pain and analgesic kelompok 3

8/17/2019 Pain and Analgesic Kelompok 3

1/40

Pain and Analgesic

1


2/40

Introduction

• The International Association for the Study of Pain(IASP) denes Pain as, “an unpleasant sensoryand emotional experience associated withactual or potential tissue damage, or

described in terms of such damage”(WHO,2012)

• Improed pain management has not only led toincreased comfort in trauma patients, !ut has also

!een sho"n to reduce mor!idity and improe long#term outcomes ($ohen et al, %&&')

• nalgesic is a medicine that reliees or reducespain

%


3/40

enitions

• Agology * the science and study of pain

• Allodynia * pain caused !y a stimulus that is notnormally painful

• Analgesia * the a!sence, or decrease, of pain in thepresence of a stimulus that "ould normally !e painful

• +yperalgesia * an increased sensitiity to a stimulusthat is normally painful

• ociception * the reception, conduction, and centralnerous processing of nere signals resulting in theperception of pain

• Somatic pain * pain originating from s-in, .oints,muscles, and other deep tissues

• /isceral pain * pain originating from the internal organs


4/40

enitions

o0ious stimulus * a stimulus "hich is actually orpotentially damaging to !ody tissues

Pain threshold * the point at "hich an indiidual .ust

!egins to feel pain is relatiely consistent amongnormal indiiduals

Pain tolerance * the greatest amount of pain that asu!.ect "ill tolerate aries greatly among indiiduals

2adiculalgia * pain along the distri!ution of one or

more sensory nere roots

2adiculitis * an in3ammation of one or more nereroots

4ind#up * a cascade of eents resulting from ongoing

stimulation of nociceptors and actiation of 5Areceptors causes hyperalgesia and opioid tolerance


5/40

Principles for the pharmacologicalmanagement of pain

$orrect use of analgesic medicines "ill relieepain in most patient "ith persisting pain dueto medical illness and relies on the follo"ing

-ey concepts6• !sing a two"step strategy

• #osing at regular inter$als

• !sing the appropriate route of

administration %also ad$erse e&ects 'drug interactions)

• dapting treatment to the indi$idual

WHO, 2012 7


6/40

Pain Path"ays 8 5echanism

Anatomy of Pain transmission and sites of analgesicaction


7/40

9


8/40

:


9/40

;


10/40

Pain $lassication Systems

1 Pathophysiological $lassication

# ociceptie (Somatic and /isceral)

#europathic

#5i0ed Pain

% Pain uration

#Acute

#$hronic


11/40

Physiological Pain

• Is a protectie mechanism

• $auses aoidance

• >ittle to no tissue in.ury

• Pain stops once the stimulus is remoed

Pathological Pain

2esults from tissue in.ury

In3ammation occurs in the area

ere damage

2elease of neurotransmitters "ith ongoing stimulation ofnociceptors

$an lead to hyperalgesia

Persists after the stimulus is remoed


12/40

Types of Pain

cute Pain

• ?ccurs immediately after a stimulus is receied

• Seerity can ary

• 2esponds "ell to treatment

• Su!sides once stimulus is remoed

(hronic Pain

Persists "ell past initial stimulus (


13/40

Physiology of Pain

• amaged cells releasesu!stances "hichstimulate nociceptors andin3ammation

• o0ious stimuli actiatenociceptors, "hich!ecome sensitiBed "ithstimulation, resulting in a

lo"ered stimulationthreshold

• A#delta nociceptors are myelinated, conduct impulsesrapidly, trigger sensation of rst pain (sharp, pric-ing pain)

• $#!ers are unmyelinated, stimulated !y chemicals releasedin damaged or in3amed tissues, and mediates slo", !urningpain


14/40

Physiology of Pain

• SensitiBed nociceptorscause the release ofglutamate andneuro-inins from the

aCerent terminals in thespinal cord

• Actiates 5A (#methyl##asparate)

receptors, "hich areimplicated inhypersensitiity ("ind#up)

• ACerent neurons in the spinal cord relay the signal tomultiple areas in the !rain, resulting in the perception ofpain

