Professional Documents
Culture Documents
PERIOPERATIF
2
Topik yang akan dibahas
1. Apa itu nyeri? (definisi nyeri)
2. Mengapa nyeri harus dikelola?
3. Apa itu nyeri pascabedah?
4. Konsekwensi nyeri pascabedah
5. Prinsip dasar pengelolaan nyeri pasca
bedah
6. Analgesia multimodal
7. Strategi multimodal analgesia guna
meningkatkan outcome pembedahan
8. Penutup
Definisi Nyeri
Perasaan sensorik
dan pengalaman
emosional yg tidak
menyenangkan
- Akibat adanya kerusakan
jaringan yang nyata atau yang
berpotensi rusak,
- Atau digambarkan seperti
adanya kerusakan jaringan.
Acute pain:
Nyeri yang muncul pada pasien yang baru saja
menjalani prosedur bedah.
Bisa diakibatkan dari prosedur pembedahan
atau komplikasi yang berkaitan dgn prosedur
tsb.
Pain management in the perioperative setting:
Semua tindakan yg dilakukan sebelum, saat,
sesudah pembedahan yg bertujuan mengatasi
nyeri post operatif sebelum px dipulangkan.
Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated
Report by the ASA Task Force on Acute Pain Management, 2004.
Mekanisme Umum Nyeri
Poisons
mechanical , thermal , chemical
Tissue damage
Release of mediators
Hydrogen and potassium ions,
neurotransmitters, kinins,
prostaglandins
Stimulation of nociceptors
Transmission to CNS
via afferent pathways
7
Alur Nyeri Nosisepsi Neuron III Persepsion
SS
Transduction
Nociceptor
Mechanical Conduction/
Transmission
Transmission
Modulation
Neuron II
Thermal
Neuron I
Chemical
Nociceptor
Modified by AHT
Mengapa nyeri harus
dikelola atau diobati?
The Epidemiology and the Magnitude of
Postoperative Pain
Nyeri post operative adalah masalah medis yg utama,
ekonomi, sosial dan problem kemanusiaan , karena :
Im worried that
I wont wake up,
after the
surgery
Im worried to have
PAIN, after the
surgery
Physiological Psychological/Emotional
Consequences Consequences
Sympathetic overactivity: Fear
Tachycardia, hypertension
Increased cardiac work
Anxiety
Increased oxygen Apprehension
consumption, etc
Respiratory dysfunction
GIT dysfunction ileus
Renal suppression Suffering
oligouria
Immunosuppression
Thromboembolic
Surgery
X
Nyeri Klinik Hilang Nyeri
(Nyeri Patofisiologis) Setelah sembuh kronik
(2-10%)
Kenapa hal ini dapat terjadi
Setelah pembedahan, setelah
kerusakan jaringan atau jaringan
mengalami inflamasi, terjadi
proses:
SENSITISASI PERIFER
SENSITISASI SENTERAL
Sensitizing Soup
Hydrogen ion Histamine Purines Leucotrine
Norepinephrine Potassium ion Cytokines Nerve Growth Factor
Bradykinin Prostaglandins 5-HT Neuropeptides
Inhibitory
Interneuron
Nociceptor NE
Terminal ending MU
SP SP
Glu
Glu
Post Synaptic Membrane of SP
PERIPHERAL
ACTIVITY
CENTRAL
SENSITIZATION
Decreased Increased
Nerve damage threshold to spontaneous
peripheral Expansion of activity
stimuli receptive
field
Prinsip Dasar Pengelolaan
Nyeri Pasca Bedah
Pengelolaan Nyeri Perioperatif
Mencegah, menekan atau
meminimalisasi terjadinya proses
sensitisasi perifer maupun
sensitisasi sentral.
10
G S G&L
Tverskoy et al. Postoperative pain after inguinal herniorrhaphy with
different types of methods. Anesth Analg 1990;70:29-35.
Berbagai Cara Pengelolaan
Nyeri Pasca Bedah.
Berbagai Teknik Pengelolaan Nyeri
Pascabedah
PCA (Patient Controlled Analgesia)
Epidural/Intratekal dgn opioid
Epidural/Intratekal dgn anestetik lokal
Blokade saraf (infiltrasi, interkostal, intrapleural
dll)
Opioid
NSAID COX-1 atau COX-2 inhibitor)
Paracetamol (COX-3 inhibitor)
Gabapentanoid (gabapentin, pregabalin)
Tramadol
Ketamin
MULTIMODAL ANALGESIA
Dll.
Apa itu Analgesia Multimodal?
(Balanced Analgesia)
Mengkombinasikan 2 atau lebih analgesik
yang memiliki mekanisme kerja yang
berbeda, menghasilkan analgesia yang
sinergik dengan efek samping yang kurang
Optimal analgesia
due to synergistic/additive
Potentiation effects
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.
Effect Magnitude
Blood loss or 30%
transfusion
requirements
Pulmonary 40%
complications
Thromboembolic 50%
complications
Ileus (abdominal 2 days
procedures)
Mortality (acute hip 25%
surgery)
= Reduced.
Beda Pembedahan Beda Intensitas
Nyeri
Different Different
types pain
of pain intensity
Different
procedures
Different risks
and benefits of Different
analgesic location
techniques of pain
Perioperative Multimodal Analgesia
Parecoxib
Ketamine
Ibuprofen
ivNMDA
COX2 inhibitor antagonists
iv
NSAIDs
iv Better analgesia:
synergy
Multimodal additivity
COXIB
Tramadol
OPIOID
Ketamine
PARACETAMOL
Gabapentanoid
(Morphine, Fentanyl)
(Gabapentin, Pregabalin)
Choice of Analgesic Technique
(Analgesic Ladder of WFSA)
Pain And
NSAID Oral route unavailable
Intensity and Rectal paracetamol & NSAID Opiate:
High Tech: PCA
Paracetamol Low tech: IM algorithm Epidural
infusion analgesia
NSAID
and
Paracetamol
Pain Paracetamol
decreases as
time passes
Fast Track Surgery
Wilmore and Kehlet (BMJ 2001; 322: 437-476)
Surgery is undergoing revolutionary
change due to newer approaches to
pain control
Regional anesthesia (epidural, spinal or
nerve blocks)
Minimal invasive surgery
Optimal pain control
Aggressive postoperative rehabilitation
Early mobilization
Early oral nutrition
Minimal use of tubes, drains and catheters