dasar dasar nyeri akut, neuropatik dan kronik
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Dasar-dasar Nyeri Akut, Neuropatik dan Kronik
Andi Husni TanraKetua Program Studi Sp2 Ilmu Anestesi
Fakultas Kedokteran Universitas Hasanuddin
Makassar
Dibawakan pada kuliah perdana peserta fellow IPM ke-2, 7 Nov 2017 di Makassar
Menurut IASP 1979 “ Pain is define as: an unpleasant sensory
and emotional experience associated with actual or potential
tissue damage or describe in term of such damage. (Harold
Merskey )
Definisi Nyeri
Makna dari definisi ini adalah:
Key word of pain is unpleasant sensory and emotional
experience (rasa yg tdk menyenangkan sensorik dan emotional).
Associated with actual tissue damage (Acute Pain =Nociceptive
pain)
Due to potential tissue damage (Nociceptive pain = Physiological pain =
withdrawal Reflex)
Described in term of such damage (digambarkan seperti adanya
kerusakan jaringan .(tapi tidak) chronic pain .
• Nyeri nosiseptif adalah nyeriyang terjadi akibat adanyasuatu stimulus kuat(Mekanik, termal ataukimiawi) pada jaringan yang intact (utuh).
• Jadi ada Potential tissue damage yang menghasilkanwithdrawal reflex.
• Belum ada kerusakanjaringan.
• Gunaya sebagai alat proteksitubuh dari berbagaikerusakan.
1. Nociceptive Pain
WITHDRAWAL REFLEX
Nociceptive pain Minimal tissue damage
1. Acute Pain
• With actual tissue damage (ada kerusakan jaringan).
• Noxious stimulus Nociceptive painAcute Pain.
Nociceptive Pain
Sebenarnya pembedahan dimulai dgn nyeri nosiseptif nyeri akutnyeri inflamasi sembuh nyeri hilang, kalau sembuh tapi nyerinya menetap nyeri kronik.
Acute pain is the normal, predicted physiologic response to an adverse chemical, thermal, or
mechanical stimulus… associated with surgery, trauma, or acute illness.
Nyeri Akut adalah; respon fisiologik normal yang dapat diramalkan terhadap stimulus perusak
kimiawi, termal atau mekanik …. berkaitan denganpembedahan, trauma, atau penyakit akut
Definition of Acute pain
` (Federation of State Medical Board of the United Stated 1999.)
Mechanical
Thermal
Chemical
Transduction
Conduction
Modulation
Transmission
Persepsion
Neuron I
Neuron II
Neuron III
Modified by AHT
Transmission
Action potential
Diantara simulus noksius dan persepsi ada 5 proses yg tersendiri yaitu; Nosisepsi (respons saraf terhadap stimulus noksius)
1. Transduksi2. Konduksi3. Modulasi4. Transmisi5. Persepsi
Mekanisme Nyeri Nosiseptif atau Nyeri Akut
Ciri chas nyeri nosiseptif
• Nyeri yang di tandai dengan
Adanya jaringan rusak atau inflamasi
Nyeri kalau diraba, ditekan ataudigerakkan.
• Gejala nyerinya
Aching (sakit) atau
Throbbing (berdenyut)
Alur nyeri dimulai dari aktivasi nosiseptor.
AbnormalCentral processing
Maladaptive, low-threshold painDisease state of nervous system
PeripheralNerve damage
Neural lesionPositive and negativesymptoms
Neuropathic pain
Spontaneous painPain hypersensitivity
Injury
Stroke
Modified by AHT
. Neuropathic PainAccording to IASP.Pain as ‘initiated or caused by a primary lesion or
dysfunction in the nervous system. Depending on
where the lesion or dysfunction occurs within the
nervous system, neuropathic pain can be peripheral
or central in origin
2. Neuropathic Pain
Neuropathic Pain: Positive and Negative Sensory Symptoms
Positive symptoms
(due to increased activity)
Dysesthesia (dys = sulit)
Sensory abnormalities and pain often co-exist
Paresthesia (Par = tdk biasa)
Spontaneous pain
Hyperalgesia
Allodynia Anaesthesia
Negative symptoms(due to deficit of function)
Nervous system damage
Hypoesthesia
Hypoalgesia
Analgesia
1. Jensen TS et al. Eur J Pharmacol 2001;429:1–11; 2. Gilron I et al. Can Med Assoc J 2006;175:265–75; 3. Baron R. et al. Lancet Neurol. 2010
Gejala Nyeri Neuropatik
• Umumnya pasien menyatakannya nyerinyasebagai nyeri yang lain dari biasanya.
