Penatalaksanaan Nyeridr. Pangkuwijaya P, Sp.An

Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential

tissue damage or described in terms of such damage (IASP, 1979) Adopted from Mersky, 1964 Pain can be manifested without actual tissue damage or organic pathology Pain is very subjective Prevention is better or more efficacious than treatment (pre-emptive Analgesia(Nociception The detection of tissue damage by transducers in the skin and other tissues and the propagation of this information to the central nervous system by A-δ and C fibersin the peripheral nerves

Normal Sensory Function

Modulation Excitability in dorsal horn neurons is determined by balance between excitatory inputs from

primary afferents and inhibitory inputs (local and descending)Modulation

Physiological Pain

Features of Physiological Pain Pain (Aδ and C fibers) can be differenttiated from touch (Aβ fibers) Pain as symptom Pain serves a protective function Pain acts as a warning of potential damage Pain is transient Pain is well localized Pathology recognized Stimulus-response pattern is the same as with other sensory modalitiesClinical Pain Inflammatory response Peripheral nerve injury Peripheral sensitization Central sensitization Metabolic and endocrine changes Affective componentPeripheral Sensitization

Pathological Pain

Features of Clinical Pain Pain can be elicited by Aδ and C as well as Aβ fibers Pain as disease Occurs in the context of peripheral sensitization Occurs in the context of central sensitization Pain outlast the stimulus Pain spread to non-damaged areas No biologic usefullness Pain is ‘pathological’ Associated with inflammation, neuropathy, etcTypes of Pain Nociceptive Neuropathic IdiopathicPain Assessment The cornerstone of pain management Both on rest and with activity Using a valid measurement toolTaking the History Comprehensive history History of pain problem Past medical history Psychological and psychosocial history Family historyCharacteristic of the Pain Provocating/palliating factors Quality Radiation: location and distribution Severity/intensity Temporal : duration and periodicity Response to previous analgesic and disease-modifying agent Effect of pain on activity of daily livingQuality of Pain Nociceptive pain Deep somatic /visceral Dull Diffuse Poorly localized Suferficial Sharp Well localized Neuropathic pain Pins and needles burningLocation and Distribution Localized Pain Projected Pain Referred Pain Reflex sympathetic painSeverity / Intensity

History of the Pain Pain at onset Pain during the interval Present painPhysical Examination General physical examination Neurologic examinationPain Assessment

Analgesic Agents Paracetamol NSAIDs Tramadol Opioids Local anestheticsMultimodal analgesia – gamber

Analgesia Ladder for Post-operative Pain

General Strategy for the Management of Acute Pain

Number Needed to Treat (NNT)Patients with 50% reduction in pain vs placebo

Post operative Pain Cycle with PRN Medications

Profile of Plasma Drug Levels During PCA Therapy

Titrate Opioids to Effects

Barriers to Adequate Pain Control