone
OxyContin
8-12 hrs
Oxymorphone
Opana ER
12 hrs
Fentanyl
Duragesic
48-72 hrs
Methadone
6-12 hrs
Opioid Resistance
limiting side effects
Small group of patients
Pathophysiology of true
resistance ?
Downregulation of number -receptors:
Peripheral nerve damage
Long--term use of opioids
Long
Cholecystokinin (CCK):
Control of opioid sensitivity
Cancer syndromes
DeDe-activation of opioid
opioid--receptors:
GURK--receptor activation
GURK
Inhibition of -receptor
OpioidOpioid-Induced Hyperalgesia (OIH)
Opioid Dose Conversions

Use equianalgesic charts as a guideline,
always titrate to response
Incomplete cross tolerance among
opioids, recommend reducing calculated
equivalent by 3030-50%
Dose reductions not necessary when
switching routes of the same drug
Close observation in the first few days
Equianalgesic Conversion Chart

Drug
Equianalgesic ORAL
Equianalgesic IV
Codeine
200 mg
130 mg
Hydrocodone
30 mg
---
Morphine
30 mg
10 mg
Hydromorphone
7.5 mg
1.5 mg
Oxycodone
20 mg
---
(patch ~ morphine)
0.1 mg (100 mcg)
Meperidine
300 mg
75 mg
Methadone
10 mg ACUTE
5 mg ACUTE
Fentanyl
Opioid--Induced Neurotoxicity
Opioid
(OIN)
Neuropsychiatric syndrome
Cognitive dysfunction
Delirium
Hallucinations
Myoclonus/seizures
Hyperalgesia//allodynia
Hyperalgesia
OIN: Treatment
Opioid rotation
Reduce opioid dose
Hydration
Circadian modulation
Psychostimulants
Other Rx
Opioid Rotation
Metabolites cause OIN
Change to another opioid analgesic
25 - 50% dose reduction
Morphine/hydromorphone
Morphine/
hydromorphone/oxycodone
/oxycodone
Second line agents:
- fentanyl/
fentanyl/sufentanil
sufentanil
- methadone
Cancer Pain
Breakthrough Pain:
Incidental pain
Severe transitory increase in pain on
baseline of moderate intensity or less
Caused by movement, positioning,
cough, wound dressing, etc
Often associated with bony metastases
Portenoy
R. Sem Onc, 1997;24:S16-7-S16-12
Components of ModerateModerate-to
to-Severe Chronic Cancer Pain
Around-the-Clock
Medication
Breakthrough
Pain
Breakthrough Pain
Ideal Agent:
Agent:
Potent, pure opioid agonist
Potent,
Rapid onset
Early peak effect
Short duration
Easily administered
Sublingual/Transmucosa
Sublingual/
Transmucosa routes
advantageous
Breakthrough Pain
Medication type
Fentanyl
Fentanyl
Fentanyl
Fentanyl
Sublingual Dose
12.5 g
25.0 g
50.0 g
100.0 g
Each step repeated 1 - 2 x q 15 min

What anesthesiologist can do

for cancer pain patients:
1. Neurolytic block:
- Alcohol 100%
- Phenol glycerin 15%
- RFG
2. Epidural / Spinal opioid
3. Ganglion block
4. Neural blockade
5. Etc
SUMMARY:
1. Pain is common problem and a major symptom of
cancer patient.
2. Pain is one at most feared aspect and can cause
to suicide.
3. Cancer pain can be organic or psychological pain.
4. Organic pain may be somatic,
neuropathic pain or combined.
visceral
or
5. Total pain is a BIOPSYCHOSOCIOCULTUROSPIRITUAL problem.

6. Basic principle of cancer pain treatment is
following WHO guidelines (three step ladder
analgesic).
7. CANCER PAIN management should be treated
integrated and comprehensive
include spiritual
approach.
NSAID--Opioid Commercial Drug Combinations

NSAID
Combination
Trade Name
Strength mg
Dose by pill
Aspirin +
caffeine +
dihydrocodeine
Synalgos
356.4+30+16
1-2 q4 hr
Moderate to
moderate
severe pain
Good for postoperative

and breakthrough
pain. Also, headaches
and migraine attacks
Aspirin +
carisoprodol +
codeine
Soma
Compound
w/codeine
325+200+16
1-2 TID-QID
(6)
Painful muscle
spasm

and breakthrough
pain, especially pain
associated w/spasm
Aspirin +
codeine
Empirin w/
codeine #3
Empirin w/
codeine #4
325+30
1-2 q4 hr

and breakthrough pain
325+60
1 q4 hr
Mild to
moderate
pain
LortabASA
500+5
1 q4 hr
Moderate
severe
acute pain

and breakthrough pain.
No longer available in the
United States
Aspirin +
hydrocodone
Indication
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Nyeri Kanker

MANAJEMEN NYERI / PPKC

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Bukti tentang nyeri kanker

Hambatan Penanganan Nyeri Yang Efektif

Gejala kanker stadium lanjut

MANAJEMEN NYERI / PPKC

Prevalensi Nyeri Kanker

MANAJEMEN NYERI / PPKC

203,000-365,400 kasus kanker

Nyeri merupakan keluhan utama 89%

Nyeri yang tidak tertangani

MANAJEMEN NYERI / PPKC

Definisi Nyeri (IASP 1979):

CANCER PAIN IS TOTAL PAIN

Loss of social position

Loss of job prestige and income

Friends who do not visit

Chronic fatigue and insomnia

Fear of hospital or nursing home

Worry about family

Loss of dignity and bodily control

MANAJEMEN NYERI / PPKC

Uncertainty about future

A cancer is not only a

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Penyebab stimulus nyeri visceral :

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B. Nyeri non nosiseptif

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Allodynia: Nerve Injury Leads to Central

After Nerve Injury

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Klasifikasi nyeri kanker

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Various Schemes for Classifying Cancer Pain

- Primarily caused by cancer

- Nociceptive (somatic, visceral)

Location of cancer pain syndromes:

- Head and neck pain

Clinical Characteristics of the Pathophysiologic

- Character of somatic pain is aching, stabbing,

- Character of pain usually gnawing or cramping

Clinical Characteristics of the Pathophysiologic

- Character of pain often described as burning, pricking, electric-like

- Character of pain similar to that of nerve compression may also be

- Associated symptoms include cutaneous vasodilation, increased

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Penyebab nyeri kanker

MANAJEMEN NYERI / PPKC

Penyebab nyeri kanker

MANAJEMEN NYERI / PPKC

2. Nyeri yang berhubungan dengan

Penyebab Nyeri Kanker

MANAJEMEN NYERI / PPKC

Penyebab Nyeri Kanker

COBALT RADIATION BURN

3.Nyeri yang tidak berhubungan

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Penyebab nyeri kanker

Acute Herpes ZosterMANAJEMEN NYERI / PPKC