Modul 10

PENGELOLAAN NYERI

Dept. Anestesiologi & Terapi Intensif

FK-USU/RSUP H.Adam Malik- Medan

The task of a doctor :

TO CURE IS SOMETIMES
TO TREAT IS OFTEN
TO COMFORT IS
ALWAYS
2

NYERI
Nyeri adalah pengalaman sensorik dan
emosional yang tidak menyenangkan
akibat kerusakan jaringan, baik aktual
maupun potensial, atau yang
digambarkan dalam bentuk kerusakan
tersebut
3

NOCICEPTIVE PAIN

Klasifikasi

Noxius Pheripheral Stimuli

Nosiseptif

Pain
Autonomic Response
Witdrawal Reflex

Heat
Cold
Intense
Mechanical
Force

Brain
Nociceptor
sensory neuron

Heat
Spinal cord

Cold

Adaptif

INFLAMMATORY PAIN
Spontaneous Pain
Pain Hypersensitivity

Inflammation
Macrophage

Inflamasi

Reduced Threshold : Aliody

Increased Response : Hypera

Mast Cell
Neutrophil
Granulocyte

Tissue Damage

Brain
Nociceptor
sensory neuron
Spinal cord

Nyeri

NEUROPATHIC PAIN
Spontaneous Pain
Pain Hypersensitiv

Neuropatik

Brain
Peripheral Nerve
Damage
Spinal cord Injury

Maladaptif

FUNCTIONAL PAIN
NOCICPTOR

Fungsional

Spontaneous Pai
Pain Hypersensit
Brain

NOCICPTOR
Normal Peripheral
Tissue and Nerves
NOCICPTOR

Abnormal Central
Processing

PAIN SERIES OF EVENTS

Pain

Modulation
Descending
modulation
Ascending
input

Dorsal
Horn

Dorsal root
ganglion

Conduction
Transduction

Spinothalami
c
tract

Peripheral
nerve
Trauma

Peripheral
nociceptors
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

Modified by AHT

NOCICEPTIVE PAIN
Noxius Pheripheral Stimuli
Heat

Pain
Autonomic Response
Witdrawal Reflex

Cold

Brain
PAIN

Intense
Mechanical
Force

Nociceptor sensory neuron

Heat
Cold

Spinal cord
6

INFLAMATORY PAIN
Inflammation
Macrophage

Spontaneous Pain
Pain Hypersensitivity

Reduced Threshold : Alodyna

Increased Response : Hyperalgesia

Mast Cell
Neutrophil
Granulocyte

Brain
PAIN

Nociceptor sensory neuron

Tissue Damage

Spinal cord
7

NEUROPATHIC PAIN
Sensitiation and activation

Increased neuronal activity

Damage zone

Brain
Pgs, H+
ATP, BK
5-HT
NGF
SP, CGRP

Blood
Vessel

C - fiber

GABA

C - fiber

NMDA

Vasodilation + plasma extravasation

Nk1
AMPA

Neuropathy
Increased
NT release

Sympathetic
nervous system
Ectopic

Dorsal horn

Rahman,et al 2003
Pain Medicine & Palliative care vol.2,3 2003
Modifikasi Meliala, 2005

Ephaptic
Sprouting?

FUNCTIONAL PAIN
Spontaneous Pain
Pain Hypersensitivity
Brain

Normal Peripheral
Tissue and Nerves

Abnormal Central
Processing
9

PRESENTATION ACROSS PAIN STATES VARIES

Neuropathic Pain
Mixed Pain
Pain initiated or caused by
Pain with
a primary lesion or
neuropathic and
dysfunction in the nervous
nociceptive
system
components
(either peripheral or
cent.nervous
syst.)1
Examples

Peripheral
Postherpetic neuralgia
Trigeminal neuralgia
Diabetic peripheral
neuropathy
Postsurgical neuropathy
Posttraumatic neuropathy
Central
Poststroke pain
Common descriptors2
Burning
Tingling
Hypersensitivity to touch or
cold

Nociceptive Pain
Pain caused by injury to
body tissues
(musculoskeletal,
cutaneous or visceral)2

Examples

Low back pain

with radiculopathy
Cervical
radiculopathy
Cancer pain
Carpal tunnel
syndrome

Examples

Pain due to inflammation

Limb pain after a fracture
Joint pain in osteoarthritis
Postoperative visceral pain