• Paling sering dirasakan sebagai nyeri yang terbakar, (burning) atau seperti dikontaklistrik (tingling) atau seperti kesemutan .
• Ciri khas suatu neuropatik adalah jikaditemukan 2 gejala yakni gejala positip dannegatip. (misl. hiperalgesia dan hipestesia)
Sural nerve lesion
Peroneal nerve lesion(amputation of dig. 4)
Median nerve lesion
Post cut. lumbar nerve lesion
Peripheral nerve lesions : Allodynia and hyperalgesia
Burning, feeling like the feet are on fire
Stabbing, like sharp knives Lancinating, like electric shocks
Freezing, like the feet are on ice,
although they feel warm to touch
Modified by Meliala 2006
Inflammatory Pain Neuropathic Pain Dysfunctional Pain
(Idiopathic Pain)
Inflammatory, Neuropathic and Chronic Pain.
3. Chronic pain
Chronic pain is a pain that persists beyond normal tissue healing time, which is assumed to be three – six months.
The International Association for study of pain (IASP)
Pain that continues when it should not.
WHAT HAPPENS
LONG TERM…
“Pain is unpleasant sensory and emotional experience,
or….. ..described in terms of such damage”
• beyond the healing period
• no more tissue damage
• Longer than 3-6 months
Post herpetic Neuralgia LBP
Chronic Pain(persistent pain)
Low Back Pain
This terminology is misleading as the key
distinction between acute and chronic pain is not
the duration of pain, but for chronic pain its:
“Acute and chronic pain have nothing in common but
the four-
Persistence beyond nociception
(Pain without nociception)
Beyond expectation
Difficultes to treat
Produce suffering and reduced QoL
Chronic Pain
Characteristic of Chronic Pain?
• Subjective personal experience
• Cannot be seen, except by behavior
• Difficult to diagnose.
• Difficult to treat, and costly.
• Produce suffering and reduced QoL.
• It has no biologic value as a symptom
• Life permanently disrupted.
Duration
Tissue injury
Nerve conduction
Autonomic NS
Biological value
Social effects
Associated problems
Treatment
Prognosis
Chronic PainMonths to years
Commonly none
Slow
Generally no activation
Low or absent
Depression, anxiety, suicide
Profound
Multimodal:
• Behavioral
• Drugs have a moderate role:
Adjuvan: Antidepressants
Anticonvulsants
• Unpredictable
• Treatment aim of decreasing pain and
• suffering and improving functioning.
• Coping with pain, increase QoL
Acute PainHours to days
Present
Fast
Activated
High
Uncommon
Few
Analgesics
Predictable
Aim: cure
Adapted from Ashburn and Straats, 1999
Acute vs Chronic pain
Pain as a Continuum
http://www.slideshare.net/Painspecialist/understanding-pain-short
All chronic pain was once acute,
but not all acute pain becomes chronic.
Shipton EA Anaesth Intensive Care. 2011;39(5):824-36.
Chronic Pain
… is not prolonged acute pain
… must be considered and treated as a disease.
Central sensitization
Tachykinin (Substance P, Neurokinin A)
Glutamate
Presynaptic neurons
Ca2+
Ca2+
Na+ Na+/Ca2+
Na+
Ca2+
Depolarisasi
Protein Kinase C
Mg2+
NK1 NK2 AMPA NMDA
Postsynaptic neurons
G G
Secondary Hyperalgesia /Allodynia
Central Sensitization
neurons hiperexitable Modified by I.Yusuf 2000
PERIPHERAL ACTIVITY
CENTRAL SENSITIZATION
Lowered threshold to peripheral
stimuli
Increased spontaneous
activityExpansion ofreceptive
field
HyperalgesiaAllodynia
Tissue damage
Nerve damage
Spontaneous pain
Increase in the excitability of neurons within CNS, so that normal Inputs begin to produce abnormal response.
