Pemantauan dan Pemantauan dan Penanganan Nyeri Penanganan Nyeri

Pasca Bedah Pasca Bedah

IntroductionIntroduction Surgical procedures become increasingly Surgical procedures become increasingly

complex and were performed on sicker patientscomplex and were performed on sicker patients The period in PACU is characterized by The period in PACU is characterized by

relatively high incidence of potentially life-relatively high incidence of potentially life-threatening respiratory and circulatory threatening respiratory and circulatory complications.complications.

Postoperative pain management: minimises Postoperative pain management: minimises patient suffering, reduce morbidity and facilitate patient suffering, reduce morbidity and facilitate rapid recovery and early discharge from hospital rapid recovery and early discharge from hospital

PACUPACUNear the operating roomsNear the operating roomsProximity to radiographic, laboratory, and Proximity to radiographic, laboratory, and

other intensive care facilitiesother intensive care facilitiesOpen ward designOpen ward designPulse oxymetry, EKG, blood pressure Pulse oxymetry, EKG, blood pressure

monitors, capnography, thermometer etcmonitors, capnography, thermometer etcEmergency equipmentEmergency equipmentRespiratory therapy equipmentRespiratory therapy equipment

Speed of EmergenceSpeed of Emergence

Inhalation anesthetic: depend on alveolar Inhalation anesthetic: depend on alveolar ventilation, agent’s blood solubility, duration of ventilation, agent’s blood solubility, duration of anesthesiaanesthesia

The most frequent cause of delayed emergence The most frequent cause of delayed emergence from inhalation anesthesia is hypoventilationfrom inhalation anesthesia is hypoventilation

IV anesthetic: function of its pharmacokinetics.IV anesthetic: function of its pharmacokinetics. Preoperative medications, age, renal or hepatic Preoperative medications, age, renal or hepatic

diseasedisease

Delayed Emergence Fails to regain consciousness 60-90 minutes following

general anesthesia The most frequent cause: residual anesthetic, sedative,

and analgesic drug effect Occur as a result of drug overdose, or potentiation of

anesthetic agents by prior drug ingestion (alcohol). Naloxone (0.2 mg increments) and flumazenil (0.5 mg

increments): reverses and can exclude the effects of an opioid and benzodiazepine, respectively.

Physostigmine 1-2 mg may partially reverse the effect of other agents.

A nerve stimulator can be used to exclude significant neuromuscular blockade.

Delayed Emergence Less common causes:

hypothermia marked metabolic disturbances perioperative stroke.

Hypoxemia and hypercarbia are readily excluded by blood gas analysis.

Rare causes: hypercalcemia, hypermagnesemia, hyponatremia, and hypo- and hyperglycemia

Perioperative stroke is rare except following neurologic, cardiac, and cerebrovascular surgery

RECOVERYRECOVERY Vital signs and oxygenation should be checked

immediately on arrival. BP, PR, and RR every 5 min for 15 min or until

stable, and every 15 minutes thereafter. Pulse oximetry should be monitored

continuously in all patients recovering from general anesthesia, at least until they regain consciousness.

All patients recovering from general anesthesia should receive 30-40% oxygen

Discharge Criteria Observed for respiratory depression for at least

30 minutes after the last dose of parenteral narcotic.

Minimum discharge criteria for patients recovering from general anesthesia:(1) Easy arousability(2) Full orientation(3) The ability to maintain and protect the airway(4) Stable vital signs for at least 1 hour(5) The ability to call for help if necessary(6) No obvious surgical complications (such as

activebleeding).

Postanesthetic recovery score. (Ideally, the patient should be discharged when the total score is 10.)

'Based on Aldrete JA, Kronlik D: A postanesthetic recovery score. Anesth Analg 1970;49:924.