Common descriptors2
Aching
Sharp
Throbbing

1. International Association for the Study of Pain. IASP Pain Terminology.

10
2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11

PENYAKIT, KESAKITAN, ATAU

KEDUANYA
BERU
AME
Tanpa Ulkus
( tidak luka)

Ulkus (luka)

Penyakit
tanpa
kesakitan

Nyeri perut
fungsional
yang kronik

Penyakit
dan
kesakitan
SAKIT

SAKIT

Kesakitan
tanpa
penyakit
11

SISTEM KOMUNIKASI
OTAK

SISTEM
SARAF
CENTRAL

SISTEM
SARAF
OTONOM

SISTEM
KIMIAWI

12

75% Psychologic
25 % Somatic

Anger

Anxiety

Fear

Depression
PSYCHOLOGICAL

Noxious Stimuli

NOCICEPTIVE
13

NO BRAIN, NO PAIN

14

Faktor-faktor yang mempengaruhi

nyeri
Gejala yang melelahkan
Efek samping dan terapi
Kehilangan
posisi sosial
FISIK
pretise pekerjaan
dan pendapatan
DEPRESINYERI AMARAH
Insomnia dan
TOTAL
kelelahan kronis
Rasa tak berdaya
KECEMASAN
Cacat

Kecerobohan
Keterlambatan
diagnosis
Dokter tak di tempat
Dokter tak komunikat
Kegagalan terapi
Tak dikunjungi teman

Takut RS/perawatan
Khawatir tentang keluarga dan keuangan
Takut akan kematian
Kegelisahan spiritual
Ketidak-pastian tentang masa depan
15

PENGERTIAN MODEL NYERI

.Terapi kognitif
Restorasi fungsional

PERILAKU NYERI
(PAIN BEHAVIOUR)

PENDERITAAN
(SUFFERING)

Opioid
Tramadol
Oxcarbazepine
Gabapentin
Eperisone HCL
Paracetamol
OAINS

NYERI
(PAIN)

NOSISEPSI
(NOCICEPTION)

BIOPSIKOSOSIAL
(BIOPSYCHOSOCIAL)
BYERS AND BONICA, 2001

Antidepresan
Psikotropika
Relaksasi
Spiritual
Diklofenak
Etodolac
Dexketoprofen
Celecoxib
Modalitas fisik

Prinsip Pengobatan Nyeri

Akut
Pukul dulu, urusan belakang
Pemilihan obat :
# Efektivitas analgesik yang tinggi
# Bekerja cepat

Untuk Nyeri Akut Dan Berat

Recommended
Initial Dosing

Significant Toxicity
Significant Sedation

Pain/Analgesia Threshold
Some Analgesia

Traditional
Initial Dosing

Analgesia dosing ladder

No Analgesia

18

ANALGESIC MEDICATIONS
PRIMARY ANALGESICS
Acetaminophen
Prostaglandin synthesis inhibitors
Salicylates
Traditonal NSAIDs
COX-2-selective NSAIDs (coxibs)
Tramadol
Opioids
Traditional
Mixed

ADJUVANT MEDICATIONS

Antidepressants
Anticonvulsants
Local anesthetics
Miscellaneous agents
19

By the Ladder

Acute Pain

Pain
Deminishing

Severe
Pain

Pain
Deminishing

Strong Opioid
+/- Non Opioid
+/- Adjuvants

Moderate
Pain

Parenteral

WFSA

Weak Opioid
+/- Non Opioid
+/- Adjuvants

Mild

Non-Opioid

Pain

+/Adjuvants

Oral

20

Multimodal Analgesia ( Balanced

Analgesia )
Combination of
PERCEPTION

Combination of
analgesics that act by
different mechanisms
result in synergetic
analgesia

