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Toar JM Lalisang Digestive Surgery Division Cipto Mangunkusumo Hospital.

Jakarta

25 % of patients do not think their doctors know how to control their pain,

20% feel that their doctor does not consider their pain a problem,
and 1 in 8 state their physician never asks them about their pain. 4 of 5 patients think they must live with their pain.

1 Patients also need to feel that their pain is important and that there are many options for improving their pain and level of daily activities.

Unpleasant sensation and emotional experience accompanied with potential and actual tissue damage

PAINFUL ?

Pain Seminar, Lecture #4, PAIN MECHANISMS: CNS, p. 29

Disease

pain

disease

Pain

Doctor

Patient

Pain is always subjective

Patients Self-report of pain is the gold Standard for assessment


IASP 1999; Portenoy RK, Lesage P. lancet, 1999

1. 2. 3. 4.

Pulse Blood pressure Temperature Respiratory rate

Pain: The Fifth Vital Sign1*

*Trademarks are the property of their respective owners.

1 American

Pain Society Web site.

Vital signs are taken seriously. If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated

James Campbell

Not only as a symptom


But

Disease of pain

Investigators view

MILD

MODERATE

SEVERE

10

Patients view

NO PAIN

PAIN

Muscle atrophy & weakness Weight loss/gain Negative self-talk Poor sleep Missing work

Pain

Disability

Distress
Less active Decreased motivation Increased isolation

Belief that pain is not harmful to the patient

Normal consequence of surgery and injury


Concerns that pain relief will obscure a surgical diagnosis or mask signs of surgical complications

Underestimation of a patients pain


Failure to recognize variability in patients perceptions of pain Lack of regular and frequent assessment of pain and any pain relieving measures

Fear

that the patient will become addicted to opioids Inadequate perioperative pain education regarding postoperative analgesia Patients reluctance to request analgesia and/or fear of taking pain medications Lack of understanding of the wide variability in opioid requirements among patients, and the need to titrate analgesics to meet the needs of each patient Lack of recognition that age is a better predictor of opioid requirement than weight in the adult patient Prolonged dosing intervals/short-acting opioids have short elimination half-lives Lack of accountability for pain management

70% 60% 50%

65%
Worst Pain: Moderate to Severe Average Pain: Moderate to Severe

45% 40%

Patients (%)

40% 30% 20%

24%

26% 13%

10% 0% 24 hours 48 hours Day 7

Time After Discharge

1Beauregard

L et al. Can J Anaesth. 1998;45:304-311.

Pain as a Symphony
Complex dynamic Sensors Emotions Memory Hormones

Opiat & NSAID Powerfull drugs treating pain MANY SIDE EFFECT GI problem Dependence

Perception

Pain Transmission

Pain

Medulation
Descending modulation Ascending input Dorsal Horn Dorsal root ganglion

transmission Transduction

Spinothalamic tract

Peripheral nerve

Trauma
Peripheral nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

Surgeon makes wounds for treatment.

Wounds caused pain

Type of surgery

Severe postoperative pain

Lower abdominal surgery Major joint surgery Osteotomies Maxillofacial surgery

2to 3 days

Perineal SURGERY Thoracotomies Upper abdominal surgery

3to 4 days

Multi modal approach

Preemptive analgesia

Procedure specific pain management

2 analgesic agents that act by

different mechanisms via a single route for providing superior analgesic efficacy with equivalent or reduced adverse effects.
epidural opioids with epidural local anesthetics or clonidine, Intravenous opioids in combination with ketorolac or ketamine.

2routes of administration may be more effective


epidural or intrathecal opioid analgesia with intravenous, intramuscular, oral, transdermal subcutaneous analgesics intravenous opioids combined with oral NSAIDs, COXIBs, or acetaminophen

Multi Modal Analgesic (KEHLET, 1993)

Lowering each dosage


Effective in sinergy & additive Decrease side effect

1Kehlet

H et al. Anesth Analog. 1993;77:1048-1056.

Kenapa harus multi modal?

