acute pain service (final)kuliah 7 11-2017

Acute Pain Service

Muhammad Ramli Ahmad

Dept. of Anesthesiology, Intensive Care Unit and Pain ManagementFaculty of Medicine Hasanuddin University

Makassar

Introduction

• Acute Pain Service is a team usually consist of Anesthesiologist, Residents and trained Nurses which is aimed toward the alleviation of postoperative pain, trauma pain and other type of acute pain which is unmanageble by traditional analgesic treatments.

• Is a 24 hours services dedication and 7 days a week

What is APS?

Introduction

• Effective acute pain management will depend not on the drugs and techniques available but on the systems involved in their delivery

( Macintyre & Schug, 2007 )

Acute Pain Service

TUJUAN APS

• Tujuan formal APS adalah sebagai organisasi yang didedikasikan untuk manajemen nyeri akut pasien bedah, ibu melahirkan, atau pasien lain dengan nyeri akut

• “Brian Ready “ pencetus Acute Pain Service dari “Washington University” , Seattle USA 1988

“Brian Ready “ pencetus Acute Pain Service dari

“Washington University” , Seattle USA 1988

DEFENISI

APS (Acute Pain Service) adalah suatu bentuk

pelayanan yang berkomitmen:

• mengurangi nyeri

• membantu dengan fase awal rehabilitasi pasien

pascabedah.

• menyediakan manajemen nyeri yang efektif &

aman pasien pascabedah.

Helms JE, Barone CP. Physiologi and treatment of acute pain. Critical Care Nurse 2008;28(6):38-42

Holder KA, Dougherty TB, Porche VH, et al. Postoperative pain management. Int Anesthesiol Clin 2008;36:71-86.

Tujuan Layanan Nyeri Akut

• Peningkatan analgesia pasca bedah

• Pelatihan personil medis dan perawat dalam terapi nyeri

• Aplikasi dan peningkatan teknik analgesik baru

• Kesempatan untuk penelitian klinis

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA

NOMOR 519/MENKES/PER/III/2011

TENTANG

PEDOMAN PENYELENGGARAAN PELAYANAN ANESTESIOLOGI DAN

TERAPI INTENSIF DI RUMAH SAKIT

Menanggulangi masalah nyeri akut di rumah sakit (nyeriakibat pembedahan, trauma, maupun nyeri persalinan).

PELAYANAN NYERI DI RS DALAM

STANDAR AKREDITASI KARS

• Standar Hak Pasien Keluarga (HPK. 2.4)

– Rumah sakit mendukung hak pasien untuk mendapatkan

asesmen dan pengelolaan rasa nyeri yang tepat

• Standar Asesmen Pasien (AP 1.7)

– Semua pasien rawat inap dan rawat jalan diperiksa apakah

mengalami rasa nyeri dan diperiksa mengenai nyeri tersebut

jika ada

• Standar Pelayanan Pasien (PP. 6)

– Pasien didukung secara efektif dalam mengelola rasa nyerinya

• Standar Pendidikan Pasien Keluarga (PPK. 4)

PAIN MANAGEMENT IN JCI 6th, 2017

Standar PFR.2.2

• Rumah sakit mendukung hak pasien untuk mendapatpengkajian dan manajemen nyeri serta perawatan yang penuh hormat serta welas asih pada akhir hayatnya

Standar AOP.1.5

• Semua pasien rawat inap dan rawat jalan menjalaniskrining mengenai nyeri dan pengkajian lebih mendalamharus dilakukan bila terdapat nyeri

Standar COP.6

• Pasien didukung secara efektif dalam mengelola rasa nyerinya

• Significant improvement in the quality of postoperative pain management

– Lower pain intensity score

– Lower level of pain

– Lower incidence of side effects

( pruritus, sedation and nausea)

• Patient’s pain experience was significantly less pain than expected

• Patient were more satisfaction with their pain management

• Discharge sooner from the hospital

(Patient are happy and the surgeons are happy)

( pruritus, sedation and nausea )