OPIOID
- Systemic
- Epidural
Subarachnoid
COX-2

MODULATION

LOCAL ANESTHETIC
- Epidural
- Subarachnoid
TRANSMISSION

Paracetamol
COX-1
COX-2
TRANSDUCTION

No single drug can produce optimal analgesia without adverse

effect

21

23

24

KANKER
1/3 dapat dicegah
1/3 dapat disembuhkan
(stadium dini)
1/3 tidak dapat disembuhkan

kwalitas hidup ( ) :
Perawatan paliatif & bebas nyeri
25

POLA DASAR
PEMIKIRAN PALIATIF
1. meningkatkan kwalitas hidup
2. kematian adalah proses normal
3. tidak mempercepat / menunda
kematian
4. menghilangkan nyeri & keluhan lain
5. menjaga keseimbangan psikologis &
spiritual
6. penderita tetap aktif sampai akhir
hayat
7. membantu duka cita keluarga
26

angka kejadian
DepKes (1998) = 0,1 %
220 juta penduduk Indonesia

220.000 penderita kanker

baru / tahun
27

THE PHENOMENON of
CANCER PAIN IS VERY
COMPLEX and
COMPLICATED is the
cumulative
:
ORGANIC among
PAIN
PSYCHOLOGICAL
PAIN
SUFFERING

TOTAL PAIN
BIOPSYCHOSOCIOCULTUROSPIRIT

Somatic or
Visceral
Nociceptio
n

Neuropathi
c
Mechanism
s

Pain

Suffering

Psychologic
al State and
Traits
Loss of
Work

Psychologic
al
Disturbance
s

Social/
Familial
Functioning
Financial
Concerns

Physical
Disability

Fear
Of Death
AMERICAN CANCER SOCIETY 1988

TOTAL SUFFERING
Pain
+ physical symptoms
+ psychological problems
+ social difficulties
+ cultural factors
+ spiritual concerns Spiritual
Spiritual
- Total Suffering

Pain
Pain

Total
Suffering

Cultural
Cultural

Physical
Physical
Symptom
Symptom
ss

Psychological
Psychological
Social
Social

The distinction between Clinical Pain and Total

Suffering
Physica
Physica
ll
Pain
Pain

Clinica
Clinica
ll
Pain
Pain
Spiritual
Spiritual

Total
Suffering
Cultural
Cultural

Physical
Physical
Symptom
Symptom
ss

Psychologic
Psychologic
al
al
Social
Social

Unrelieved
pain
Pain
Pain
Spiritual
Spiritual

Physical
Physical
Symptom
Symptom
ss

Cultural
Cultural

Psychologi
Psychologi
cal
cal
Social
Social

Unresolved or untreated
pain
Pain
Pain
Physical
Physical
Sympto
Sympto
ms
ms

Spiritu
Spiritu
al
al

Psychologi
Psychologi
cal
cal

Cultura
Cultura
ll
Social
Social

Classification of pain experienced by

patients with cancer
TEMPORAL PATHOPHYSIOLOGICAL
acute
chronic

nociceptive
somatic
visceral

neuropathic
central
peripheral
sympathetic

psychogenic

AETIOLOGICA
L

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

CANCER
Can
be divided into 2 catagories
PAIN
1. ORGANIC PAIN
2. PSYCHOLOGICAL
PAIN
ORGANIC PAIN
1. Nociceptive pain
Somatic pain
(skin, muscle, connective tissue)
Visceral pain
(thoracic and abdominal viscera)
2. Non nociceptive pain
Neuropathic pain (deafferentiation
pain) damage of peripheral or

MECHANISM of NOCICEPTIVE PAIN

Nociceptive pain means pain with
nociception
Nociceptive means activity of afferent
neurons induced by a noxious stimulus
TRANSDUCTION

TRANSMISSION
MODULATION
PERCEPTION

PERCEPTION

Cortex

Thalamocortical
projections

MODULATION
Thalamus

TRANSMISSION

TRANSDUCTION
Spinothalamic
tract

Primary
Afferent
Nociceptor

Noxious
Stimulus

PERCEPTION

Cortex
Epidural Opioid
Subarachnoid Opioid

Thalamocortical
projections

LA

Intravenous
Intrapleural
Intraperitoneal
Incisional

LA

MODULATION

Thalamus

Systemic
Opioids

Epidural
Subarachnoid
Celiac Plexus

TRANSMISSION

TRANSDUCTION
Spinothalamic
tract

Primary
Afferent
Nociceptor

Noxious
Stimulus

SOMATIC PAIN
Characteristic of pain:
constant
aching, quawing
well localized
Example
: bone metastasis.
tumor of the soft
tissue
Mechanisms
: activation of nociceptors

release algesic
substances
(specially
prostaglandins)
Continuous activation may
produce

