Scribd Logo
Upload

Welcome to Scribd!

  • 113 views

    Nyeri Zaldiar

    Uploaded by

    Eugunia Edgar
    This document discusses pain assessment and management. It defines pain, describes types of pain including neuropathic and nociceptive pain, and symptoms of neuropathic pain. It also discusses pain therapies like medications, nerve blocks, acupuncture, and more. Targets of pain therapies and the ABC approach to pain management are explained.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Nyeri Zaldiar

    Uploaded by

    Eugunia Edgar
    113 views47 pages
    This document discusses pain assessment and management. It defines pain, describes types of pain including neuropathic and nociceptive pain, and symptoms of neuropathic pain. It also discusses pain therapies like medications, nerve blocks, acupuncture, and more. Targets of pain therapies and the ABC approach to pain management are explained.

    Original Description:

    penatalaksanaan nyeri

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document discusses pain assessment and management. It defines pain, describes types of pain including neuropathic and nociceptive pain, and symptoms of neuropathic pain. It also discusses pain therapies like medications, nerve blocks, acupuncture, and more. Targets of pain therapies and the ABC approach to pain management are explained.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    113 views47 pages

    Nyeri Zaldiar

    Uploaded by

    Eugunia Edgar
    This document discusses pain assessment and management. It defines pain, describes types of pain including neuropathic and nociceptive pain, and symptoms of neuropathic pain. It also discusses pain therapies like medications, nerve blocks, acupuncture, and more. Targets of pain therapies and the ABC approach to pain management are explained.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 47

    SEKILAS

    PENATALAKSA
    NAAN NYERI
    Dr. AWALUDDIN NOOR, Sp.S

    Prima Resort Kuningan


    9 April 2010

    Definisi Nyeri (Pain) dari


    IASP
    (International Association for the Study of Pain)

    Pain (Nyeri) adalah suatu


    pengalaman sensorik dan
    emosional yang berkaitan
    dengan kerusakan
    jaringan atau diduga ada
    kerusakan jaringan

    Nyeri adalah

    pengalaman sensorik
    yang berkaitan
    dengan aktivasi
    nociceptor dan
    lintasan nyeri
    Nyeri adalah suatu
    pengalaman
    emosional
    Kerusakan jaringan
    tidak mesti ada

    JENIS NYERI
    Neuropathic Pain

    Mixed Pain

    Pain initiated or caused by a


    primary lesion or dysfunction
    in the nervous system
    (either peripheral or
    central nervous system)1

    Pain with
    neuropathic and
    nociceptive
    components

    Examples
    Peripheral
    Post herpetic neuralgia
    Trigeminal neuralgia
    Diabetic peripheral neuropathy
    Postsurgical neuropathy
    Posttraumatic neuropathy
    Central
    Posts troke pain
    Common descriptors2
    Burning
    Tingling
    Hypersensitivity to touch or cold

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

    Examples

    Examples

    Low back pain with

    radiculopathy
    Cervical
    radiculopathy
    Cancer pain
    Carpal tunnel
    syndrome

    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

    Pain due to inflammation


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

    Common descriptors2
    Aching
    Sharp
    Throbbing

    Neuropathic Pain is
    Different from
    Muscle/skeletal
    Pain
    Neuropathic Pain
    Muscle/skeletal Pain
    Chronic pain (months/years)

    Acute pain (hours or days)

    Caused by injury or disease to nerves Caused by injury or inflammation that


    affects both the muscles and joints
    Mild to excruciating pain that can last
    indefinitely

    Moderate to severe pain that


    disappears when the injury heals

    Causes extreme sensitivity to touch


    simply wearing light clothing is
    painful

    Causes sore, achy muscles

    Sufferers can become depressed or


    socially withdrawn because they see
    no relief in sight and may experience
    sleep problems

    Sufferers can become anxious and


    distressed but optimistic about relief
    from pain

    Wall PD. Textbook of Pain. 4th ed; 1999; Jude EB. Clin in Pod Med and Surg.1999;16:81-97;
    Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997: Goldman L.
    Cecil Textbook of Medicine. 21st ed; 2000

    Symptoms of Neuropathic Pain


    Characterized Differently
    Neuropathic Pain

    Muscle/Skeletal Pain

    Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997; Galer BS et
    al. Diabetes Res Clin Pract. 2000;47:123-128

    Neurophatic
    pain

    Nociceptive/
    imflammatory/
    musculoskletal
    pain

    Thick, myelinated, fast


    conducting neurons
    Mediate the feeling of initial
    fast, sharp, highly localized
    pain.