WHY PROVIDED APS

Aktivitas APS

• Seleksi regimen analgesik yang sesuai

• Syarat protokol dan panduan yang

terstandarisasi

• Program peningkatan audit dan kualitas

• Edukasi

Kriteria Kualitas Dasar untuk APS

• Personil yang ditugaskan untuk APS

• Kebijakan selama jaga malam dan akhir pekan

• Protokol manajemen nyeri tertulis

• Penilaian dan dokumentasi skor nyeri yang teratur sekurang-kurangnya sekali sehari

Stamer UM, et al. Reg Anesth Pain Med, 2002

Konsep Layanan Nyeri Akut

• APS berbasis dokter anestesi

( Ready et al, 1988; Macintyre et al, 1990; Schug & Haridas, 1993

)

• APS berbasis perawat yang dipimpin dokter

anestesi

(Harmer, 2001; Nagi, 2004)

• APS berbasis perawat

(Shapiro et al, 2004; Rawal, 2005)

Why ANESTHESIOLOGIST ?

Anesthesiologists are a logical choice to provide pain relief in the immediate postoperative period, since they are:

• Familiar with pharmacology of all analgesia

• Aware of the short and long-term effect of drugs given intra-operatively

• Knowledgeable about pain pathway and their interruption

• Skilled in technique needed to pain control

(PCA or EA).

Mengorganisasi APS

Sumber daya manusia

Fasilitas dan perlengkapan

Ketersediaan obat-obatan

Dukungan rumah sakit

APS

Several Requirements

to Start APS

1. A commitment to spend money on new equipment and staff salaries

2. Adequate supervision to ensure that new techniques are performed effectively and safely

3. Commitment by anesthesiologist to provide medical management for the service (available 24 hours a day and 7 days a week)

4. A priority to educate both medical and nursing staff

How to Start an APS

1. Discussion with other disciplines (particularly the

surgeons)

2. Development of Guidelines and Observation Form

(protocol).

3. Training Program for Medical and Nursing

Personnel.

4. Continuous Training, Audit and Quality Assurance

APS Wahidin general Hospital,

Makassar

• Learn from many case to establish :

– Standard Regimen

– Place of Epidural Insertion

– Care for the side effect

• Good analgesia, less side effect with patient

satisfaction

• Buku Panduan Pelayanan APS RS Wahidin

PELAYANAN APS (ACUTE PAIN SERVICE) DI RS

Wahidin Sudirohusodo Makassar, Indonesia, 2004-2014

201

342 369458

663

858

1042 10521104

12731392

0

200

400

600

800

1000

1200

1400

1600

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

total

total COMPETENCYCOMMITMENT AND CONSISTENCYHOSPITAL SUPPORT

http://web.kars.or.id/id

http://web.kars.or.id/id

Kaji derajat Nyeri dan didokumentasikan (Assesment awal)

DPJP-RESIDEN-PERAWAT

Skala Nyeri 7-10 : Berat

Lapor DPJP

Konsul Tatalaksana Nyeri

Tatalaksana Nyeri oleh Tim Tatalaksana Nyeri

Pemantauan derajat nyeri setiap 1 jam dan

disesuaikan dengan rute pemberian obat (1 jam

setelah diberi obat Oral dan 30 menit setelah

diberi obat Intra Muscular dan Intra Vena

RESIDEN- PERAWAT

Skala nyeri 1-3 : Ringan

Pemantauan derajat nyeri setiap pergantian jaga dan

didokumentasikan (catatan Observasi komprehensif )

Edukasi manajemen nyeri

TIDAK NYERI : 0Pemantauan setiap

pergantian jaga

DPJP-RESIDEN

Skala Nyeri 4-6 : Sedang

Lapor DPJP

Tatalaksana penanganan nyeri oleh DPJP

Pemantauan derajat nyeri setiap 2 jam (catatan

Observasi komprehensif )







Lapor DPJP







RESIDEN- PERAWAT






pergantian jaga

DPJP-RESIDEN


Lapor DPJP







RESIDEN- PERAWAT


Pemantauan derajat nyeri setiap

pergantian jaga dan

didokumentasikan (catatan Observasi

komprehensif )