Dari sisi obatnya


Tidak ada satu pun analgesik yang sempurna dan dapat mengatasi semua jenis nyeri

Masing-masing memiliki kelemahan dan keunggulan


Secara klinis akan memberikan hasil yang lebih baik daripada pemakaian analgesik tunggal

Dari sisi nyerinya

1.Sebagian besar nyeri bersifat multi facet dan multi source.

2.Nyeri akan bersifat dinamis dan berubah sesuai progresifitas penyakitnya.

PERCEPTION
Pain

OPIOID - Systemic - Epidural - Subarach Tramadol

Descending modulation Ascending input

Dorsal Horn

LOCAL ANESTHETIC - Epidural - Subarachnoid


Dorsal root ganglion

TRANSMISSION

LA COX-1 COX-2
TRANSDUCTION
Trauma

Spinothalamic tract

Peripheral nerve

Peripheral nociceptors

No single drug can produce optimal analgesia without adverse effect


Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

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PERCEPTION: Tramadol, opioid

MODULATION: Tramadol,opioids, antidepressants

TRANSMISSION: Paracetamol, tramadol, opioids

Mekanisme Multi Modal

TRANSDUCTION: NSAIDs, COX-2 inhibitors, local anesthetics

Pre-emptive

Preventive analgesia:
any perioperative analgesic regimen able to control pain-induced sensitization of the central nervous system to decrease both the development and the persistence of pathologic pain

introduction of an analgesic regimen before the onset of noxious stimuli prevent sensitization of the nervous system to subsequent stimuli that could amplify pain

the pain intensity and its consequences may be procedure-related Some analgesic modalities may only apply to certain surgical procedures The risk-benefit ratio of different analgesics may also vary according to the surgical procedure the risk and clinical implications of postoperative bleeding associated with certain analgesics are also procedure-specific Postoperative pain may also depend on the choice of surgical technique

Tramadol+ APAP

NSAIDS

Nonspecific COX-2 specific

Opioids Local anesthesia Adjunctive therapy

Gastrointestinal1,2

Peptic ulceration; gastrointestinal hemorrhages Esophagitis and strictures Small and large bowel erosive disease Inhibition of platelet aggregation Increased risk of bleeding Reversible acute renal failure Fluid and electrolyte disturbance/edema Chronic renal failure and interstitial fibrosis Interstitial nephritis Nephrotic syndrome

Hematologic

Cardiorenal1

Exacerbation of Hypertension Congestive heart failure Angina

1Brooks 2Girgis

P. Am J Med. 1998;104(suppl 3a):9S-13S. L et al. Drugs Aging. 1994;4(2):101-112. 3Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.

Pain relief requirements can vary greatly from one individual to another, and even in the same individual from one time to another. Side-effects also vary from person to person. The prescription therefore needs to be tailormade to benefit the patient

Multimodal analgesia using local anesthetic, NSAIDs and opiates provides improved pain control, decreased nausea, and faster discharge following laparoscopic cholecystectomy. (I, A [Michaloliakou et al., 1996]) Pain following upper abdominal surgery produces inspiratory muscle dysfunction. This dysfunction is reduced with analgesia. (I, A [Vassilakopoulos et al., 2000]) IV PCA morphine produces better analgesia than IM morphine, without any increase in postoperative hypoxemia. (I, A [Wheatley et al., 1992]) Patients using IV PCA morphine used more morphine and had better analgesia than patients receiving IM morphine on demand. IV PCA patients also experienced more fatigue and had less vigor than patients receiving IM morphine. (I, A [Passchier et al., 1993]) Epidural analgesia, with a combination of opiates and local anesthetic, provides better pain control during rest and activity, and is the treatment of choice. It is also associated with more rapid recovery of bowel function. (I, A [George et al., 1994; Mann et al., 2000; Liu et al., 1995]; III, A [Mulroy et al., 1996]) Epidural analgesia is associated with less postoperative myocardial ischemia (than IV PCA with morphine). (II-2, A [deLeon-Casasola et al., 1995]) For optimal analgesia, the thoracic epidural route should be used for pain relief after upper abdominal surgery. (I, A [Wiebalck et al., 1997; Chisakuta et al., 1995; George et al., 1994])

