PENGELOLAAN NYERI

Dept. Anestesiologi & Terapi Intensif FK-USU/RSUP H.Adam Malik- MedanModul 10

TO CURE IS SOMETIMESTO TREAT IS OFTENTO COMFORT IS ALWAYSThe task of a doctor :*

N Y E R INyeri adalah pengalaman sensorik dan emosional yang tidak menyenangkan akibat kerusakan jaringan, baik aktual maupun potensial, atau yang digambarkan dalam bentuk kerusakan tersebut*

KlasifikasiNyeriAdaptifMaladaptifInflamasiNosiseptifFungsionalNeuropatik*

SpinothalamictractPeripheralnerveDorsal HornDorsal root ganglionPainAscendinginputDescendingmodulationPeripheralnociceptorsTraumaAdapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049. Modified by AHT* PAIN SERIES OF EVENTS

HeatColdIntenseForceMechanicalHeatColdPainAutonomic ResponseWitdrawal Reflex

Nociceptor sensory neuronNOCICEPTIVE PAINNoxius Pheripheral StimuliSpinal cordBrainPAIN*

MacrophageNeutrophilGranulocyteTissue DamageSpontaneous PainPain Hypersensitivity Reduced Threshold : Alodyna Increased Response : Hyperalgesia

Nociceptor sensory neuronINFLAMATORY PAINInflammationSpinal cordMast CellBrainBrainBrainBrainBrainBrainPAINBrainBrainPAINBrainBrainPAIN*

Increased neuronal activityBrainDorsal hornIncreasedNT releaseGABAAMPANk1C - fiberNMDAEctopicEphapticSprouting?NeuropathySympatheticnervous systemNEUROPATHIC PAINSensitiation and activationC - fiberNGFSP, CGRPVasodilation + plasma extravasationATP, BK5-HTPgs, H+BloodVesselDamage zoneRahman,et al 2003Pain Medicine & Palliative care vol.2,3 2003Modifikasi Meliala, 2005*

Normal PeripheralTissue and NervesFUNCTIONAL PAIN

Abnormal CentralProcessingSpontaneous PainPain Hypersensitivity

Brain*

ExamplesPeripheralPostherpetic neuralgiaTrigeminal neuralgiaDiabetic peripheral neuropathyPostsurgical neuropathyPosttraumatic neuropathyCentralPoststroke painCommon descriptors2BurningTinglingHypersensitivity to touch or coldExamples Pain due to inflammationLimb pain after a fractureJoint pain in osteoarthritisPostoperative visceral pain Common descriptors2AchingSharpThrobbingExamples Low back pain with radiculopathyCervical radiculopathyCancer painCarpal tunnel syndromePRESENTATION ACROSS PAIN STATES VARIES1. 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*

PENYAKIT, KESAKITAN, ATAU KEDUANYASAKITSAKITPenyakittanpakesakitanPenyakit dankesakitanKesakitantanpapenyakitUlkus (luka)Tanpa Ulkus ( tidak luka)Nyeri perutfungsional yang kronikBERUA M E*

SISTEM KOMUNIKASIOTAKSISTEMSARAFCENTRALSISTEMSARAFOTONOMSISTEMKIMIAWI*

Noxious Stimuli PSYCHOLOGICALNOCICEPTIVEAB75% Psychologic25 % Somatic*

NO BRAIN, NO PAIN*

Faktor-faktor yang mempengaruhi nyeri Gejala yang melelahkan Efek samping dan terapi

FISIK

NYERI TOTAL

KECEMASAN

Takut RS/perawatanKhawatir tentang keluarga dan keuanganTakut akan kematianKegelisahan spiritualKetidak-pastian tentang masa depan Kehilangan posisi sosial pretise pekerjaan dan pendapatan Insomnia dan kelelahan kronis Rasa tak berdaya Cacat

Kecerobohan Keterlambatan diagnosis Dokter tak di tempat Dokter tak komunikatif Kegagalan terapi Tak dikunjungi temanAMARAHDEPRESI*