Lapor DPJP







RESIDEN- PERAWAT






pergantian jaga

DPJP-RESIDEN


Lapor DPJP










Lapor DPJP







RESIDEN- PERAWAT






pergantian jaga

DPJP-RESIDEN


Lapor DPJP









Lapor DPJP


Pemantauan derajat nyeri setiap 2 jam

(catatan Observasi komprehensif )




Lapor DPJP







RESIDEN- PERAWAT






pergantian jaga

DPJP-RESIDEN


Lapor DPJP










Lapor DPJP







RESIDEN- PERAWAT






pergantian jaga

DPJP-RESIDEN


Lapor DPJP







DPJP-RESIDEN


Lapor DPJP



Pemantauan derajat nyeri setiap 1 jam dan disesuaikan

dengan rute pemberian obat (1 jam setelah diberi obat

Oral dan 30 menit setelah diberi obat Intra Muscular dan Intra Vena

Penyediaan Obat Anagesia

• Non-Opioid : Parasetamol, NSAIDs

• Opioid

• Adjuvant analgesia : anti neuropatik

• Morphine HCl : ampul, oral sustained release• Pethidine HCl : ampul• Fentanyl : ampul, transdermal• Hidromorfon : oral sustained release • Codein: oral• Tramadol : oral, ampul• Oxycodone : ampul, oral sustained release

APS Wahidin general Hospital,

Makassar

• Learn from many case to establish :

– Standard Regimen

– Place of Epidural Insertion

– Care for the side effect

• Good analgesia, less side effect with patient

satisfaction

• Buku Panduan Pelayanan APS RS Wahidin

Buku Panduan Pelayanan APS RS

Wahidin

• TUJUAN APS

• PAIN ASSESSMENT

• PETUNJUK PENATALAKSANAAN

• TROUBLE SHOOTING

• MANAJEMEN EFEK SAMPING DAN

KOMPLIKASI

APS patient record

Pain assessment

Verbal Rating ScaleNumeric Rating Scale Visual Analogue ScoreWong-Baker Faces Pain Scale

Resident-based Acute Pain Service in the

ward and HCU Wahidin Hospital

makassar

Melepas kateter epidural pada hari 2-3di bangsal

Diagram kasus APS sesuai pembedahan

2004-2014, n= 8754

2348

22012016

1388

801

total

Orthopaedi

ObsGyn

Digestive

Urologic

dll

Jumlah Kasus APS RS Wahidin pertahun

tahun 2004 – 2014, n=8754 kasus

201

342 369458

663

858

1042 10521104

1273

1392

0

200

400

600

800

1000

1200

1400

1600

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Cas

es

Years

Diagram Intensitas Nyeri ( NRS ) n=8754,

tahun 2004-2014

10.88

85.39

3.73 0.000.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

0 1 - 3 4 - 6 7 - 10

Persentase tingkat nyeri

Persentase tingkat nyeri

Diagram tingkat kepuasan n=8754, tahun 2004-

2014

0.005.96

79.40

14.62

tidak puaskurang puaspuassangat puas

Methods of Postoperative Pain Relief

1. Epidural Analgesia)

2. PCA (Patient Controlled Analgesia)

3. Preventive Multimodal Analgesia.

Two standard methods of postoperative pain relief in APS

1.Epidural Analgesia

- Injeksi larutan anestesilokal kedalam ruangepidural.

- Efek anestesi lebihlambat .

- Efek anestesi terbentuksecara segmental.

- Penggunaan untukanalgesia post operasimakin populer.

