MANAJEMEN NYERI AKUT Aries Perdana Departemen Anestesiologi dan Terapi Intensif FKUI-RSCM
DEFINISI • The IASP “ An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ”
Complex mechanism; physical, emotional, cognitive Subjective, highly individual Cannot be objectively measured A Complex sensory modality essential for survival
DEFINISI • “ Whatever the experiencing person says it is, excisting Whenever he or she say it does “ • (Margo Mc Caffey) • Pengelolaan nyeri merupakan kewajiban moral, penanganan nyeri yang tidak adekuat dan tidak optimal mencederai hak pasien. • Joint Commission International ; manajemen nyeri merupakan bagian dari standar mengenai hak-hak pasien
PERMASALAHAN NYERI AKUT • Nyeri mencakup hampir 80 % keluhan ke dokter. • Amerika Serikat dengan 215 juta penduduk; – 51% ( > 100 juta ) mengeluhkan nyeri pada satu atau lebih bagian tubuh termasuk pergelangan, pinggang, wajah, atau migrain/ sakit kepala. – 34 juta orang mengalami nyeri akibat cedera disebabkan sprain, strain, fraktur, kontusio, dislokasi, crush atau luka bakar.
PERMASALAHAN NYERI AKUT • Hasil survey ; 53 % pasien terdiagnosis nyeri akut pascabedah dengan 80 %-nya mengeluh nyeri moderat - severe dalam beberapa jam- hari. • Nyeri persisten pascabedah ; herniotomi 5-35 %, amputasi 50-85%, histerektomi 5-30 %, operasi payudara & torakotomi ( 25-60%), • Nyeri kronik 10,1- 55,2 % dari populasi yg di observasi. • Nyeri kronik setelah operasi ; 10-50% dan 2-10 % diantaranya masuk kategori severe.
Teori pain • Specific theory (specialized receptors pain center in the brain) . Ada jalur khusus • Pattern theory : form a pattern (“central summation”) bisa menjelaskan phantom limb phenomenon • Gate control theory (Melzack and Wall) • Neuromatrix theory “body-self neuromatrix” (physical, psychological, cognitive make up, experience) Massage from the brain opens the gate (stress, low mood), closes the gate (distraction, enjoyment, endorphins)
Gate control theory of pain Final pain experience Messages from brain opens the gate: (stress, low mood) or closes the gate: (distraction, enjoyment, endorphins)
CORTEX CEREBRI spine
Noxious Stimuli
Messages from other parts of the body, pain, muscle tension etc
Nociceptor
SPECIFIC CHARACTERISTIC Acute Pain • “ pain of recent onset and probable limited duration. It is usualy has an identifiable temporal and causal relationship to injury or disease “ .
Chronic Pain • “commonly persists beyond the time of healing of an injury and frequently there may not be any clearly identifiable cause “.
Ready and Edwards
KARAKTERISTIK NYERI AKUT • Sifat proteksi, • Pulih bila proses penyembuhan telah terjadi, • Durasi pendek, • Patologi yang dapat diprediksi, • Prognosis dapat di prediksi, • Modalitas utama terapi ; analgesik.
KARAKTERISTIK NYERI KRONIK • Nyeri persisten walau proses penyembuhan telah terjadi • Faktor yang tidak dapat diidentifikasi • Durasi panjang, setelah 3-6 bulan proses kesembuhan. • Secara umum tidak memiliki manfaat, • Patologi tidak dapat diduga dan • Terapi perlu multidisiplin.
ACUTE PAIN • Pain related to trauma : intended : surgery, medical procedures unintended/accidentally : traffic accident, musculoskeletal injury, procedure-related complication • Pain in concurrent medical illness • Acute pain related to cancer or cancer treatment • Labor pain .
