PRESENTASI

BEDAH
ORTHOPAEDI
Oleh :
Mahasiswa Magister Farmasi
Klinik Fakultas Farmasi
Universitas Airlangga
2014

TERAPI ANALGESIK BEBERAPA PASIEN

BEDAH F (KASUS ORTHOPAEDI)

Nama Px/
umur
Diagnosis

Ny.IAR/31 th

Unstable pelvis stable

HD+Amputasi traumatik below
knee (D) OF Femur (D) 1/3
tengah gr IIIA + Simpisialiris gr
III + CF numerus (D) 1/3 tengah
dg lesi n. Radialis + OF
antebrakhiali (D) segmental +
OF metacarpal II + OF Head
metacarpal IV + OF baris
phalang promixal dig. II, III
manus (D)
Tindakan
16/5
Amputasi above knee (D) ec
traumatic
Repair laserasi perinei +
labium mayor (S) + pasang
drain + pasang tampon
vagina
Skala nyeri 6
Terapi
Inj. Ketorolac 3x1 (15/5 17/5)
Inj. Tramadol 3x100mg (15/5

An. M.M./10 th
EDH FTP (s) + CF tibia 1/3
tengah (d) post craniomotomy
evaluasi EDH +post LAC H-0
+ post osteoplastis

Craniomotomy evaluasi EDH

+post LAC H-0 + post
osteoplastis

4
Inj. Ketorolac 3 x30mg
(22/5,23/5)

Nama Px/
umur

Ny.SU/48 th

Tn.S/21 th

Diagnosis

OF intercondyler femur
(D)

OF Antebrachial 1/3 Distal Grade II

OGF + OF Cruris (S) 1/3 Tengah
Grade Ii OCP + CF Femur D/S

Tindakan

2/5 - Debridemen
screwing+TST

4/5- Debridement + LAC +TST DS

+BKC

10/5 - Debridemen
screwing +TST

20/5-Platting antebrachial (D)

6
Ketorolak 3x30 mg (2/55/5)
Tramadol 3x100 mg (3/54/5, 6/5-10/5)
Parasetamol 3x500 (5/57/5, 11/5-26/5 prn)

7
Ketorolak 3x30 mg (3/5-7/5,
20/5-23/5)
Tramadol 3x100 mg (8/5-10/5)
Paracetamol 3x500 (11/5-19/5,
24/5-28/5)

Skala nyeri
Terapi

Jenis Nyeri

(Dipiro, 2011)

NYERI AKUT

NYERI KRONIS

SIGNS
Hypertension, tachycardia,
diaphoresis, mydriasis, and
pallor, but these signs are not
diagnostic.
In some cases there are no
obvious signs.
Comorbid conditions usually not
present.
Outcome of treatment generally
predictable.

Signs
Hypertension, tachycardia,
diaphoresis, mydriasis, and
pallor are seldom present.
In most cases there are no
obvious signs.
Comorbid conditions often
present (e.g., insomnia,
depression, anxiety).
Outcome of treatment often
unpredictable.

Laboratory Tests
Pain is always subjective.
There are no specific laboratory
tests for pain.
Pain is best diagnosed based on
patient description and history.

Laboratory Tests
Pain is always subjective.
Pain is best diagnosed based on
patient description and history.
There are no specific laboratory
tests for pain; however, history
and/or diagnostic proof of past
trauma (e.g., computed
6
tomography) or (Dipiro,
present2011)
disease

Analisis Nyeri yang

Digunakan

Wong Baker Face

Scale

Merupakan metode yang simple dan banyak

digunakan memiliki kekurangan yaitu kurang
sensitif dan tidak dapat digunakan untuk anakanak < 2 th
8

PENATALAKSANAAN
NYERI AKUT
9

10

11

(Dipiro, 2011)

Skala Nyeri dan Terapi Pasien

Nama
Px/
umur
Skala
nyeri
Tingkat
Nyeri

An. MM/10 th

Ny.IAR/31 th

Ny.SU/48 th

Tn.S/21 th

Moderate-Severe

12

Multimodal Management of Acute Pain : The Role

of NSAID

13

Efek Samping Penggunaan Opioid

14

(Dipiro, 2011)

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16

FARMAKOKINETIKA
ANALGESIK
17

Paracetamol

Ketorolac

Tramadol

Bioavail 70-90%
ibility
Tmax
10-60 minutes

80-100%

70-90%

0,09 hour

2-3 hour

Onset

10 minutes

1 hour

6-8 hours

6 hour

Food
decreases
rate but not
extent of
absorption

Food does not

significantly
alter the rate or
extent of
18
absorption

<1hour

Duratio 4-6 hour

n
Food
Food may delay
absorption
following
administration

Paracetamol
Pregnancy B
Breast
Yes
milk
Placenta
Cross Placenta
Plasma
25%
Protein
Binding
Metabolis Liver
m
Sulfate and
glucuronide
conjugation
Oxidized by CYP2E1
and CYP3A4
Ekskresi
Mainly excreted in
urine as conjugates