BASIC CONSEP EPIDURAL ANALGESIA

Epidural BlockLocal Anesthetic

ACTHADHGHTSH

Central COX-2

inhibition

CytokinesIL-1βIL-2IL-6TNF

NorepinephrineEpinephrineCortisolAldosteroneRenin

Sympathetic efferent

COX-2

The Pain Pathway

Dimodifikasi dari Reuben SS, Acute Pain Management 2009Pebedahan/ luka operas

PAIN

Humoral Pathway ( Inflamation Mediator )

Pelepasan TNF-, IL-1β, IL-6, dan IL-10

Neural Pathway(Nociseption)

AktivasiCOX-2Otak

Aktivasi COX-2 Sirkulasi

Transduction

Modulation

Transmission

Perception

Central Sensitization

COX-2Spinal Cord

Peripheral Sensitization

The Stress Response Involves Release of

Neuroendocrine Hormon and Cytokines

Shield CJ, Redmond P. An Evidenced Based Guide to Practice . 2006

The Stress Response Involves Release of

Neuroendocrine Hormon and Cytokines

NYERIResponStress

Nosisepsi

ResponNeuroendokrin

Respon Immun

TRAUMAPEMBEDAHAN

Input neuronalaferen

sitokinsirkulasi

NYERI, RESPON STRESS , NEUROENDOKRIN, DAN IMUN

MENGAPA EPIDURAL TIDAK EFEKTIF DALAM

MENEKAN RESPON HUMORAL

COX-2 yang berperan dalam nyeri dilepaskan dalam sirkulasiA Working Hypothesis

Perifer Sentral (SSP)

Stimulus Noxius/Cedera

Pelepasan Asam Arakhidonat

Prostaglandin

Sensitivitas nosiseptor

perifer

Aktivasi SSP di tingkat medulla

spinalis (menurunkan ambang

nyeri)

COX-2

Kondisi patofisiologis atau

stimulus inflamasi

Expression of COX-2

Prostaglandin

Sensitisasi Sentral

Sensititivitas Nyeri yang

Abnormal

Nyeri

IL-1β

IL-6?

PGES?

Advantages of Epidural

Analgesia

• Superior Pain Relief• Less Systemic Side Effects• Lower Incidence of DVT and Pulmonary Emboli• Decrease Blood Loss Intraoperatively during

Orthopedic, Urologic, Gynecologic and Obstetric Procedures

• More Rapid Recovery of Bowel Function• Earlier Ambulation• Suppression of Neuroendocrine Stress

Response

Grass JA. The Role of Epidural Anesthesia and Analgesia in Postoperative Outcome. Anesthesiol Clin North America 01-JUN-2000; 18(2): 407-28

Proposed Advantages of

Epidural

• Better pain relief

– LA blocking spinal nerve roots

– May mobilize earlier

• Opioid sparing

– Dosage of opioid is much less: avoiding its

complications; e.g N&V, over-sedation

– Block sympathetic/ spare vagal innervation: better

peristalsis of bowels.

– Opioid can cause constipation

Placement of catheter

High to mid thoracic( between T5-T8 )

Thoracic surgeryUpper abdominal surgery( esophagectomy, gastric, open chole,

pancreas )

Mid to Low thoracic( between T8-T12 )

Lower abdominal surgery ( colectomy )Nephrectomy

Low thoracic to high lumbar ( between T10 – T12 )

Lower abdominal surgery Pelvic surgery ( hysterectomy, radical prostectomy )

Lumbar ( between L1 – L4 )

All lower extremity procedures Hip surgery

The epidural catheter is placed in a centrally located

interspace so that all of the affected dermatomes

would receive the benefits of the infusion

Epidural anesthesia/

analgesia

Thoracotomy Th 5 -7

Upper abdominal incision Th 7 – 9

Lower abdominal laparatomy Th 10 – 11

Pelvic sugery/ Lower limb surgery

L 2-4

Level of insetion shoud be in the middle of dermatome of planned incision.