BIOPSIKOSOSIAL(BIOPSYCHOSOCIAL)PENGERTIAN MODEL NYERIBYERS AND BONICA, 2001

Prinsip Pengobatan Nyeri AkutPukul dulu, urusan belakang

Pemilihan obat : # Efektivitas analgesik yang tinggi # Bekerja cepat

Untuk Nyeri Akut Dan BeratRecommendedInitial DosingTraditionalInitial DosingNo AnalgesiaSome AnalgesiaPain/Analgesia ThresholdSignificant SedationSignificant ToxicityAnalgesia dosing ladder*

ANALGESIC MEDICATIONSPRIMARY ANALGESICSAcetaminophenProstaglandin synthesis inhibitorsSalicylatesTraditonal NSAIDsCOX-2-selective NSAIDs (coxibs)TramadolOpioidsTraditionalMixedADJUVANT MEDICATIONSAntidepressantsAnticonvulsantsLocal anestheticsMiscellaneous agents*

*

Multimodal Analgesia ( Balanced Analgesia )OPIOID- Systemic- EpiduralSubarachnoid COX-2 LOCAL ANESTHETIC- Epidural- Subarachnoid ParacetamolCOX-1COX-2No single drug can produce optimal analgesia without adverse effectCombination of analgesics that act by different mechanisms result in synergetic analgesia*

*

*

K A N K E R1/3 dapat dicegah1/3 dapat disembuhkan (stadium dini)1/3 tidak dapat disembuhkan

kwalitas hidup ( ) :Perawatan paliatif & bebas nyeri*

POLA DASAR PEMIKIRAN PALIATIFmeningkatkan kwalitas hidupkematian adalah proses normaltidak mempercepat / menunda kematianmenghilangkan nyeri & keluhan lainmenjaga keseimbangan psikologis & spiritualpenderita tetap aktif sampai akhir hayatmembantu duka cita keluarga*

angka kejadian DepKes (1998) = 0,1 %

220 juta penduduk Indonesia

220.000 penderita kanker baru / tahun*

THE PHENOMENON of CANCER PAIN IS VERYCOMPLEX and COMPLICATED is the cumulative among : ORGANIC PAIN PSYCHOLOGICAL PAIN SUFFERINGTOTAL PAINBIOPSYCHOSOCIOCULTUROSPIRITUAL

PainSomatic or Visceral NociceptionNeuropathic MechanismsPsychological DisturbancesSufferingPsychological State and TraitsLoss of WorkPhysical DisabilityFearOf DeathFinancialConcernsSocial/ Familial FunctioningAMERICAN CANCER SOCIETY 1988

TotalSufferingTOTAL SUFFERINGPainPhysicalSymptomsSpiritualCulturalSocialPsychologicalPain+ physical symptoms+ psychological problems+ social difficulties+ cultural factors+ spiritual concerns- Total Suffering

ClinicalPainPhysicalPainPhysicalSymptomsSpiritualCulturalPsychologicalSocialTotalSufferingThe distinction between Clinical Pain and Total Suffering

PainPhysicalSymptomsSpiritualCulturalPsychologicalSocialUnrelieved pain

PainPhysicalSymptomsSpiritualCulturalPsychologicalSocialUnresolved or untreated pain

Classification of pain experienced by patients with cancer psychogenicTEMPORALPATHOPHYSIOLOGICALAETIOLOGICAL

due to cancer due to therapy due to general illness but no cancer un related to cancer or therapy

nociceptive somatic visceral

neuropathic central peripheral sympathetic

acute chronic

CANCER PAINCan be divided into 2 catagoriesORGANIC PAINPSYCHOLOGICAL PAINORGANIC PAINNociceptive pain Somatic pain (skin, muscle, connective tissue) Visceral pain(thoracic and abdominal viscera)Non nociceptive pain Neuropathic pain (deafferentiation pain) damage of peripheral or CNS.