ACUTE PERIOPERATIVE PAIN
• Pain that present in surgical patient, because of : preexisting disease surgical procedure combination of both
Faktor2 yang mempengaruhi Pain • Faktor fisiologik Umur, Fatigue, Genetic makeup, Memory, Stress response, Fungsi neurologik • Faktor psikologik Fear and anxiety, Coping (internally or externally controlled), faktor kultural
ASPEK PSIKOLOGIS NYERI AKUT • Input nosiseptik berkepanjangan ; pascabedah, trauma, luka bakar berdampak terhadap fungsi psikologis dan merubah persepsi nyeri. • Kegagalan mengatasi nyeri akut berdampak ; kecemasan, sulit tidur, demoralisasi, merasa tidak mampu, hilang kendali, tidak mampu berpikir dan berinteraksi dengan orang lain, POCD. • Pada kondisi ekstrem pasien tidak mampu berkomunikasi dan kehilangan otonominya.
ASPEK PSIKOLOGIS NYERI AKUT • Nyeri ; pengalaman subjektif yang memiliki kaitan dengan kerusakan jaringan. • Faktor psikologis yang berpengaruh terhadap pengalaman nyeri ; Proses atensi, Memori dan pembelajaran, Proses berpikir, Kepercayaan, Mood, Respon perilaku dan interaksi dengan lingkungan.
FARMAKOGENOMIK DAN NYERI AKUT • Pengaruh variasi genetik terhadap respon terapi. • Meningkatnya variasi genetik yang memodulasi nociseptik, sensitifitas terhadap kondisi nyeri dan respon terhadap farmakoterapi. • Mengkaitkan ekpresi gen dengan manfaat atau toksisitas obat bertujuan membangun sistem yang rasional untuk optimalisasi terapi obat berfokus pada faktor genetik dan memastikan manfaat maksimal dan efek samping minimal.
KENDALA MANAJEMEN NYERI 1. Penyedia layanan; kurang memahami prinsip manajemen nyeri permasalahan saat identifikasi efektif, tindakan terapi dan manajemen nyeri. 2. Organisasi kesehatan ; Manajamen nyeri efektif memerlukan komunikasi interaktif, kerjasama interdisiplin, periode asesmen dan asesmen ulang terstruktur, dan monitoring kontinyu dari efektifitas dan efek samping.
KENDALA MANAJEMEN NYERI 3. Sisi pasien ; o Tidak mengakui keluhan nyeri oleh berbagai alasan, o Nyeri merupakan hal sederhana dan bagian dari keseharian normal, o Label sebagai pasien dengan komplain tinggi, o Budaya dan pengaruh sosial membuat pasien cenderung mengurangi keluhan nyeri. o Informasi yang salah mengenai efek samping obat. o Beberapa populasi mengalami kesulitan komunikasi mengeksresikan nyeri.
SURVEY NYERI PADA PROGRAM PENDIDIKAN DOKTER UMUM o Saat pendidikan, dokter umum hanya mendapatkan rata-rata 12 jam topik nyeri sepanjang program pendidikan 2- 6 tahun, o Mahasiswa kedokteran hewan mendapatkan waktu 2 x lebih banyak. o Kuantitas pengajaran topik nyeri dalam kurikulum tidak mencukupi untuk mengatasi masalah nyeri pada populasi
SURVEY NYERI PADA PROGRAM PENDIDIKAN DOKTER UMUM o Perubahan metode pengajaran di modifikasi berfokus pada ; kemampuan pemecahan masalah, pembelajaran terfokus dan pengembangan skil. o Mahasiswa mendapatkan kesempatan langsung berinteraksi dalam layanan nyeri di RS sehingga mengetahui posisi dokter umum dalam praktik klinis.
KEUNTUNGAN MANAJEMEN NYERI AKUT • Mengontrol nyeri yang adekuat, • Mengurangi risiko luaran menyimpang, • Menjaga kemampuan fungsional sekaligus psikologis, • Merubah kualitas hidup, • Memperpendek waktu tinggal Rumah Sakit dan mengurangi biaya.