Benefit of EA

excellent analgesia

less sedation

earlier ambulation

decreased incidence of pulmonary complications

decreased incidence of venous thrombosis

earlier return of bowel function

decreased stress response

Planning for EA

• Preoperative consent

– Patient selected and education

– Medical and surgery problem

• Placement of epidural catheter

• Regimen EA for postoperative pain

• Care for side effect and trouble shooting

Agent for epidural analgesia

Opioids m orphine, fentanyl

Local anesthetic ( lidocaine, bupivacaine, ropivacaine,

levo-bupivacaine )

Epidural opioid doses

drug Single dose Onset ( min )

Duration ( h )

Infusionsolution ( μg/ml )

Continuous Infusion

Fentanyl 50 – 100 μg 5 - 10 2.5 - 4 5-10 25 – 100 μg/h

Sufentanyl 10 – 50 μg 5 2 - 4 1 10 – 20 μg/h

Meperidine 20 – 50 mg 5 -15 6 2500 10 – 30 mg/h

Methadone 2 – 8 mg 10 6 - 10 10 – 15 0.1 – 0.3 mg/h

Morphine 1 – 5 mg 30 -60 18 10 0.05 – 0.1 mg/h

Hydromorphone 0.5 – 1 mg 10 - 15 10 -12 5 -10 0.05 – 0.1 mg/h

Opioid and Local anesthetic combination

• synergistically.

• decreased concentration of the local anesthetic

and a lower dose of the opioid may be

possible.

• Provides better analgesia with fewer side

effects Common opioids concentration Common LA concentration

Morphine 10 mcg/mlHydromorphone 10mcg/mlFentanyl 2-5mcg/mlMeperidine 2mg/ml

Common infusion rate : 5 – 14 cc / hr

Bupivacaine 0.1% (1mg/ml).Bupivacaine 0.05% (0.5mg/ml)Ropivacaine 0.2% (2mg/ml)

Regimen Epidural combination

Wahidin Makassar Hospital APS1. Bupivacaine or Levo-bupivacaine 0.0625 – 0.125 %

+ Fentanyl 2 mcg/ml, Infusion continuous rate 3–8 ml/hr

2. Patient Controlled Epidural AnalgesiaLoading dose 6-8 ml, Background 3-4 ml/hr, bolus dose 2-3 ml/hr,Lock out Interval 15 menit

Side effect of EA

Due to local anesthetic used

Motoric block

Very rare

Most likely due to catheter deviating or migration

R/ pull catheter out 0.5 – 1 cm

decrease LA concentration

Rest or orthostatic hypotension

Due to sympathetic blockade

R/ well hydrated

Systemic LA toxicity

CNS and CV symptoms

Side effect of EA

2. Due to opioid usedRespiratory depression

Early onset or Delayed onset

R/ Naloxone 100 mcg slowly

Sedation

Impending respiratory depression

R/ decrease opioid dose

Nausea and vomiting

reduced after repeated doses,

can often be managed with antiemetics

Pruritus

usually of the face and chest

R/ Diphenhydramine, Naloxone

Urine retention

decrease in detrusor muscle contraction

R/ catheterisation

Other complication

• Epidural abscess

• Epidural hematoma

• Subdural puncture

• Migration epidural catheter to vessel

Epidural BlockLocal Anesthetic

ACTHADHGHTSH

Central COX-2 inhibition

CytokinesIL-1βIL-2IL-6TNF

NorepinephrineEpinephrineCortisolAldosteroneRenin

Sympathetic efferent

COX-2

2.Patient Controlled Analgesia (PCA)

Patient Controlled Analgesia

• PCA diartikan sebagai pemberian analgesik terutama opioid intravena yang sesuai dengan kebutuhan dan secara berkalahdibawah kontrol oleh pasien sendiri.

• Tehnik ini didasarkan pada penggunaan mikroprosesor pada PCA yang diprogram ntuk menghantarkan sejumlah dosis opioid saatpasien menekan tombol demand

• Dikontrol perawat, dikontrol orang tua, dikontrol pasangan

• i.v. , s.c., epidural, intranasal

• Fenomena opioid: analgesia terjadi pada dosis yang lebih rendah daripada sedasi

Konsep Penting Titrasiion

Patient experiences effect of drug

Drug works

Patient administers drug

Patient experiences pain

Good pain relief?

Wait!