MECHANISM of NOCICEPTIVE PAINNociceptive pain means pain with nociceptionNociceptive means activity of afferent neurons induced by a noxious stimulus TRANSDUCTION TRANSMISSION MODULATION PERCEPTION

PERCEPTIONCortexThalamocorticalprojectionsThalamusSpinothalamictractPrimaryAfferentNociceptorNoxiousStimulusMODULATIONTRANSMISSIONTRANSDUCTION

PERCEPTIONCortexThalamocorticalprojectionsThalamusSpinothalamictractPrimaryAfferentNociceptorNoxiousStimulusMODULATIONTRANSMISSIONTRANSDUCTIONSystemicOpioidsLAEpidural SubarachnoidCeliac PlexusIntravenousIntrapleuralIntraperitonealIncisional LAEpidural OpioidSubarachnoid Opioid

SOMATIC PAIN Characteristic of pain:

Example :

Mechanisms : constant aching, quawing well localized activation of nociceptors release algesic substances (specially prostaglandins) bone metastasis. tumor of the soft tissue Continuous activation may produce sensitization of nociceptor

VISCERAL PAIN Characteristic of pain: constant aching or dull poorly localized usually with nausea and vomit often referred to cuttaneous sites occational colicky or cramp activation of nociceptors pancreatic cancer liver/lung metastasis with shoulder pain Mechanism : Example :

NEUROPHATIC PAIN(DEAFFERENTIATION PAIN) Characteristic of pain:

Mechanisms : Example : burning pain paroxysmal shooting or electrical shock-like pain spontaneous discharges of peripheral or central n.s. loss of central inhibition metastasis brachial or lumbosacral plexopathies post herpetic neuralgia

AETIOLOGICAL OF PAIN1. due to cancer

2. due to therapy

3. due to general illness but not cancer4. unrelated to cancer or therapy

Pain associated with direct tumor involvementDue to invasion of boneBase of skullOrbital syndromeParasellar sinus syndromeSphenoid sinus syndromeClivus syndromeJugular foramen syndromeOccipital condyle syndromeVertebral bodyAtlantoaxial syndromeC7-T1 syndromeL1 syndromeSacral syndromeGeneralized bone painMultiple metastaseIntramedullary neoplasm

Due to invasion of nervesPeripheral nerve syndromeParaspinal massChest wall massRetroperitoneal massPainful polynueropathyBrachial, lumbal, sacral plexopathiesLeptomeningeal metastaseEpidural spinal cord compressionDue to invasion of visceralDue to invasion of blood vesselsDue to invasion of mucous membranes

Pain associated with cancer therapy Surgery Postthoracotomy syndromePostmastectomy syndromePostradical neck dissection syndromePostamputation syndromes Chemotherapy Painful polyneuropathyAseptic necrosis of boneSteroid pseudorheumatismMucositis Radiation Radiation fibrosis of brachial or lumbosacral plexusRadiation myelophatyRadiation-induced peripheral nerve tumorsMucositisRadiation necrosis of bone

Pain due to general illness but not cancer Myofascial pains Postherpetic neuralgia Osteoporosis Debiliting (decubitus ulcer) etc

4. Pain unrelated to cancer or therapy about one-fifth of pain reported by patients with advanced cancer are unrelated to cancer or therapy

arthritis

ischaemic heart disease

peripheral vascular disease

JENIS NYERI KANKERNosiseptif

Neurogenik

Psikogenik

*

NYERI NOSISEPTIF

ada rangsangan nosiseptor

saraf normal dan utuh

somatik / visceral

*

NYERI NEUROGENIKakibat kerusakan saraf perifer / sentral : terpotong tekanan kronis

nyeri simpatetik : (?) : analgetik non opioid/opioid (+) : blok saraf simpatetik

*

NYERI PSIKOGENIKnon fisik / kejiwaan

akibat : marah cemas depresi

*

PENYEBAB NYERI KANKER1. faktor jasmani : akibat tumor ( 70%) berhubungan dengan tumor akibat pengobatan tumor tidak langsung