• “Date control” occurs in the spinal cord, resulting in earlyinhi!ition of nociception, allo"ing escape


15/40

Physiology of Pain

• Stimulation of medularycenters result inhyperentilation,increased cardiac output,

and increased !loodpressure

• escending neurons actto modulate pain !y

reducing sensation

• /arious neurotransmitters are released6 glutamate,norepinephrine, serotonin, gamma#amino!utyric acid (DAEA)and endorphins

• Analgesia can !e induced !y !loc-ing the nociceptieprocess at one or more points


16/40

Physiology of Pain

Pain F ociception

4hat is the diCerenceG

Pain is a product of higher !rain center processing

of signals it has receied

ociception refers to the peripheral and centralnerous systems processing informationgenerated !y stimulation of nociceptors !y

no0ious stimuliociception can occur in the a!sence of pain


17/40

Physiology of Pain

There are four distinct processes inoledin nociception "hich can !e modulated !yanalgesics6•

Transduction * translation of the no0iousstimulus into electrical actiity at theperipheral nociceptor

• Transmission * the propagation of nereimpulses through the nerous system

•5odulation * modication of nociceptietransmission !y inhi!ition of the spinaldorsal horn cells !y endorphins

•Perception * the nal conscious su!.ectieand emotional e0perience of pain


18/40

Actions of Analgesics on PainProcesses

Transduction6• $an !e !loc-ed !y local anesthetics !y in.ection either at the site of

in.uryHincision or intraenously

• $an !e decreased !y use of SAIs "hich decrease the production ofprostaglandins at the site of in.ury

Transmission6• $an !e preented !y local anesthetics !y in.ection along peripheral

neres, at nere ple0us, or in the epidural or su!arachnoid spaces

5odulation6

• $an !e augmented !y in.ection of local anesthetics or alpha%#adrenergic

agonists ga!apentin may also eCect modulationPerception6

• Altered !y use of general anesthetics or systemic in.ection of opioidsandHor alpha%#agonists


19/40


20/40

Pain Assesment


21/40

Pain Assesment

%1WHO, 2012


22/40

acial e0pression

*+! -O.!/ +(/


23/40

%


24/40

• Pharmacologic management of pain inolesadministering pain medication to reliee thepatientJs pain (Kamienski and Keogh, 2006).

•

*nclude6K on#narcotic analgesics

K onsterioidal anti#in3ammatory drugs(SAIs)

K arcotic analgesics

K Salicylates

%'


25/40

%7


26/40

?rgan system responses to

Pain =L2?=?$2I=6 ↑$atecholamines and ↑sympathetic actiity Acute phase reactants * ↑coagula!ility

2S ↓ Pulmonary function and shallo" respiration ↑2esp rate Pulmonary edema and A2S Pneumothora0 secondary to !arotrauma

$S ↑I$T and herniation Spinal cord in.uries


27/40

$/S ↑S/2 "ith tissue hypoperfusion, lactic acidosis

Tachycardia leads to cardiac e0haustion ↑After load 8 $ardiac failure, Pulmonary edema

DIT $ushingMs ulcers and ↓↓ gut motility

5usculo#s-eletal Spasm and Immo!ility 2ha!domyolysis and hyper-alemia

2enal

AT H 2enal failure 5eta!olic

Acidosis and electrolytes distur!ances


28/40

on#narcotic analgesics

• Lsed to treat mild to moderate pain

• 5any -inds are not addictie

• Aaila!le oer#the#counter

• Lsed to treat headaches, menstrual pain(dysmenorrheal), pain from in3ammation,minor a!rasions, muscular aches and pain,and mild#to#moderate arthritis

• >o"er eleated !ody temperature (antipyretic)• =0amples6 acetaminophen and SAIs

(aspirin, i!uprofen, and $?N#% inhi!itors)

%:


29/40

arcotic analgesics

• arcotic analgesics are -no"n asnarcotic agonists

• Act on the central nerous system toproide relief from moderate andseere pain

• Also used to suppress coughing !y

acting on the respiratory and coughcenters in the medulla of the !rainstem

%;


30/40

(Kamienski and Keogh, 2006. Page.