VISCERAL
PAIN

Characteristic of
pain:
constant
aching or dull
poorly localized
usually with nausea and
vomit
often referred to cuttaneous
sites:
Mechanism

colicky or cramp
occational
activation of
nociceptors
Example:pancreatic cancer
liver/lung metastasis with
shoulder

NEUROPHATIC PAIN
(DEAFFERENTIATION
PAIN)

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

AETIOLOGICAL OF PAIN
1. due to cancer
2. due to therapy
3. due to general illness but not
cancer
4. unrelated to cancer or
therapy

1. Pain associated with direct tumor

involvement
Baseto
of invasion
skull
Due
of bone
Orbital syndrome
Parasellar sinus syndrome
Sphenoid sinus syndrome
Clivus syndrome
Jugular foramen syndrome
Occipital condyle syndrome

Vertebral body
Atlantoaxial syndrome
C7-T1 syndrome
L1 syndrome
Sacral syndrome

Generalized bone pain

Multiple metastase
Intramedullary neoplasm

 Due to invasion of nerves

Peripheral nerve syndrome
Paraspinal mass
Chest wall mass
Retroperitoneal mass
Painful polynueropathy
Brachial, lumbal, sacral
plexopathies
Leptomeningeal metastase
Epidural spinal cord compression

Due to invasion of visceral

Due to invasion of blood vessels
Due to invasion of mucous
membranes

2. Pain associated with cancer

Surgery
therapy
Postthoracotomy syndrome
Postmastectomy syndrome
Postradical neck dissection syndrome
Postamputation syndromes

Chemotherapy
Painful polyneuropathy
Aseptic necrosis of bone
Steroid pseudorheumatism
Mucositis

Radiation
Radiation fibrosis of brachial or lumbosacral
plexus
Radiation myelophaty
Radiation-induced peripheral nerve tumors
Mucositis

3. 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 KANKER

1. Nosiseptif
2. Neurogenik
3. Psikogenik

48

NYERI NOSISEPTIF
1. ada rangsangan nosiseptor
2. saraf normal dan utuh
3. somatik / visceral
49

NYERI NEUROGENIK
akibat kerusakan saraf perifer /
sentral :
terpotong
tekanan kronis
nyeri simpatetik :
(?) : analgetik non opioid/opioid
(+) : blok saraf simpatetik
50

NYERI PSIKOGENIK
non fisik / kejiwaan
akibat :
marah
cemas
depresi

51

PENYEBAB NYERI KANKER

1. faktor jasmani :
akibat tumor ( 70%)
berhubungan dengan tumor
akibat pengobatan tumor
tidak langsung
2. faktor kejiwaan :
marah
cemas
depresi
52

SIFAT NYERI KANKER

1.

a k u t

2.

k r o n i s

53

DERAJAD NYERI KANKER

1. r i n g a n
2. s e d a n g
3. b e r a t
54

nyeri ringan
tidak mengganggu kegiatan
sehari-hari
penderita dapat tidur
nilai VAS = 1 - 3
55

nyeri sedang
mengganggu kegiatan seharihari
penderita masih dapat tidur
nilai VAS = 4 - 6
56

nyeri berat
mengganggu kegiatan seharihari
penderita tidak dapat tidur
nilai VAS = 7 - 10
57

VISUAL ANALOGUE
SCALE
0
|

Tidak
nyeri

1
|

2
|

3
|

4
|

5
|

6
|

7
|

8
|

9
|

10
|

Nyeri
sangat hebat

SMILEY ANALOGUE SCALE

58

PENGELOLAAN NYERI
KANKER

efficacy , safety,
economy & humanity
tepat indikasi
tepat obat
tepat dosis & cara pemberian
tepat penderita
waspada effek samping obat
59

tepat obat
macam analgesik :
derajad nyeri
( ringan / sedang / berat )
jenis nyeri
( nosiseptif / neurogenik /
psikogenik )
tidak semua nyeri membutuhkan
opioid !!
60

tepat dosis
individual
efek maksimal
efek samping minimal
61

tepat cara pemberian

oral ( enteral / suppositoria /
parenteral )
jenjang bertingkat WHO
tepat waktu = by the clock
jangan pro re nata
62