ADVERSE OUTCOMES ASSOCIATED WITH MANAGEMENT OF ACUTE PAIN o o o o o o o
Respiratory Depression Circulatory Depression Sedation Nausea andVomiting Pruritus Urinary Retention Impairment of GI tract Function
ADVERSE OUTCOME OF UNDERTREATMENT OF ACUTE PAIN • Thromboembolic or Pulmonary Complications • Needless Suffering • Development of Chronic Pain
Pain: ongoing evaluation: initial assessment and early management of pain.
C. Price et al. Br. J. Anaesth. 2014;112:816-823 © The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email:
[email protected]
Initial assessment and early management of pain.
C. Price et al. Br. J. Anaesth. 2014;112:816-823
© The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email:
[email protected]
ASESMEN NYERI Manajemen nyeri akut diawali dengan asesmen nyeri ; o Riwayat penyakit sekarang dan terapi nyeri sebelumnya. o Karakteristik nyeri ; Gambaran ; awal, pola dan sumber. Lokasi ; tempat utama dan penyebaran. Severitas ; asesmen self-report ( visual, numerik ) Sumber ; somatik, visceral atau neuropatik. Faktor pencetus nyeri dan mengurangi nyeri, Kontektual ; sosial, budaya, emosional, spiritual.
ASESMEN NYERI • Pendekatan single-multidimensi mengevaluasi karekteristik nyeri; intensitas, durasi, lokasi, somatosensori, dan pengalaman emosional. • Bentuk self-report terhadap dimensi tunggal. – Skala kategori ; deskripsi verbal atau visual – Numeric rating scale ; anak-anak menggunakan warna atau wajah menampilkan berbagai ekpresi . – Visual analog scale ; skala garis sepanjang 10 cm, menggambarkan variasi intensitas nyeri. • Bentuk self-report menilai efek multidimensi pengaruh pengalaman subjektif ; aspek sensori, afektif, evaluatif.
ASESMEN NYERI ; AKUT VS KRONIK ASESMEN NYERI AKUT
• Sederhana dan straighforward, • Fokus pada penilaian lokasi dan intensitas nyeri . • Tambahan ; asesmen nyeri awal, asesmen nyeri saat statis dan dinamis, asesmen nyeri saat terapi
ASESMEN NYERI KRONIK
• Nyeri persisten memiliki dampak psikologis, emosional, kognitif, sosial dan keluarga. • Asesmen nyeri kronis lebih menantang dan perlu skil tersendiri. • Perlu asesmen komprehensif
Patient Instructions (McCaffery, Beebe et al. 1989): “ Please indicate the intensity of current, best, and worst pain levels over the past 24 hours on a scale of 0 (no pain) to 10 (worst pain imaginable) ”
Numeric Pain Rating Scale
Visual Analag (Pain) Scale
ANAMNESIS RIWAYAT NYERI KRONIK 1. Dimana lokasi nyeri dan Intensitas nyeri yang dirasakan? 2. Deskripi nyeri yang dialami ? burning, aching, stabbing, shooting, throbbing dll, 3. Bagaimana nyeri bermula ? dan Kapan nyeri terjadi ? 4. Apa saja yang dapat mengurangi nyeri ? dan apa saja yang mencetuskan nyeri ? 5. Bagaimana nyeri mempengaruhi anda ? ; Pola tidur, aktifitas fisik, pekerjaan, status ekonomi, perasaan, keluarga, sosial, aktifitas sex. 6. Apa saja terapi yang telah diberikan ? 7. Efek dari terapi dan ada efek samping ? 8. Apakah anda mengalami depresi, cemas ?
EXPERT OPINION REGARDING PAIN ASSESSMENT o Self-reporting of pain should be used. o The pain measurement tool chosen should be appropriate to the individual; developmental, cognitive, emotional, language and cultural. o Scoring should incorporate different components of pain including the functional capacity. o In postoperative should include static (rest) and dynamic (eg pain on sitting, coughing) pain. o Uncontrolled or unexpected pain requires a reassessment of the diagnosis and consideration of alternative causes (eg new surgical/ medical diagnosis, neuropathic pain).