Yes No

Prinsip PCA

Pasien nyeri

Sedasi

Analgesia

Absorpsi dari

tempat injeksi

Injeksi diberikan

Mempersiapkan

injeksi

Memanggil perawat

Perawat merespon

“Skrining”

Tanda-tanda

obat habis

PCA

X

Prinsip Dasar

Lingkaran umpan balik sederhanaPersepsi nyeri

Meminta analgesik

Penghilang nyeri adekuat atau tidak

Konsentrasi analgesia efektif minimum (MEAC)Pasien akan mentitrasi opioid yang diberikan untuk

mencapai konsentrasi obat plasma, dengan:Analgesia yang baik dan efek samping minimal

Opioid FK/FD yang sesuai untuk PCA

Tidak ada perbedaan besar dalam efektivitas atau opioid berbeda yang digunakan untuk PCA

Efektivitas PCA

• PCA dengan opioid memberikan analgesia yang

secara signifikan lebih baik dibanding opioid yang

diberikan dengan teknik konvensional (bukti level I)

• Konsumsi opioid tidak berbeda signifikan dengan

pemberian lain (bukti level I)

• PCA tidak sama efektifnya dengan analgesia epidural

(bukti level I)

• PCA tidak memberikan analgesia yang sempurna

tetapi kepuasan pasien yang tinggi

Indikasi untuk PCA

• Operasi mayor dan dipuasakan

• Nyeri bermakna

• Kontraindikasi terhadap epidural

• Dimotivasi dan diedukasi dengan baik untuk

menggunakan PCA

Kontraindikasi PCA

• Pasien menolak

• Tidak mampu memahami konsep PCA

• Efek samping berat yang diinduksi opioid

• Berusia < 5 tahun

• Anak-anak dengan keterlambatan

pertumbuhan

• Anak-anak dengan gangguan kesadaran

Parameter Pemberian Obat

• Dosis bolus

• Interval lockout

• Dosis muatan

• Background infusion

• Batas dosis

Analgesik Opioid yang Digunakan pada PCA

Opioid Konsentrasiobat( mg/ml )

Dosis bolus( mg )

Intervallockout( mnt )

Laju infus( mg/hr ) *

fentanyl 0.01 0.01-0.02 5-10 0.02 – 0.1

hydromorphone 0.2 0.1 – 0.5 5 - 10 0.2 – 0.5

meperidine 10 5-15 5-12 5-40

morphine 1 0.5 - 3 5-12 1-10

oxycodone 1 1 5-12 1

Pengaturan PCA

Opioid Loadingdose

Dosis bolus Intervallockout( mnt )

Continuousdose

fentanyl 50-100 mcg 10-15 mcg 5-15 10 mcg/jam

Tramadol 50-100 mg 10 – 20 mg 5 - 10 -

meperidine 50-100 mg 10-15 mg 5-12 10 mg/jam

morphine 5-10 mg 1-1.5 mg 5-12 1 mg/jam

oxycodone 2-5 mg 1-1,5 mg 5-12 1 mg/jam

3. Preventive Multimodal

Analagesia

Preemptive Analgesia

Pre - Incision Surgery Post operative

Incision(Noxious Signal)

• Prevent acute pain• Prevent chronic pain as

a result of untreated acute pain

Preemptive Analgesia

Pain stimuli : Central Sensitization & “Wind-Up”

• Prevent central sensitization

• hyperalgesia

Preemptive therapy (administration of drugs at pre-incision) was consider : Prevent central sensitization, hyperalgesia incidence severity of postoperative pain

Concept of Preemptive Analgesia

All experimental studies showed “VERY CONVINCING” however clinical studies were not UNANIMOUS

There is a gap between EXPERIMENTAL and CLINICAL INVESTIGATION.