    Rabaan
    Tekanan

    Very thin, unmyelinated, slowconducting


    Mediate slow, dull, more
    diffuse, often burning pain.

    Nerve Fibers
    Class

    Velocity

    Function

    A-

    Fast

    Motor

    A-

    Fast

    A-

    Intermediate

    Touch,
    pressure
    Muscle tone

    A-

    Intermediate

    Pain,
    temperature

    Small

    Motor

    Small

    Pain

    Targets of Pain Therapies


    Pharmacotherapy
    Non-opioid analgesics
    Opioid analgesics
    Nerve Blocks
    Adjuvant analgesics (neuropathic,
    musculoskeletal)

    tramadol

    Electrical Stimulation

    Acetaminofen

    Transcutaneous electrical nerve


    stimulation (TENS)
    Percutaneous electrical nerve
    stimulation (PENS)

    Alternative methods
    (NSAID)
    Gottschalketal.,2001

    Acupuncture
    Physical Therapy
    Chiropractics
    Surgery

    ABC Tx. Nyeri

    Anamnesa nyeri secara sistematik dan


    teratur
    Berpikiran positif (percaya) terhadap
    keluhan pasien atau keluarga
    Carilah metode kontrol nyeri yang nyaman
    untuk pasien dan keluarga
    Dilakukan intervensi yang tepat waktunya,
    logis dan terkoordinasi
    Edukasi pasien dan keluarga untuk
    mengatasi nyeri sekuat mungkin

    Analgesics
    Non-opioid analgesics (non-opioids):
    paracetamol, acetylsalicylic acid, metamizole* and
    nonsteroidal anti-inflammatory drugs (NSAIDs).

    Opioid analgesics (opioids):


    weak opioids (codeine, dihydrocodeine,

    tramadol) and strong opioids (i.e., morphine).


    Papaver somniferum

    Co-analgesics: a diverse group of drugs, with primary


    indications for conditions other than pain, with analgesic
    properties relevant to some conditions. Commonly used
    adjuvant analgesics include antiepileptic drugs (AEDs), tricyclic
    antidepressants (TCAs) and local anaesthetics (LAs).

    Diagnosis

    Drug Treatment

    Acute and chronic pain

    NSAIDS , Opioids (al tramadol),


    Paracetamol

    Myofascial pain
    dysfunction

    Analgesics , tricyclics,
    centrally-acting muscle
    relaxants, glucocorticoids

    Neuropathic pain,
    neuralgias

    Carbamazepine, phenytoin,
    baclofen, tricyclics,
    gabapentin, others?

    Acetaminophen
    May inhibit COX selectively in central nervous

    system
    Only weak inhibitor of peripheral COX (peroxide
    effects?)
    Inhibits effects of substance P in CNS?
    Inhibits effects of glutamate in CNS?

    Paracetamol
    1.

    2.
    3.

    4.

    Paracetamol is an effective analgesic for acute pain


    (Level I*).
    Paracetamol is an effective adjunct to opioids (Level I).
    NSAIDs given in addition to paracetamol improve
    analgesia (Level I).
    IV paracetamol is an effective analgesic after surgery
    (Level II), is as effective as ketorolac (Level II) and
    equivalent to morphine after dental surgery with better
    tolerance (Level II).