Half life

2.7hours (adult)

Ketorolac
D
Yes (Small
amounts)
Cross Placenta
>99%

Tramadol
C
Yes (Small amount)

Liver :
conjugation with
glucuronic acid

Liver :
CYP 2D6, CYP3A4,
CYP2B6

Excreted in urine
(92%) as parent
drug (60%) or
metabolites
(40%) and in
feces (6%)
5,09 hours in

Urin
Unchanged drug 30%
Metabolite 60%

Cross placenta
20%

4.5-9.5 hours

19

Ketorolac

21

(AHFS ,2011, Lacy, 2009

Dosis Ketorolak
Dewasa
:

Anak :

Guideline of Pain Management

2012

2-16 years : I.V.: Initial dose: 0.5 mg/kg followed by

0.25-1 mg/kg every 6 hours for up to 48 hours;
maximum daily dose: 90 mg
Weight <50 kg: 15 mg every 6 hours.
(BNF for Children, 2012; Lacy, 2009)

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An. M.M./10 th,

Terapi :
Inj. Ketorolac 3
x30mg (22/5,23/5)
Paracetamol tab
3x500 (tgl24-26/5)
Tn.S/21 th :
Ketorolak 3x30 mg
(3/5-7/5, 20/523/5)
Tramadol 3x100
mg (8/5-10/5)
Paracetamol
3x500 (11/5-19/5,

Dosis kurang
sesuai
Rekomendasi :
Anak 10 th/ BB:
25 Kg :
15 mg/6 jam
Penggunaan
ketorolak 5 hari
Rekomendasi :
Monitoring
tanda2
perdarahan
23

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Potensi Golongan NSAID

25

26

27

Caution
GI
Effects

Can cause peptic ulcers, GI bleeding, and/or

perforation.Contraindicated in patients with active
peptic ulcer disease, recent GI bleeding or perforation,
or a history.
Serious GI events can occur at any time and may not be
preceded by warning signs and symptoms.Geriatric
individuals are at greater risk for serious GI events.

Renal
Effects

NSAID use may compromise existing renal function;

dose-dependent decreases in prostaglandin synthesis
may result from NSAID use, reducing renal blood flow
which may cause renal decompensation.
Contraindicated in patients with advanced renal
impairment and in patients at risk for renal failure due
to volume depletion.

Hematol
ogic
Effects

Inhibits platelet function. Contraindicated in patients

cerebrovascular bleeding, or incomplete hemostasis and
in patients at a high risk of bleeding (ex. patients on anticoagulation therapy)
Sinatra, R.S., 2011.Multimodal Management of acute Pain : Role of NSAID.28
Pharmacy Practice News

Tramadol
MoA : Analog opioid. inding of parent and
M1 metabolite to -opioid receptors and
weak inhibition of reuptake of
norepinephrine and serotonin.
Uses : Management of moderate to
moderately severe pain. Efficacy
established in patients with moderately
severe acute or chronic pain, including
postoperative, gynecologic, obstetric, and
cancer pain

29

(AHFS ,2011, Lacy, 2009

Tramadol Comparation
Potency
1:10 morphine
Comparable with
petidine
Similar with ketorolac
Adverse Effect :
15-40%
Nausea/Vomitting
10-46%
Constipation
1-<5%
Euphoria
Respiratory
Depresion

30

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Dosing: Renal Impairment :

Clcr <30 mL/minute: Administer 50-100 mg
dose every 12 hours (maximum: 200 mg/day).
Dosing: Hepatic Impairment:
Cirrhosis: Recommended dose: 50 mg every 12
hours.

33

Ny.IAR/31 th, Terapi :

Inj. Ketorolac 3x1
(15/5 17/5)
Inj. Tramadol
3x100mg (15/5
19/5)
Paracetamol 3x500
mg (17-25/5)

Kombinasi ketorolak
dan
tramadol

tidak
terdapat
evaluasi skala nyeri
pasien.

Rekomendasi :
evaluasi
Dilakukan
pain
scale,
reassesment
pada
interval
tertentu,
Ny.SU/48 th
monitoring
efek
Ketorolak 3x30 mg
samping
dan
(2/5-5/5)
komplikasi

Tramadol 3x100
mengetahui
mg (3/5-4/5, 6/5penggunaan
analgesik
yang
10/5)
efektif.
Parasetamol 3x500

34

35

36

Parasetamol
MoA

38

(AHFS 2011, Lacy 2011

Dosage :
Adult : 325-650 mg every 4-6 hours or 1000 mg 34 times/day; do not exceed 4 g/day
Hepatic Impairment :
Use with caution. Limited, low-dose therapy is
usually
well
tolerated
in
hepatic
disease/cirrhosis.
However,
cases
of
hepatotoxicity at daily acetaminophen dosages
<4 g/day have been reported. Avoid chronic use
in hepatic impairment.
Renal Impairment :
Clcr 10-50 mL/minute: Administer every 6 hours.
Clcr <10 mL/minute: Administer every 8 hours
(metabolites accumulate).
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