Curriculum Vitae Nama : Dr. Tinni T. Maskoen, dr., SpAnKIC,KMNJabatan : Kepala Perawatan Intensif RS. Hasan Sadikin Bandung

Ketua Program Studi Pendidikan Konsultan Intensive Care (KIC) Fakultas Kedokteran Universitas Padjadjaran/RS. Hasan Sadikin BandungAlamat : Departemen Anestesiologi & Terapi Intensif Fakultas Kedokteran Universitas Padjadjaran/RS. Hasan Sadikin Jalan Pasteur no. 38 Bandung 40161Telp : 022-2038285/08122369670Fax : 022-2038306E-mail : ttmaskoen@yahoo.co.id

ANALGESIC NSAID’S IN WFSA LADDER

TINNI T MASKOENMEDICAL FACULTY UNPAD – HASAN SADIKIN HOSPITALBANDUNG

Makasar, November 2,2012

INTRODUCTION

The effective relief of pain is of paramount importance to anyone treating patients undergoing surgery.

There is now evidence that pain relief has significant physiological benefit. Earlier discharge from hospital. Reduce the onset of chronic pain syndromes.

Makasar, November 2,2012

Pain

Pain serves a biological function. It signals the presence of damage or

disease within the body. In the case of postoperative pain it is

the result of the surgery

Makasar, November 2,2012

Activation of the Central Nervous

System at the Spinal Cord Level

Tissue DamageActivation of the

Peripheral Nervous System

Transmission of the Pain Signal to the

Brain

Pain

The Pain Response

Samad TA et al. Nature. 2001;410:471-5.

Nociception

Spinothalamic

tractPeripheral

nerve

Dorsal Horn

Dorsal root ganglion

Pain

Modulation

Transduction

Ascendinginput

Descendingmodulation

Peripheralnociceptors

Trauma

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

Perception

Transmission

Prostaglandins produced in response to tissue injury; increase sensitivity of nociceptor (pain)

Nociceptor then releases substance P, which dilates blood vessels and increases release of inflammatory mediators, such as Bradykinin (redness & heat)Substance P also promotes degranulation of mast cells, which release histamine (swelling)

1

2

3

Pain-sensitive tissue

Painful stimulus

Prostaglandin

Substance P

Histamine

Mast cellBlood vessel

Bradykinin

Nociceptor

Substance P

23

1

Inflammation Tissue

Surgical pain

Review Multimodal strategies to improve surgical outcomeThe American Journal of Surgery 183 (2002) 630–641

WHO Analgesic Ladder

Pain managementPain symptom

intensity

Drug selection

Constant moderate to severe pain

Intermittent pain

Long acting analgesics +prn short acting

analgesics

prn short acting analgesics

MildModeratesevere

Surgical pain

Minor surgeryHerniotomyVaricose veinGynecological laparotomy

Moderate surgeryHip replacementHysterectomymaxillofacial

Major surgeryThoracotomyMajor abdominal surgeryKnee surgery

Paracetamol /NSIADs / weak opiods

Wound infiltration

Peripheral nerve block

Paracetamol /NSIADs +Wound infiltrationPeripheral nerve blockSystemic opioidsPCA

Paracetamol /NSIADs Epidural anesthesia systemic opioidsPCA

Treatment modality

Surgical procedure

The Continuum of Pain

<1 month

Time to resolution

3-6 months

AcutePain

ChronicPain

•Usually obvious tissue damage

• Increased nervous system activity

•Pain resolves upon healing•Serves a protective function

•Pain for 3-6 months or more2

•Pain beyond expected period of healing2

•Usually has no protective function3

•Degrades health and function3

1. Cole BE. Hosp Physician. 2002;38:23-30.2. Turk and Okifuji. Bonica’s Management of Pain. 2001.3. Chapman and Stillman. Pain and Touch. 1996.

Insult

WFSA Analgesic Ladder

Factors influencing analgesic requirements

Age Pre-operative analgesic use. Coexisting medical conditions Cultural factors and personality Preoperative patient education Past history of poor pain management Site of operation

Treatment …

Pharmacologic• Opioid• Non opioid - Aspirin - Acetaminophen - NSAID’s• Adjuvant

NSAID

Side effects Therapeutic effects

TXA2

PGE2

PGI2 PGI2

Contraindication of NSIAD

Pre-existing renal impairment (Cr)

Cardiac failure

Severe liver dysfunction

Uncontrolled hypertension

Aspirin-induced asthma

History of GI bleeding

Known hypersensitivity

NSIAD used with caution

High risk of intraoperative hemorrhage

Diabetes

Bleeding or coagulation disorders.

Pregnant and lactating woman

Children or advanced age

Concurrent used other NSIAD ,ACEI , cyclosporin, methotrexate

Non Opioid

Non Selective NSAIDsAspirin IbuprofenNaproxenFenoprofen IndomethacinKetorolac

COX-2 Selective inh• Rofecoxib• Celecoxib• ValdecoxibOthers• Acetaminophen• Clonidine• Ketamin

Potential side effects of NSAID

REVIEW ARTICLE WHITE ANESTH ANALGNON-OPIOID ANALGESICS AND ACUTE POSTOPERATIVE PAIN 2005;101:S5–S22

-Operative site bleeding- GI bleeding- Renal tubular dysfunction- Allergic reaction- Bronchospasm- Hypertension- Pedal edema

Pain management

Preemptive analgesia & Multimodal analgesia⇩ doses of each analgesic Improved actinociception due to

synergistic/additive effectsmay⇩ reduce severity of side effect of each

drugs

Potentiation

• Reduced doses of each analgesic

• Improved pain relief due to synergistic or additive effects

• May reduce severity of side effects of each drug

Benefits of Multimodal Pain Therapy1

1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.

Morphine

NSAIDs,acetaminophen,nerve blocks

Multimodal Therapy Can Provide

Enhanced Analgesia

1Crews JC. JAMA. 2002;288:629-632.2Samad TA et al. Trends Mol Med. 2002;8:390-396.3Atcheson R et al. Management of Acute and Chronic Pain. London, England: BMJ Books; 1998:23-50.

Resume

Pain relief has significant physiological benefit, such as earlier discharge from hospital and reduce the onset of chronic pain syndrome.

Surgical pain produce complexity neurohumoral, infammation and amplifying responses and should be treated according to WFSA Analgesic Ladder

• Multimodal Pain Therapy should be done to reduced doses of each analgesic, improved pain relief due to synergistic or additive effects and reduce severity of side effects of each drug

Thank You