End Points of Pain Assessment • A reduced experience of pain; • Increased comfort; • Improved physiological, psychological and physical function; • Increased satisfaction with pain management. • These points are not just started after the pain treatment; otherwise, must be considered since the beginning of pain assessment
PERIOPERATIVE PAIN MANAGEMENT STARTED AT PREOPERATIVE PERIOD • Preoperative anxiety, catastrophising, neuroticism and depression • are associated with higher postoperative pain intensity (Level IV). • Preoperative anxiety and depression are associated with an increased number of PCA demands and dissatisfaction with PCA (Level IV). • Risk factors that predispose to the development of chronic postsurgical pain include the severity of pre- and postoperative pain,intraoperative nerve injury andpsychosocial factors (Level IV)
ROUTES & METHOD OF ADMINISTRATION
p.o transmucosal (sublingual, rectal) s.c i.m i.v neuraxial nerve blocks : epidural peripheral nerve blocks conventional vs patient controlled analgesia (PCA)
CONSIDERATION FOR USING NSAID • • • • • •
Aged 65 or older; Have had a stomach (gastric) ulcer or bleeding; Have had asthma; Have had kidney problems; Have had problems with anti-inflammatories before. COX-2 inhibitors control pain as well as NSAIDs. They may cause fewer gastric and bleeding problems, especially when used for a short time. However,they can have similar effects on the kidneys
OPIOID DISADVANTAGES • May cause nausea and vomiting, • Drowsiness, itching and constipation, • Respiratory depression
EVIDENCE • Tramadol is an effective treatment for neuropathic pain (Level I [Cochrane Review]). • Gabapentin, non-steroidal NSAIDs and ketamine are opioid-sparing medications and reduce opioid-related side effects (Level I). • In appropriate doses, droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron are effective in the preventionof postoperative nausea and vomiting (Level I [Cochrane Review]). • Droperidol, dexamethasone and ondansetron are equally effective in the prevention of postoperative nausea and vomiting (Level I). • Paired combinations of 5HT3 antagonist, droperidol or dexamethasone provide superior prophylaxis of postoperative nausea and vomiting than either compoundalone (Level I). • Haloperidol is effective in the prevention of postoperative nausea and vomiting
EVIDENCES • Naloxone, naltrexone, nalbuphine, droperidol and 5HT3 antagonists are effective treatments for opioidinducedpruritus (Level I). • Opioids in high doses can induce hyperalgesia (Level I). • Tramadol has a lower risk of respiratory depression andimpairs gastrointestinal motor function less than other opioids at equianalgesic doses (Level II). • Pethidine is not superior to morphine in treatment of painof renal or biliary colic (Level II). • Morphine-6-glucuronide is an effective analgesic (Level II).
EVIDENCES • In the management of acute pain, one opioid is not superior over others but some opioids are better in some patients (Level II). • The incidence of clinically meaningful adverse effects of opioids is dose-related (Level II). • Opioid antagonists are effective treatments for opioidinduced urinary retention (Level II). • Assessment of sedation is a more reliable way of detecting early opioid-induced respiratory depression than adecreased respiratory rate (Level III-3).
EVIDENCE • Paracetamol is an effective analgesic for acute pain; the incidence of adverse effects comparable to placebo (Level I [Cochrane Review]). • Non-selective NSAIDs are effective in the treatment of acute postoperative and low backpain,renal colic and primary dysmenorrhoea (Level I [Cochrane Review]). • Coxibs are effective in the treatment of acut postoperative pain (Level I [Cochrane Review]). • With careful patient selection and monitoring, the incidence of nsNSAID-induced perioperative renal impairment is low (Level I [Cochrane Review]). • Non-selective NSAIDs do not increase the risk of reoperation for bleeding after tonsillectomy in paediatric patients (Level I [Cochrane Review]). • Coxibs do not appear to produce bronchospasm in individuals known to have aspirin exacerbated respiratory disease (Level I).