KADAR OBAT

TOKSISITAS
ANALGESIA
NYERI

(a)

(b)

(b)

(c)

(a) = dosis kurang adekuat

(b) = pemberian "bila perlu saja"
(c) = pemberian sesuai jadwal ('by the clock')

WAKTU
WAKTU

63

64

ANALGESIC - LADDER
DARI WHO
Bebas
Bebas nyeri
nyeri
kanker
kanker
Opioid
Opioid kuat
kuat ::
++ Non-opioid
Non-opioid
++ Ajuvan
Ajuvan
Nyeri
Nyeri tetap
tetap
atau
atau bertambah
bertambah
Opioid
Opioid lemah
lemah ::
++ non-opioid
non-opioid
++ Ajuvan
Ajuvan
Nyeri
Nyeri tetap
tetap
atau
atau bertambah
bertambah

Non-opioid
Non-opioid
++ Ajuvan
Ajuvan
Nyeri
Nyeri
65

waspada effek samping

obat
analgesik non opioid :
anafilaksis
gangguan hemostasis
perdarahan
opioid

:
mual , muntah
konstipasi
retensi urine
66

LANGKAH PENGOBATAN NYERI

KANKER
NYERI KANKER
JASMANI
NEUROGENIK
Cramp like

Antidepresan
Trisiklik

KEJIWAAN
NOSISEPTIK

Shooting

Antikonvulsi

Ringan

ANO

Sedang

Berat

ANO
+
Opioid
lemah

ANO
+
Opioid
kuat Psikofarmaka
Psikoterapi

PERTIMBANGKAN ?

67

PERTIMBANGKAN
Ajuvan analgetik
Penanggulangan ESO opioid
Pengobatan non farmakologis

EVALUASI
Berhasil

ANO = analgesik non opioid

ESO = efek samping obat

Tidak berhasil
Re-evaluasi
Konsultasi
Rujuk
68

ANALGESIK NON OPIOID

parasetamol
asam asetil salisilat / aspirin
obat anti inflamasi non steroid
= NSAID
69

OPIOID LEMAH
CODEIN : 6 X 10 mg/hari
nyeri (+) ??
dosis (

) 50-100 %

dosis maksimal : 6 X 40 mg/hari

70

OPIOID KUAT
MORFIN oral :

6 X 2,5 mg/hari

nyeri (+) ?

mengantuk (?)

dosis ( )
50-100 %

dosis ( )
50-25 %

dosis optimum
MORFIN ORAL LEPAS LAMBAT
71

cara pemberian morfin

1.
2.
3.
4.
5.
6.
7.
8.

oral ( paling cocok )

subkutan
patch
intravena
intramuskuler
rektal
spinal / epidural
intraventrikuler
72

ketakutan
toleransi
ketergantungan fisik
ketergantungan psikis
BUKAN ALASAN
MENUNDA MORFIN !!
risiko adiksi (-)
73

OBAT AJUVAN
mengurangi/menghilangkan keluhan lain
menambah analgetik :
anti konvulsi
anti depresi
kortikosteroid
mengurangi keluhan :
neuroleptik
anti cemas
anti depresi
laksan, dll.
74

PEDOMAN KHUSUS
oral
jenjang bertingkat WHO
( keberhasilan = 80-90 % )
sesuai jadual
dosis individual
plasebo (-)
75

76

pemantauan hasil
terapi
nyeri (+) ???

re evaluasi

!!!
77

PENGELOLAAN NYERI KANKER

SECARA NON FARMAKOLOGI
1. 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 k
4. p s i k o t e r a p i
5. k e m o t e r a p i
6. r a d i o t e r a p i
7. a k u p u n t u r
78

RINGKASAN
keluhan utama: nyeri (45-100%)
80-90% nyeri bisa ditanggulangi
pengelolaan :
tepat indikasi
tepat obat
tepat dosis & pemberian
tepat penderita
waspada effek samping
79

RINGKASAN
tidak semua nyeri bisa di
tanggulangi dengan opioid
penanggulangan :
farmakologis & non farmakologis

pendekatan holistik :
bio-psiko-sosio-kultural-spiritual

meninggal dalam damai & iman

80

?
81

82

poliklinik paliatif & bebas

nyeri

83

84

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