Penanganan Nyeri Pasca Penanganan Nyeri Pasca OperatifOperatif

The Goals of Pain ManagementThe Goals of Pain Management

Improve quality of life for the patientImprove quality of life for the patientFacilitate rapid recovery and return to full Facilitate rapid recovery and return to full

functionfunctionReduce morbidityReduce morbidityAllow early discharge from hospitalAllow early discharge from hospital

Pain: Pain: "An unpleasant sensory and "An unpleasant sensory and emotional experience associated with emotional experience associated with actual or potential tissue damage, or actual or potential tissue damage, or described in terms of such damage." described in terms of such damage." (IASP 1979)(IASP 1979)

Physiology of painPhysiology of painThere is individual variation in response to pain, There is individual variation in response to pain, which is influenced by genetic makeup, cultural which is influenced by genetic makeup, cultural background, age and gender. background, age and gender. Certain patient populations are at risk of Certain patient populations are at risk of inadequate pain control and require special inadequate pain control and require special attention. attention. Paediatric patientsPaediatric patients Geriatric patientsGeriatric patients Patients with difficulty in communicating ( critical Patients with difficulty in communicating ( critical illness, cognitive impairment or language barriers)illness, cognitive impairment or language barriers)

Physiology of painPhysiology of pain

Postoperative pain can be divided into acute Postoperative pain can be divided into acute pain and chronic pain:pain and chronic pain:

Acute pain is experienced immediately after Acute pain is experienced immediately after surgery (up to 7 days)surgery (up to 7 days)

Pain which lasts more than 3 months after the Pain which lasts more than 3 months after the injury is considered to be chronic paininjury is considered to be chronic pain

Physiology of painPhysiology of pain The type of pain:The type of pain:

somatic (from skin, muscle, bone)somatic (from skin, muscle, bone)visceral (from organs within the chest and visceral (from organs within the chest and

abdomen)abdomen)neuropathic (damage or dysfunction in the neuropathic (damage or dysfunction in the

nervous system). nervous system). Patients often experience more than one Patients often experience more than one

type of paintype of pain

Positive role of painPositive role of pain

Providing a warning of tissue damageProviding a warning of tissue damage Inducing immobilisation to allow Inducing immobilisation to allow

appropriate healingappropriate healing

Negative effects of painNegative effects of painShort term negative effects of acute pain:Short term negative effects of acute pain: Emotional and physical suffering for the patientEmotional and physical suffering for the patient Sleep disturbance (with negative impact on mood and Sleep disturbance (with negative impact on mood and

mobilisation)mobilisation) Cardiovascular side effects ( hypertension, tachycardia)Cardiovascular side effects ( hypertension, tachycardia) Increased oxygen consumption (negative impact in CAD)Increased oxygen consumption (negative impact in CAD) Impaired bowel movement (opioids induce constipation or Impaired bowel movement (opioids induce constipation or

nausea, pain may also be an important cause of impaired nausea, pain may also be an important cause of impaired bowel movement or PONV)bowel movement or PONV)

Negative effects on respiratory function (leading to Negative effects on respiratory function (leading to atelectasis, retention of secretions and pneumonia)atelectasis, retention of secretions and pneumonia)

Delays mobilisation and promotes thromboembolism (post Delays mobilisation and promotes thromboembolism (post operative pain on mobilisation is one of the major causes operative pain on mobilisation is one of the major causes for delayed mobilisation)for delayed mobilisation)

Principles of successful pain Principles of successful pain assessmentassessment

Assess pain both at rest and on movement to evaluate Assess pain both at rest and on movement to evaluate the patient's functional status.the patient's functional status.

The effect of a given treatment is evaluated by assessing The effect of a given treatment is evaluated by assessing pain before and after every treatment intervention.pain before and after every treatment intervention.

In the surgical Post Anaesthesia Care Unit (PACU) or In the surgical Post Anaesthesia Care Unit (PACU) or other circumstances where pain is intense, evaluate, other circumstances where pain is intense, evaluate, treat, and re-evaluate frequently (e.g. every 15 min treat, and re-evaluate frequently (e.g. every 15 min initially, then every 1-2 h as pain intensity decreases).initially, then every 1-2 h as pain intensity decreases).

On the surgical ward, evaluate, treat, and re-evaluate On the surgical ward, evaluate, treat, and re-evaluate regularly (e.g. every 4-8 h) both the pain and the regularly (e.g. every 4-8 h) both the pain and the patient's response to treatment.patient's response to treatment.

Principles of successful pain Principles of successful pain assessmentassessment

Define the maximum pain score above which pain relief Define the maximum pain score above which pain relief is offered the intervention threshold). For example, is offered the intervention threshold). For example, verbal ratings score of 3 at rest and 4 on moving, on a verbal ratings score of 3 at rest and 4 on moving, on a 10-point scale.10-point scale.