EVIDENCE • In general, aspirin increases bleeding after tonsillectomy (Level I). • Non-selective NSAIDs given in addition to paracetamol improve analgesia compared with paracetamol alone (Level I). • Paracetamol given in addition to PCA opioids reduces opioid consumption but does not result in a decrease in opioidrelated side effects(Level I). • Non-selective NSAIDs given in addition to PCA opioids reduce opioid consumption and the incidence of nausea, vomiting andsedation (Level I). • Non-selective NSAIDs and coxibs are effective analgesics of similar efficacy for acute pain (Level I).
EVIDENCE • Preoperative coxibs reduce postoperative pain and opioid consumption,and increase patient satisfaction (Level I). • Coxibs given in addition to PCA opioids reduce opioid consumption butdo not result in a decrease in opioid-related side effects (Level I). • Coxibs and non-selective NSAIDs have similar adverse effects on renal function (Level I). • Non-selective NSAIDs do not significantly increase blood loss after tonsillectomy but do increase the need for reoperation due to bleeding(Level I). • Parecoxib and/or valdecoxib compared with placebo do not increase the risk of cardiovascular adverse events after noncardiac surgery (Level I).
EVIDENCES •
• • • •
Coxibs and non-selective NSAIDs are associated with similar rates of adverse cardiovascular effects,in particular myocardial infarction; naproxen may be associated with a lower risk than other non-selective NSAIDs and celecoxib may be associated with a lower risk than other coxibs and nonselective NSAIDs overall (Level I). Perioperative non-selective NSAIDs increase the risk of severe bleeding after a variety of other operations compared with placebo (Level II). Coxibs do not impair platelet function; this leads to reduced perioperative blood loss in comparison with non-selective NSAIDs (Level II). Short-term use of coxibs results in gastric ulceration rates similar to placebo (Level II). Use of parecoxib followed by valdecoxib after coronary artery bypass surgery increases the incidence of cardiovascular events and is therefore contraindicated (Level II).
EVIDENCES • Several analgesics with different mechanisms of action, each working at different sites in the nervous system • Acetaminophen • Non-steroidal anti-inflammatory drugs (NSAIDs) • Opioids • • Anticonvulsants • • Antidepressants • • Local anaesthetics • • NMDA Antagonists • • Non-pharmacologic methods
PRE-EMPTIF ANALGESIA • Studi ; pemberian analgesik sebelum stimulus nyeri terjadi lebih efektif merubah sensitisasi sentral di tanduk dorsalis ketimbang pemberian analgesik setelah nyeri timbul. (Woolf ). • Pre-emptif analgesia ; Teori mengatasi nyeri sebelum pembedahan dimulai akan merubah manajemen nyeri pascabedah
PREVENTIF ANALGESIA • Keuntungan terapi analgesik yang persisten melebihi durasi yang diharapkan. • Nyeri pascabedah dan konsumsi analgetik relatif berkurang dibanding terapi lain, terapi placebo atau tanpa terapi sepanjang efek yang dimonitor melebihi durasi yang diharapkan. • Intervensi dapat dilakukan sebelum atau setelah pembedahan.
KESIMPULAN Rekomendasi manajemen nyeri akut ; • Kualitas konsultasi nyeri yang memadai. • Penggunaan manajemen pengambilan keputusan klinis untuk menentukan tingkat stratifikasi asuhan nyeri. • Penggunaan sumber daya untuk membantu pasien membuat keputusan atas informasi yang didapat. • Monitoring efek terapi. • Identifikasi dini risiko tinggi mengalami dis-abilitas kronik agar mendapat ; pengelolaan lebih intensif, alokasi sumber daya lebih memadai, dan penurunan dis-abilitas.