    Mekanisme Kerja Tramadol


    Dua mekanisme kerja yang saling melengkapi:

    1. Kerja di opioid:
    - Agonis reseptor
    - Metabolit aktif
    (O-desmethyltramadol/M1)

    2. Kerja di monoaminergic:
    Menghambat re-uptake
    serotonin/noradrenalin

    Mekanisme Kerja Tramadol


    Tramadol
    Menuju Otak

    Descending pathway

    Neuron dari saluran spinothalamic

    Serotonin/Noradrenalin
    -Receptor

    2-Receptor

    Tramadol

    Transmiter nyeri

    Spinal neuron

    Rangsang Nyeri

    Enkephalin

    PAIN PHARMACOTHERAPHY

    Choose drugs based on:


    mechanism of pain
    safety and pharmacology of aging
    match pain severity with drug potency
    use combined drug and non-drug strategies
    Use adequate dose; appropriate route
    Anticipate, prevent and manage side effects

    Rationale for a fixed-dose


    combination analgesic
    Enhanced analgesia
    Reduced doses of components - fewer side effects
    Rapid onset of action and lasting duration
    Broad spectrum of efficacy in terms of indications
    and pain intensity
    Higher patient compliance and ease of
    administration

    Fixed drug combinations ( ZALDIAR)


    Fixed combinations are appropriate for on-demand treatment
    typically used in acute pain conditions and situations of non-stable
    pain or intermittent pain in chronic conditions.
    A fixed analgesic combination simplifies drug delivery without the
    need for complicated dose-escalating regimens and, therefore,
    improves compliance.

    Free drug combinations


    Free drug combinations are particularly appropriate for the
    management of stable chronic pain syndromes.
    The main advantage of free drug combinations is that they allow the
    dose regimen to be tailored to individual requirements. On the other
    hand, this may be time-consuming because it involves a gradual and
    dose-escalating strategy.

    Kombinasi NSAID
    Kombinasi 2 NSAID:

    Tidak dianjurkan
    Efek samping meningkat
    Tidak menambah efikasi

    Kombinasi NSAID
    dengan Pelindung
    Lambung:
    Ditujukan untuk sedikit
    mengatasi masalah efek
    samping terhadap
    lambung.
    Dapat diberikan bersama
    golongan PPI,
    Misoprostol

    Kombinasi NSAID dan


    Analgetik (paracetamol)
    Masih dapat
    dipertanggungjawabkan

    ZALDIAR
    (37,5 MG TRAMADOL PLUS 325 MG PARASETAMOL)

    PHAROS INDONESIA

    Komposisi :
    37.5 mg Tramadol plus 325 mg Taracetamol

    Indikasi

    Mengurangi nyeri sedang sampai berat

    Sediaan

    Tablet salut film

    Kemasan :
    Box isi 10 tablet
    Harga 1 box : Rp 65.000
    Harga 1 tablet Rp 6.500

    INDIKASI ZALDIAR
    Nyeri sedang sampai berat seperti :

    Nyeri Pasca Operasi

    Trauma karena
    kecelakaan
    Low-back pain

    Bedah minor

    Rehabilitasi pasca
    cedera olahraga

    Nyeri Osteoarthritis
    Tambahan pengobatan
    pada OA/RA yang telah
    diberi NSAID/COX-2

    Dosis Untuk Dewasa (>12


    Tahun)

    Dosis ZALDIAR fleksibel tergantung dari


    intensitas nyeri.
    Untuk nyeri yang berat dosis awal bisa
    2 tablet kemudian diberikan setiap 6 jam

    Rata-rata dosis per hari 3-4 tablet

    Maksimal 8 tablet per hari


    (Sama dengan 300 mg tramadol/2600 mg parasetamol)

    ZALDIAR: Onset cepat durasi


    lama
    Pain relief probabilities

    Tramadol/paracetamol

    Paracetamol
    1

    Tramadol
    0
    0

    10

    Waktu (jam)

    Kerja analgesik yang saling melengkapi:


    Onset cepat dari parasetamol dikombinasi dengan durasi lama dari
    tramadol

    Perhatian pada kelompok


    pasien berikut :
    ZALDIAR jangan diberikan pada:
    Anak-anak <12 tahun
    Selama hamil
    Selama menyusui
    Kategori ZALDIAR C

    Kontraindikasi

    Hipersensitif terhadap tramadol dan parasetamol

    Acute intoxication alkohol, hypnotic, analgesik


    sentral, opioids atau obat psychotropic

    Pemberian bersamaan dengan MAO inhibitor or


    within two weeks of withdrawal

    Gangguan fungsi hati berat

    Epilepsi yang tidak sedang dalam pengobatan

    Peringatan
    Dosis maksimal 8 tablet per hari
    No concurrent use of any other products containing
    paracetamol or tramadol