1913, first idea by Crile

1983, revival by Woolf

1988, highlighted by wall

Controversy

“WHY IS SO”

• Mc Quay• Bach• Tverskoy• Kissin• Kehlet• Katz

Defenition/ terminalogy / Administer Analgesic

Insufficient affent blokadePatial preemptive effect in controlIntesity of noxius stimuliOutcome measurement problem

Analgesia Preventif

Pra-insisi Pembedahan Pasca bedah

Insisi(Sinya noksius)

Analgesia Preventif

Durasi kerja obat lebih lama daripada target preemtif

Analgesia Preventif

or

Durasi kerja obat yang menliputi seluruh periode perioperatif

Analgesia Preventif Broader definition of preemptive

Analgesia Preventif

Analgesia Multimodal (Balanced Analgesia)

Intervensi polifarmakologik nosisepsi pada titik yang

bijaksana pada jalur dan proses nosiseptif

Or

Maipulasi

polifarmakologik

• Transduksi OAINS (COX1 & COX2)

• Transmisi Anestetik lokal

• Modulasi Opioid atau antagonis NMDA

dan COX2

Menggunakan 2 atau lebih obat dengan kerja

yang berbeda

Manfaat Terapi Nyeri Multimodal

1Kehlet H et al. Anesth Analog.

1993;77:1048-1056.

Potensiasi

• Mengurangi dosis

setiap analgesik

• Meningkatkan

penghilang nyeri

akibat sinergitas atau

efek aditif

• Dapat mengurangi

keparahan efek

samping setiap obat

Opioid

OAINS,

asetaminofen,

blok saraf

NSA

ID

CO

XIB

Tram

ado

l

Ket

amin

e

Gab

ape

nta

no

id(G

ab

ap

enti

n, P

reg

ab

alin

)

PARACETAMOL

OPIOID(Morphine, Fentanyl, Oxycodone)

Obat-obat yang memiliki“opioid Sparing effect”

– Paracetamol

– NSAIDs/Coxibs

– Alpha;2;Delta Ligands (pregabalin)

– Systemic Local Anaesthetics

– Ketamine

– Alpha;2 Agonists

(clonidine/dexmedetomidine)

– Corticosteroids

Opioid Dose and Clinically MeaningfulOpioid Related Adverse Events (CME)

0 5 10 15 20

Morphine equivalent dose in 24 hours (mg)

25

Nu

mb

er

of

CM

Es

on

da

y1

aft

er

lap

aro

sco

pic

ch

ole

cs

yte

cto

my

2 events

1 event

No event

–33%

Zhao et al, J Pain Symp Manag

2004;28:35

> 3 events

Reduction in

clinically meaningful

opioid related ADE

ADE = adverse drug

event

‘Once threshold reached, every further 3–4 mg increase will beassociated with 1 clinically meaningful opioid-related symptom’

Dibutuhkan obat yang memiliki OpioidSparing Effect yang tinggi

-30%

(non-opioid)

Op

ioid

Op

ioidPai

n in

tens

ity

X

Stimulus intensity

Anti-

hyper

algesic

Normal

pain

response

Sensitised

pain response

Partially desensitised

pain response

Local anesthetics

CorticosteroidsNSAIDsCOXIBs

Local Anesthetic

DRG

OpioidsGabapentinoids

Clonidine

Modify by AHT

KetaminParacetamol

COXIBs

Transduction

TransductionModulation

Perception

Transmission

Modulation

Target Point of Analgesic Drugs

ANALGESIA MULTIMODAL PREVENTIF

Pra-Insisi Intra operasi Pasca bedah

Kombinasi opiat, teknik anestesi regional, OAINS, analgesik ajuvan lainnya

Respon stres perioperatif

Nyeri dinamis (pada pergerakan)

Pemulihan pasca bedah & memperbaiki luaran klinis

Konsumsi opiat

Efek samping analgesik (tidak ada dukungan dari ulasan literatur baru)

Conclution

• Solution of inadequate postoperative pain relief lies in developing Acute Pain Service.

• APS has been shown to reduced morbidity and

mortality, increased out put and out come of

postoperative pain patients

• Increased stisfaction of the patients

• Shorten LOS in ICU and Hopital low cost

Thank you!FOR YOUR ATTENTION

acute pain service (final)kuliah 7 11-2017

Health & Medicine