2. faktor kejiwaan : marah cemas depresi *

SIFAT NYERI KANKER

a k u t

k r o n i s

*

DERAJAD NYERI KANKER

1. r i n g a n

2. s e d a n g

3. b e r a t

*

nyeri ringan

tidak mengganggu kegiatan sehari-hari

penderita dapat tidur

nilai VAS = 1 - 3*

nyeri sedangmengganggu kegiatan sehari-hari

penderita masih dapat tidur

nilai VAS = 4 - 6*

nyeri beratmengganggu kegiatan sehari-hari

penderita tidak dapat tidur

nilai VAS = 7 - 10*

VISUAL ANALOGUE SCALE0 1 2 3 4 5 6 7 8 9 10| | | | | | | | | | |TidaknyeriNyerisangat hebat SMILEY ANALOGUE SCALE*

PENGELOLAAN NYERI KANKER efficacy , safety, economy & humanity tepat indikasi tepat obat tepat dosis & cara pemberian tepat penderita waspada effek samping obat*

tepat obatmacam analgesik : derajad nyeri ( ringan / sedang / berat ) jenis nyeri ( nosiseptif / neurogenik / psikogenik )

tidak semua nyeri membutuhkan opioid !!*

tepat dosis

individual

efek maksimal

efek samping minimal*

tepat cara pemberianoral ( enteral / suppositoria / parenteral )

jenjang bertingkat WHO

tepat waktu = by the clock jangan pro re nata *

TOKSISITAS

ANALGESIA

NYERIKADAR OBAT*

*

ANALGESIC - LADDERDARI WHO*

waspada effek samping obatanalgesik non opioid : anafilaksis gangguan hemostasis perdarahan

opioid : mual , muntah konstipasi retensi urine*

LANGKAH PENGOBATAN NYERI KANKERNYERI KANKERJASMANIKEJIWAAN

NEUROGENIKNOSISEPTIKCramp like

AntidepresanTrisiklikShooting

Anti-konvulsiRingan

A N OSedang

A N O+OpioidlemahBerat

A N O+OpioidkuatPsikofarmakaPsikoterapiPERTIMBANGKAN ?*

PERTIMBANGKANAjuvan analgetikPenanggulangan ESO opioidPengobatan non farmakologisEVALUASIBerhasilTidak berhasil Re-evaluasi Konsultasi RujukANO = analgesik non opioidESO = efek samping obat*

ANALGESIK NON OPIOID

parasetamol

asam asetil salisilat / aspirin

obat anti inflamasi non steroid = NSAID*

OPIOID LEMAHCODEIN : 6 X 10 mg/hari

nyeri (+) ??

dosis ( ) 50-100 %

dosis maksimal : 6 X 40 mg/hari*

OPIOID KUATMORFIN oral :6 X 2,5 mg/hari

nyeri (+) ? mengantuk (?)

dosis ( ) dosis ( ) 50-100 % 50-25 %

dosis optimum

MORFIN ORAL LEPAS LAMBAT*

cara pemberian morfinoral ( paling cocok )subkutanpatchintravenaintramuskulerrektalspinal / epiduralintraventrikuler*

ketakutantoleransiketergantungan fisikketergantungan psikis

BUKAN ALASAN MENUNDA MORFIN !!

risiko adiksi (-) *

OBAT AJUVANmengurangi/menghilangkan keluhan lainmenambah analgetik : anti konvulsi anti depresi kortikosteroidmengurangi keluhan : neuroleptik anti cemas anti depresi laksan, dll.*

PEDOMAN KHUSUS

oraljenjang bertingkat WHO ( keberhasilan = 80-90 % )sesuai jadualdosis individualplasebo (-)*

*

Chart1

32109199174230

1130

23168161

307211482

283814787

NO-PAIN

MILD-P

MOD-P

SEV-P

LOSS

RESULT OF TREATMENT

Sheet1

TN23

NR10916

NS8

NB1

TK61

Sheet1

109

23168161

TN

NR

NS

NB

TK

RESULT TX MILD PAIN

Sheet2

NO-PAIN321233028

MILD-P1091167238

MOD-P19981114

SEV-P174147

LOSS23030618287

Sheet2

NO-PAIN

MILD-P

MOD-P

SEV-P

LOSS

RESULT OF TREATMENT

Sheet3

pemantauan hasil terapi

nyeri (+) ???