Pain control with intercostal nerve block in combination with opiates is more effective than opiates alone after subcostal incisions. Intercostal nerve blocks do not significantly improve analgesia following midline incisions. (I, B [Engberg et al., 1985]) Phenol with local anesthetic has been shown to increase the duration of intercostal block and improve analgesia following cholecystectomy. (I, B [Maidatsi et al., 1998]) Infiltration of the incision/wound with local anesthesia improved postoperative analgesia provided by epidural bupivicaine/morphine during mobilization and reduced the need for supplemental intramuscular morphine. (I, B [Bartholdy et al., 1994]) Ketorolac given before or after laparoscopic cholecystectomy reduced postoperative pain and facilitated the transition to oral pain medication. (I, A [Lane, 1996]) Pain relief promotes return of respiratory function. (I, A [Vassilakopoulos et al., 2000]) Aggressive perioperative management with epidural, NSAIDs, early feeding, and ambulation is associated with improved recovery and rapid discharge after laparoscopic colonic surgery. (II-3, B [Kehlet et al., 1999]; II-3, A [Bardram et al., 1995]) Laparoscopic cholecystectomy is associated with less pain than open cholecystectomy. (I, A [McMahon et al., 1994]) Patient-controlled epidural analgesia with a background infusion is more effective than patient-controlled epidural analgesia alone after gastrectomy. (I, A [Komatsu et al., 1998])

Multimodal analgesia using local anesthetic, NSAIDs, and opiates provides improved pain control, decreased nausea, and faster discharge following laparoscopic cholecystectomy. (I, A [Michaloliakou, 1996]) Active removal of residual pneumoperitoneum reduces postoperative pain following laparoscopic cholecystectomy. (I, A [Fredman et al., 1994]) Suprahepatic suction drains placed by the surgeon have been shown to reduce shoulder tip pain following laparoscopic cholecystectomy. (II3, B [Jorgensen et al., 1995])

Epidural analgesia produces better pain control at rest and with activity. It is also associated with earlier return to normal mental status in the elderly, better satisfaction, and more rapid recovery of bowel function. (I, A [Liu et al., 1995; Mann et al., 2000]) Aggressive perioperative management with epidural, NSAIDs, early feeding, and ambulation is associated with improved recovery and rapid discharge after laparoscopic colonic surgery. (II3, A [Bardram et al., 2000]; II-3, B [Kehlet, 1999; Bardram et al., 1995])

Epidural opiates in the postoperative period provide better analgesia with fewer side effects than IV PCA morphine. (I, A [ErikssonMjoberg et al., 1997]) Ambulation in the perioperative period is associated with a decreased risk of thromboembolic complications and more rapid recovery of bowel function. (II-3, A [Bardram et al., 2000])

Benefits of Effective Pain Management are simple and straightforward. Effective pain management can: Increase patient satisfaction. Increase the speed of recovery. Decrease hospital length of stay. Decrease overall hospital costs. Reduce the likelihood of chronic pain. Decrease the likelihood of complications. Increase productivity. Decrease suffering. Improve quality of life.

Pain is a major health problem and remains a challenge to healthcare providers Pain is subjective and must be frequently assessed on an individual patient basis. Undertreatment of pain can lead to serious negative sequelae, including:
Cardiac complications Respiratory depression Anxiety Depression

Summary

Benefits of pain management are:

Increased speed of recovery Decreased length of hospital stay and overall hospital costs Decreased likelihood of developing chronic pain Increased patient satisfaction and productivity

Long-acting opioids are proven effective for treatment of around-the-clock pain.

Thorough documentation and patient contracts allow healthcare professionals to safely provide effective pain management to their patients.

Post operative pain is still a challenging problem, with a wide variations of treatment options

Therefore treatment of post operative pain needs a good collaboration of several disciplines to provide good post operative pain care.

Which one is your patient ???????

To chose an adequate painkiller

Solve the problems without create a problems

THX for U Attention

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