Pain and response to treatment, including adverse Pain and response to treatment, including adverse effects, are documented clearly on easily accessible effects, are documented clearly on easily accessible forms, such as the vital sign sheet. forms, such as the vital sign sheet.

Patients who have difficulty communicating their pain Patients who have difficulty communicating their pain require particular attention. (cognitively impaired, require particular attention. (cognitively impaired, severely emotionally disturbed, children, patients who do severely emotionally disturbed, children, patients who do not speak the local language, and patients whose level not speak the local language, and patients whose level of education or cultural background differs significantly of education or cultural background differs significantly from that of their health care team).from that of their health care team).

Principles of successful pain Principles of successful pain assessmentassessment

Unexpected intense pain, particularly if Unexpected intense pain, particularly if associated with altered vital signs (hypotension, associated with altered vital signs (hypotension, tachycardia, or fever) is immediately evaluated. tachycardia, or fever) is immediately evaluated. New diagnoses, such as wound dehiscence, New diagnoses, such as wound dehiscence, infection, or deep venous thrombosis, should be infection, or deep venous thrombosis, should be considered.considered.

Immediate pain relief without asking for a pain Immediate pain relief without asking for a pain rating is given to patients in obvious pain who rating is given to patients in obvious pain who are not sufficiently focused to use a pain rating are not sufficiently focused to use a pain rating scale.scale.

Family members are involved when appropriate.Family members are involved when appropriate.

Specific tools for pain Specific tools for pain assessmentassessment

Facial expressions: a pictogram of six faces with Facial expressions: a pictogram of six faces with different expressions from smiling or happy through to different expressions from smiling or happy through to tearful. This scale is suitable for patients where tearful. This scale is suitable for patients where communication is a problem, communication is a problem,

Verbal rating scale (VRS): the patient is asked to rate Verbal rating scale (VRS): the patient is asked to rate their pain on a five-point scale as "none, mild, their pain on a five-point scale as "none, mild, moderate, severe or very severe".moderate, severe or very severe".

Numerical rating scale (NRS): This consists of a simple Numerical rating scale (NRS): This consists of a simple 0 to 5 or 0 to 10 scale which correlates to no pain at 0 to 5 or 0 to 10 scale which correlates to no pain at zero and worst possible pain at 5 (or 10). zero and worst possible pain at 5 (or 10).

Visual analogue scale (VAS): This consists of an Visual analogue scale (VAS): This consists of an ungraduated, straight 100 mm line marked at one end ungraduated, straight 100 mm line marked at one end with the term " no pain" and at the other end "the worst with the term " no pain" and at the other end "the worst possible pain". possible pain".

DocumentationDocumentation The nurse responsible for the patient reports the The nurse responsible for the patient reports the

intensity of pain and treats the pain within the intensity of pain and treats the pain within the defined rules of the local guidelines.defined rules of the local guidelines.

The physician responsible for the patient may The physician responsible for the patient may need to modify the intervention if evaluation need to modify the intervention if evaluation shows that the patient still has significant pain.shows that the patient still has significant pain.

The treatment strategy to be continued is The treatment strategy to be continued is discussed by the physician responsible for the discussed by the physician responsible for the patient in conjunction with the ward nurses.patient in conjunction with the ward nurses.

The physician and nurses pay attention to the The physician and nurses pay attention to the effects and side effects of the pain treatment.effects and side effects of the pain treatment.

Treatment optionsTreatment options a. Pharmacological methods of pain treatment:

step-wise and balancedstep-wise and balanced Balanced (multimodal) analgesia Uses two or more analgesic agents that act by Uses two or more analgesic agents that act by

different mechanisms to achieve a superior analgesic different mechanisms to achieve a superior analgesic effect without increasing adverse events compared effect without increasing adverse events compared with increased doses of single agents. (e.g. epidural with increased doses of single agents. (e.g. epidural opioids + epidural local anaesthetics; intravenous opioids + epidural local anaesthetics; intravenous opioids can + NSAIDs.opioids can + NSAIDs.