    Tidak direkomendasikan pada pasien dengan


    gangguan ginjal (creatinin clearance <10ml/mm)

    Jangan diberikan pada pasien dengan gangguan


    hati berat

    Tidak direkomendasikan pada pasien dengan


    gangguan pernafasan berat

    Interaksi
    Kontra indikasi / tidak direkomendasikan
    digunakan bersamaan dengan:

    MAO inhibitors, Alcohol,


    Carbamazepine, Opioid agonistsantagonists

    STUDI KLINIS

    Nyeri setelah bedah mulut


    (gigi)
    Medve RA et al. Anesthesi Prog, 2001

    Tujuan:
    Membandingkan efikasi dan keamanan dari
    tramadol/parasetamol (ZALDIAR) dengan tramadol atau
    parasetamol monoterapi

    Dosis:

    Tramadol 75 mg/parasetamol 650 mg


    75 mg tramadol
    650 mg parasetamol
    400 mg ibuprofen
    Plasebo

    Desain penelitian:
    1200 pasien dengan nyeri sedang sampai berat

    setelah bedah (cabut) gigi geraham paling belakang


    (geraham bungsu) yang di random menjadi 3, double
    blind, paralel group, studi dosis tunggal yang
    diobservasi selama 8 jam.
    Tiga pusat penelitian terdiri dari 400 pasien; yang

    terdistribusi merata dalam pengobatan

    Medve RA et al. Anesth Prog, 2001

    Hasil penelitian: efikasi

    *P .0001 vs Tramadol/paracetamol; P = .0004 vs Tramadol/paracetamol;

    P .0001 vs all active treatments

    TOTPAR 8 = Total pengurangan nyeri dalam 8 jam


    SPID = Jumlah perbedaan intensitas nyeri dalam 8 jam

    Kesimpulan penelitian
    ZALDIAR pada pasien bedah
    gigi
    Pengurangan / penurunan intensitas nyeri dengan
    ZALDIAR lebih superior dibanding tramadol atau
    parasetamol sendiri atau plasebo
    Mula kerja ZALDIAR lebih cepat dan durasi kerja lebih
    lama dibanding tramadol atau parasetamol sendiri.
    Masing-masing komponen dari ZALDIAR berkontribusi
    terhadap efikasi analgesik
    ZALDIAR adalah analgesik kuat dengan

    onset cepat, durasi panjang yang efektif


    dalam pengobatan nyeri akut

    Efek samping setelah


    pemberian ZALDIAR ( 5%)
    Tramadol/
    paracetamol
    (n=240)

    Tramadol
    (n=238)

    Paracetamol
    (n=240)

    Ibuprofen
    (n=240)

    Placebo
    (n=239)

    Nausea
    (mual)

    56 (23%)

    56 (24%)

    22 (9%)

    23 (10%)

    38 (16%)

    Vomiting
    (muntah)

    51 (21%)

    49 (21%)

    17 (7%)

    16 (7%)

    23 (10%)

    Dizzines
    (pusing)

    11 (5%)

    12 (5%)

    10 (4%)

    7 (3%)

    9 (4%)

    Hasil penelitian: onset (mula kerja)

    Hasil penelitian: durasi kerja

    Pain: A conceptual approach to treatment (Biopsycosocial


    approach)

    Cognitive therapies
    Functional restoration

    Pain Behaviors
    Suffering

    Opioid
    Adjuvants
    NSAIDs?
    Acetaminophene
    Neural augmentation
    Ablative surgery

    Anti-depressants /
    psychotropics
    Relaxation
    Spiritual

    Pain
    Perception

    Nociception

    Local block

    NSAIDs (Movicox )
    Surgery
    Physical modalities

    1. Looser JD, Cousins MJ. Med J aust 1990;216: 153-208; 2. van den Hout JH, et al. Clin J Pain. 2003;19:87-96.; 3.
    Mynors-Wallis L, et al. Br J Psychiatry. 1997;170:113-119.; 4. Morley S, et al. Pain. 1999;80:1-13.

    HATUR NUHUN

    You might also like