Central Sensitization
WHAT HAPPENS
LONG TERM…
Examples
Peripheral
• Phantom Limp pain
• Postherpetic neuralgia
• Trigeminal neuralgia
• Diabetic peripheral neuropathy
• Postsurgical neuropathy
Central
• Poststroke pain
Common descriptors2
• Burning
• Tingling
• Hypersensitivity to touch or cold
Examples
• Pain due to inflammation
• Limb pain after a fracture
• Joint pain in osteoarthritis
• Postoperative visceral pain
Common descriptors2
• Aching
• Sharp
• Throbbing
Examples
• Low back pain with
radiculopathy
• Cervical radiculopathy
• Cancer pain
• Carpal tunnel
syndrome
Mixed Pain
Pain with
neuropathic and
nociceptive
components
Neuropathic Pain
Pain initiated or caused by a
primary lesion or dysfunction
in the nervous system
(either peripheral or
central nervous system)1
Nociceptive Pain
Pain caused by injury to
body tissues
(musculoskeletal,
cutaneous or visceral)2
Possible causes of chronic pain
1. International Association for the Study of Pain. IASP Pain Terminology.
2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
Central sensitization
• Sentral Sensitizatio is situation where second order neuron in spinal cord become Hyperexitabe(mudah terpicu), means normal nociceitive input will produce abnormal response.
• Central sensitization was primarily created by NMDA r, glutamat ligan to NMDA, Ca inflow, activated PKC Protein phosphorylation to many channels as well as receptors in turn make neurons hyperexitable.
Types of Pain: mechanism-based
1. Adapted from Julius D et al. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier; 2006, p. 35. 2. Jensen TS, et al. Pain 2011;152(10):2204-2205. 3. Treede RD, et al. Neurology 2008;70(18):1630-1635.
Nociceptive painPain caused byan inflammatory or
non-inflammatory
response to an overt or potentially tissue-damaging
stimulus1,3
Neuropathic painPain arising as a direct
consequence of a
lesion or disease
affecting the somatosensory system2-3
Centralized pain/
Idiopathic pain (Chronic pain)
Pain without identifiable nerve
or tissue damage; hypothesized to be a result persistent neuronal dysregulation or dysfunction
MIXED
Chronic pain is biopsychosocialphenomenon
Chronic pain is a biopsychosocialphenomenon,
but the ‘bio’ component is usually not classical nociception, but the result of a neurologic disease ( Central Sensitization)
Chronic pain is Biopsychosocial Phenomenon
Chronic Pain is aBiopsychosocial Phenomenon
Cognitive Behavior therapies
Functional restoration
Adjuvan drugs
Neural-augmentation
Ablative Surgery
Pain Behaviors
Suffering
Pain Perception
Nociception
Antidepressants/
psychotropics
Opioids
Relaxation
Spiritual
Local blocks
NSAIDS
Opioids
Physical
Modalities
Loeser JD.Cousins MJ.Med J Aust. 1990;153;208-212,216
XXXXXXXXCentral
Sensitization (wind-up)
Why chronic pain, is so danger ?
Because Chronic pain is • Biopsychosocial phenomenon,
Produce suffering Difficult to treat High cost Reduce quality of Life
Acute Pain is • Biomedical problem
Alarm protection A symptom of injury or disease
Biomedical vs. Biopsychosocial
Management Pain
Chronic pain
• goal of treatment is to improve function in occupational, social and emotional domains; pain relief is de-emphasised
Acute pain
• goal of treatment is to obtain pain relief
1
2
Biomedical vs. BiopsychosocialManagement of Pain
Acute pain• patient is ill, and
therefore should be free from normal responsibilities
Chronic pain
• patient is not ill, and should maintain normal activity levels as far as possible
3Biomedical vs. Biopsychosocial
Management of Pain
Acute pain primary
responsibility for improvement lies with the doctor; patient’s role is passive.
Chronic pain
primary responsibility for improvement lies with the patient -patient’s role is active.
Two great obstacles
• In treating chronic pain
1. Fear avoidance behavior
(Kinesiophobia = takut bergerak)
2. Passive treatment
(menginginkan pembedahan or massage) Mudah jadi korban pengobatan
Cancer pain
Pain
Chronic painAcute pain
Nociceptive pain
Neuropathic pain
Dysfunctional pain
Non-Cancer pain
For all the happiness mankind can gain, is not in pleasure,
but rest from pain.
John Dryden (1631-1700)
Thank you very muchFor your attention
Take home message
• Acute pain is a symptom, tell us that there is
something wrong in our body.
• Chronic pain is a disease entity and that must be
treated differently to acute pain.
• Since chronic pain is biopsychosocial phenomenon
it must be treated by multidisciplinary team with
multidisiplinary approach.