Balanced analgesia is therefore the method of choice Balanced analgesia is therefore the method of choice wherever possible, based on paracetamol and wherever possible, based on paracetamol and NSAIDs for low intensity pain with opioid analgesics NSAIDs for low intensity pain with opioid analgesics and/or local analgesia techniques being used for and/or local analgesia techniques being used for moderate and high intensity pain as indicatedmoderate and high intensity pain as indicated

2. Opioids

3. Non Opioid

4. Adjuvants

In addition to systemic administration of In addition to systemic administration of NSAIDs or paracetamol, weak opioids and NSAIDs or paracetamol, weak opioids and non-opioid analgesic drugs may be non-opioid analgesic drugs may be administered "on request" for moderate or administered "on request" for moderate or severe pain. These include ketamine (oral, severe pain. These include ketamine (oral, im, iv) and clonidine (oral, iv or im, iv) and clonidine (oral, iv or perineurally in combination with local perineurally in combination with local anaesthetics). However, the side effects anaesthetics). However, the side effects could be significant. could be significant.

5. Regional analgesia

Continuous Central Neuraxis Blockade (CCNB)Continuous Central Neuraxis Blockade (CCNB) Continuous epidural analgesia: first choiceContinuous epidural analgesia: first choice

Continuous Peripheral Nerve Blockade (CPNB)Continuous Peripheral Nerve Blockade (CPNB) Continuous Infusion (CI) Intermittent Top-up: Patient-Controlled Epidural Analgesia (PCEA):

Continuous spinal analgesia - selected cases only Continuous spinal analgesia - selected cases only (less experience with this technique)(less experience with this technique)

Continuous Peripheral Nerve Blockade (CPNB) Infiltration blocks

b. Non-pharmacological methods of pain treatment

Acute pain management serviceAcute pain management service

Treatment of postoperative pain requires good multi-disciplinary and multi-professional co-operation.

Staff training Physiology and pathophysiology of pain Pharmacology of analgesics Locally available treatment methods Monitoring routines with regard to treatment of pain Local document for treatment and assessment of pain

Audit and quality control Before establishing an acute pain service for the first time, it is

important to audit the effectiveness of the current pain management systems in your hospital.

Negative effects of painNegative effects of pain

Long term negative effects of acute pain:Long term negative effects of acute pain: Severe acute pain is a risk factor for the Severe acute pain is a risk factor for the

development of chronic paindevelopment of chronic pain There is a risk of behavioural changes in There is a risk of behavioural changes in

children for a prolonged period (up to 1 year) children for a prolonged period (up to 1 year) after surgical painafter surgical pain

Physiology of painPhysiology of painTwo major mechanisms in the physiology Two major mechanisms in the physiology

of pain:of pain:Nociceptive (sensory): Nociceptive (sensory): Inflammatory pain Inflammatory pain

due to chemical, mechanical and thermal due to chemical, mechanical and thermal stimuli at the nociceptors (nerves that respond stimuli at the nociceptors (nerves that respond to painful stimuli).to painful stimuli).

Neuropathic: Neuropathic: Pain due to neural damage in Pain due to neural damage in peripheral nerves or within the central peripheral nerves or within the central nervous system.nervous system.

The mechanism of peripheral pain The mechanism of peripheral pain sensitisationsensitisation

Normally, C- fibres (slow-conducting fibres Normally, C- fibres (slow-conducting fibres that transmit dull aching pain) are silent in that transmit dull aching pain) are silent in the absence of stimulation, but following the absence of stimulation, but following acute tissue injury in the presence of acute tissue injury in the presence of ongoing pathophysiology, these nociceptors ongoing pathophysiology, these nociceptors become sensitised and release a complex become sensitised and release a complex mix of pain and inflammatory mediators mix of pain and inflammatory mediators leading to pain sensations leading to pain sensations

The mechanism of central The mechanism of central sensitisationsensitisation

Sustained or repetitive C-nociceptor activity Sustained or repetitive C-nociceptor activity produces alterations in the response of the produces alterations in the response of the CNS to inputs from the periphery. When CNS to inputs from the periphery. When identical noxious stimuli are repeatedly identical noxious stimuli are repeatedly applied to the skin at a certain rate, there is applied to the skin at a certain rate, there is a progressive build-up in the response of a progressive build-up in the response of spinal cord dorsal horn neurons (known as spinal cord dorsal horn neurons (known as ‘wind up’). ‘wind up’).