re evaluasi !!!*

PENGELOLAAN NYERI KANKERSECARA NON FARMAKOLOGI1. a n e s t e s i a : blok saraf (lokal anestetik/ neurolitik ) opioid ( intrathecal/epidural)2. p e m b e d a h a n 3. r e h a b i l i t a s i m e d i k4. p s i k o t e r a p i5. k e m o t e r a p i6. r a d i o t e r a p i7. a k u p u n t u r*

RINGKASANkeluhan utama: nyeri (45-100%)80-90% nyeri bisa ditanggulangipengelolaan : tepat indikasi tepat obat tepat dosis & pemberian tepat penderita waspada effek samping*

RINGKASANtidak semua nyeri bisa di tanggulangi dengan opioidpenanggulangan : farmakologis & non farmakologispendekatan holistik : bio-psiko-sosio-kultural-spiritual meninggal dalam damai & iman*

?*

*

poliklinik paliatif & bebas nyeri*

*

Consultants' estimates of prevalence of use of progressively more invasive therapiesNerve blocks, palliativesurgery, and ablative surgery,1-5%.Epidural and intrathecal analgesics,2-6%.Intravenous andsubcutaneous drugs,5-20%.Oral, transdermal,and rectal drugs,75-85%.

Invasive Procedures for Cancer Pain

Between 70% and 90% of all cancer pain can be controlled with oral medication, but for those patients with unrelieved pain invasive procedures have an important role. Appropriate use of invasive measures in the 1030% of patientsmost often those with advanced diseasewho fail oral therapy can relieve nearly all cancer pain.

Phenol Studies by Mandl in 19507 reported that 6% phenol applied to cervical ganglia in animals produced local necrosis in 24 hours, complete degeneration by 45 days, and regeneration in 75 days. Thus, sensory recovery after phenol is faster than after alcohol. Phenol, like alcohol, has been administered for subarachnoid, peripheral nerve, and ganglion neurolysis.

Autonomic Nervous System Blocks

Neurosurgical Procedures

With the development of the multidisciplinary approach to pain management and an ever-growing range of available pharmacologic agents, few patients require surgical intervention to interrupt central or peripheral nociceptive pathways. The most commonly performed surgical procedure for cancer pain relief is anterolateral cordotomy, which ablates the spinothalamic tract

*****In Functional Pain, there is no peripheral lessions, however there is excitation in central neurons. This, may be caused by such decrease of inhibition due to various factors.In example: in fibromyalgia **This slide illustrates three broad categories of pain: neuropathic (pathologic), nociceptive (physiologic), and mixed pain states that encompass both nociceptive and neuropathic components, with examples of common causes of each type of pain.

The key talking points on this slide are as follows:Neuropathic pain has been defined by the International Association for the Study of Pain as initiated or caused by a primary lesion or dysfunction in the nervous system.1 Depending on where the lesion or dysfunction occurs within the nervous system, neuropathic pain can be peripheral or central in origin. Causes of peripheral neuropathic pain include postherpetic neuralgia (PHN) and diabetic peripheral neuropathy (DPN). Due to the prevalence and characteristics of PHN and DPN, these states may be considered representative of peripheral neuropathic pain.Nociceptive pain is an appropriate physiologic response that occurs when specific peripheral sensory neurons (nociceptors) respond to noxious stimuli. Nociceptive pain has a protective role because it elicits reflex and behavioral responses that keep tissue damage to a minimum.Acute pain, such as that seen with tissue inflammation and chronic pain, such that accompanying osteoarthritis, are examples of nociceptive pain.Although there are no specific descriptors for each type of pain, neuropathic pain is frequently described as burning or tingling in quality, while nociceptive pain is often described as aching or throbbing.There are cases in which an individual experiences pain sensations that are a blend of pain having a nociceptive and a neuropathic origin. For example, in carpal tunnel syndrome, it is common experience to have nociceptive pain, felt around the wrist, and neuropathic pain, felt in the distribution territory of the median nerve (fingers).

ReferencesInternational Association for the Study of Pain. IASP Pain Terminology.Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. Edinburgh, UK: Harcourt Publishers Limited. 1999.;11-57

Additional key words: descriptor******