Sub-optimal pain management can

have serious consequences…

Acute postoperative pain

Inadequate pain
management

Clinical and Decreased

psychological changes mobilisation
Induction of
chronic pain
Increased risk of
deep vein thrombosis, pulmonary embolism,
myocardial infarction and coronary ischaemia

Mortality/morbidity, longer hospital stay, re-admission, decreased quality of life,

decreased patient satisfaction and increased health costs

Ballantyne et al. Anesth Analg 1998;86:598;

Wu et al. Anesth Analg 2003;97:1078;
Pavlin et al. Anesth Analg 2002;95:627;
Anesthesiology 2004;100:1573;
Perkins et al. Anesthesiology 2000;93:1123
 Pengelolaan Nyeri Pada Trauma

DEFINITION
An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.
(IASP)

24
 Pengelolaan Nyeri Pada Trauma

MEKANISME NYERI
TRANSDUKSI

TRANSMISI

MODULASI

PERSEPSI
65
 TARGET OF PAIN THERAPIES
Pharmacotherapy
Non-opioid analgesics
Opioid analgesics
Nerve Blocks
Adjuvant analgesics (neurophatic,
musculoskeletal)
NSAID
Electrical Stimulation
Transcutaneous electrical nerve
stimulation (TENS)
Percutaneous electrical nerve
stimulation (PENS)

Alternative methods
Acupuncture
Physical Therapy
Chiropractics
Gottschalk et al., 2001
Surgery 136
How do we stop this?

Easy…

MULTIMODAL ANALGESIA

Aim…
eliminate pain (remove opportunity for
neuroplasticity)
mobilise early
decrease fear avoidance behaviour
 Nociceptor
sensitisation
Deep somatic
Referred
pain
muscle, fascia, pain
ligament

Postop
pain Reflex
Visceral
response
pain Muscle
spasm

Cutaneous
Cortical
Somatic
responses
pain
Pathogenesis of Postoperative
Pain
Surgery

•Tissue damage Nociceptive PAIN

•Inflamed tissue input

Surgery has a biphasic insults to the body

1. Trauma to tissue
2. Inflammatory response
Optimal Postop Pain Management

• Effective and safe

1

• Minimal side effects

2

• Facilitate recovery
3
• Easily managed (by doctors or
4 patients)
Main goals of Postop Pain Management

1 • To provide sufficient analgesia that

permits pleasant, normal activities (PAIN FREE)

2 • To prevent central sensitization

that leads to chronic pain (STRESS FREE)

3 • To improve surgical outcome

• Early ambulation
• Early oral nutrition
• ↓ cardiopulmonary morbidity
• ↓ psychological stress,
anxiety and insomnia
3 Methods of Post Op Pain Mgmt

1 • PRE-EMPTIVE ANALGESIA

2 • PROPHYLACTIC ANALGESIA

3 • POST-OPERATIVE ANALGESIA
Perioperative Multimodal Analgesia
Parecoxib
Ketamine
Ibuprofen
iv NMDA
iv
Cox-2 agents antagonists

NSAIDs Better analgesia

iv
 synergy

Multimodal  additivity

Reduced side effects

Paracetamol
iv

NorAdr & iv Local Anaesthesia

Opioids 5HT antagonists Jin et al. J Clin Anesth;13:524, 2001
iv
Tramadol Kehlet et al. Anesth Analg;77:1048. 1998
Woolf CJ, Science, 288:1765-1768, 2000
TERAPI FARMAKOLOGI

 OBAT ANALGETIK NON OPIOID ;

parasetamol,aspirin, OAINS

 OBAT ANALGETIK OPIOID ;

kodein,tramadol,morfin,fentanil

 OBAT ANALGETIK AJUVAN ; antikonvulsan,

anti depresan

1/7/2019 15
OBAT ANTI INFLAMASI NON
STEROID
 Aspirin : 325-650 mg 4-6 x/ hari
 Ketorolak : 10- 30 mg 4-6 x/ hari
 Indometasin: 25- 50 mg 2-3 x/ hari
 Piroksikam : 10- 20 mg 1-2 x/ hari
 Ibuprofen : 200-300 mg 3-6 x/ hari
 Na-diklofenak: 50 mg 3 x/ hari
 Meloksikam : 75 mg 1 x/ hari
 Nimesulfid : 100 mg 2 x/ hari
 Celecoxib : 100 mg 2 x/ hari

1/7/2019 16
DEXKETOPROFEN TROMETANOL =
KETESSE

 DOSIS :
umum 12,5 Mg/4-6 jam atau 25 mg/8 jam.
Post-op 25 – 75 Mg/ 8 jam.

Cara pemberian IV / IM
Kontraindikasi

 Hipersensitivitas
 Asthma
 Perdarahan lambung
 Disfungsi ginjal
 Pasien dg Tx Anti kuoagulan
 Wanita hamil & menyusui
Keunggulan DEXKETOPROFEN
TROMETANOL

Mula kerja cepat

Minimal iritasi lambung
Efektif utk nyeri central-perifer
Mengurangi opioid
Relatif aman utk : Hati
Ginjal
Multimodal
Anagesia