31/40

Pharmacological 5ethods

• Inhalational Analgesia

• ?ral Anal

•

Parenteral and =nteral• Intranasal ?piates

• Topical


32/40

Inhalational Analgesia

• Entonox (50% NO and 50% Oksigen)

• Dood for adults "ho are a!le to selfadminister

• 2apid acting !ut has a ery short halflife

• $an !e use in com!ination "ithmorphine particulary during painfulprocedures (?rthopaedic operationetc)


33/40

?ral Analgesia

• P$T and I!uprofen used formanagement of mild to moderatepain

• Important to asses the presence ofcontra#indications

• SAIs drugs are responsi!le for

large num!ers of aderse eents(DIT side eCects)


34/40

Parenteral and =nteralAnalgesia

• 5orphine is a standard parenteral analgesia andcan !e used i or po

• 4hen administering opiates, alo0one 5LST !eaaila!le

• Intraenous route has the adantage of rapidonset and the dose can !e easily titrated

• ?ral morphine is useful for less seere pain !uthas disadantage of delayed onset

• ?ral morphine used for patients "ithmildHmoderate pain from in.uries such asforearm fractures and hip fractures


35/40

Intranasal ?piates

• Are not currently approed foradministrationn !y Paramedics

• Adantages6 potent, rapid action"ithout needing parenteraladministration


36/40

Topical Analgesia

• In ulnera!le adults or needle pho!icadults, "ere enepuncture may !ereuired in a non urgent situation

• Tetracaine gel 'O can !e applied tothe s-in

• Application ta-es a!out %


37/40

etorolac

• or short"term % d) 3x of moderate*seere acute pain

• $ontraindication6 PL, DI !leed, postcoronary artery !ypass graft,anticipated ma.or surgery, seere renal InsuC, !leeding diathesis,la!or 8 deliery, nursing, and "H ASAHSAIs

• SAIs may cause an increased ris- of $/ throm!otic eents (5I,

stro-e) P? $I in peds Q1@ y• ction4 SAI R prostaglandins

• #ose4 Adults. 15–30 mg IV/IM q6h; 10 mg PO qid only ascontinuation of I5HI/ ma0 I/HI5 1%& mgHd, ma0 P? '& mgHd Peds 2–16 ! 1 mgH-g I5 1 dose , +/4=leeding, peptic ulcer #>, ? (r ' :s, ? =P, edema, diBBiness,allergy


38/40

Tramadol

• !ses4 @+hort"term 3x acute pain (Q7 d)K

• ction4 (entrally acting analgesic; nonnarcoticanalgesic

• #ose4 % ta!s P? '*@h P2 : ta!sHd ma0 Eldel!"enal

im#ai$ o&est #ossi'le dose % ta!s 1%h ma0 if $r$l Qs, hepatic9renal impair, or Hx

addictie tendencies (*4 cute intoxication #isp4 :ab6AB mg tramadol962 mg

• APAP +/4 ++3*s, :(s, opioids, CO*s ? risD of +>s;

di>>iness, somnolence, tremor, +A, H/H, constipation,0erostomia, lier to0, rash, pruritus, U s"eating, physicaldependence

• -otes4 $oid /tOH


39/40

$onclusion

• ?ptimal pain management !egins "ithaccurate and thorough pain assessment

• Pain assessment should !e integrated

into all clinical care The "ay a childperceies pain is an outcome of!iological, psychological, social, culturaland spiritual factors

• A comprehensie approach to painassessment is reuired


40/40

2eferences

• amiens-i and eogh Pharmacologyemystied 5cDra" +ill, %&&@ Pain

5anagement in Trauma Patients m * Ph!s+ed eha'il 200-3$1-2/161.

• 5anagement of Pain in Adults Pain idelines,%&&:, 1&61#7

• 4+? guidelines on the pharmacologicaltreatment of persisting pain in children "ithmedical illnesses %&&%

'&

pain and analgesic kelompok 3

Documents