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Anesthesiologist’s Competence for Pain Management

Is it compulsary or an actualization?

Eddy Rahardjo

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Reasons for a patient to see a doctor

1.1. His life is in dangerHis life is in danger– Dok, dada saya sakit kalau kerja berat

2.2. He suffers from pain or incoveniencesHe suffers from pain or incoveniences– Dok, kalau saya membungkuk, pinggang

saya sakiiiiit sekali

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What modern medicine has deceived us

• In health she performs as one coordinated body, all organs work together in harmony, as one person

• When she’s ill, the doctors break her apart, organ by organ, looking for anything wrong, while forgetting the coordination among the organs

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What modern medicine has deceived usNeurology

OphthalmologyENT

Dentistry

Head Neck SurgeonPulmonology

Cardiology

Gastro-enterologyNephrology

Obs-gyn

orthopedics

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And where is Anesthesiology?Neurology

OphthalmologyENT

Dentistry

Head Neck SurgeonPulmonology

Cardiology

Gastro-enterologyNephrology

Obs-gyn

orthopedics We will surely be left behind if we do not

fight our way in

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So now, let’s talk about some basics

1. Did we learn formally during our training?2. Did our teachers teach us seriously?3. Where did we, then, learn to manage pain?

4.4. Do we now practice pain management?Do we now practice pain management?5.5. Do we practice properly?Do we practice properly?

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Goodcommunication

approachPotentiationPotentiation

• Reduced doses ofeach analgesic

• Improved pain relief due to synergistic or additive effects

• May reduce severity of side effects of each drug

Single drug or Multimodal Pain Therapy?

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

MorphineMorphine

NSAIDs,acetaminophen,

nerve blocks

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PotentiationPotentiation

And what about this

• A 70 years old woman underwent mastectomy for left breast cancer.

• Pain medication for postop:– Pethidin 10 mg per

hour syringe pump– Ketopain 3 x 30 mg iv– Dynastat 3 x 40 mg iv

Goodcommunication

approach

Pethidin iv 10mg/hPethidin iv 10mg/h

Ketopain 3x30Dynastat 3x40

??

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Nominalstimulus

Modulation

ModulationPendekatan psikis

(termasuk komunikasi)dapat mengurangi nyeri

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• Is the combination correct as meant by “multi-modal” ?

• Is the combination correct pharmacologically?

• Are the dosing correct?

• A 45 kg, 70 years old woman underwent mastectomy for left breast cancer.

• Pain medication for postop:1.1. Pethidin 10 mg per Pethidin 10 mg per

hour syringe pump hour syringe pump (50cc filled syringe)(50cc filled syringe)

2. Ketopain 3 x 30 mg iv3. Dynastat 3 x 40 mg iv

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Look what we have done

• Ketorolac for healthy adults 10-30mg q 4-6H, daily max 90mg UK, 120mg US

• Total daily max 60mg – in > 65yo, in BW < 50kg– creatinine clearance 1.2-3L/hour

• CI : heart failure, hypertension, hypovolemia

• NOT co-administered with– other NSAIDs– anti-coagulation (incl. low dose

heparin)

• A 45 kg, 70 years old woman underwent mastectomy for left breast cancer.

• Pain medication for postop:1. Pethidin 10 mg per

hour syringe pump (50cc filled syringe)

2. Ketopain 3 x 30 mg iv3. Dynastat 3 x 40 mg iv

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paracetNSAID

COX-2 Inhib

OpioidAnestetika

Analgesic Ladder Post-Operative Pain

WFSA

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Magdi H. HannaPain Relief Research Unit, King’s College School of Medicine and

Dentistry, University of London, London, UK

• Each pain is individual and each response is different.

• Dental pain, pain from a hernia repair, a laparotomy, or major orthopaedic surgery cannot be managed in the same way.

• I want to emphasise that pain cannot be I want to emphasise that pain cannot be treated genericallytreated generically.

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Magdi H. HannaPain Relief Research Unit, King’s College School of Medicine and

Dentistry, University of London, London, UK

• The way a drug acts in one particular model is quite different from the way it acts in another.

• Information from one model cannot be translated to another.

• If one drug works beautifully in dental pain, it cannot be said that it will work beautifully in laparatomy.

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Itches“gatal”

Dull pain“kemeng”

Burning pain& Colicky

Delivery pain & Post-op pain

Surgical pain

Neuropathicpain

Who takes care of whom?

Anesthesiologists daily work

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LocalAnesthesia

NeuraxialAnesthesia

General Anesthesia

Our work as Anesthesiologists

PeripheralNerve blocks

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Itches“gatal”

Dull pain“kemeng”

Burning pain& Colicky

Delivery pain & Post-op pain

Surgical pain

Neuropathic Pain & intractables

Anesthesiologists daily work

Too busy sorry …..Too busy sorry …..

Fighting for existence

Too difficult, lacking courage

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konsep yang salah akan menghambat perkembangan

konsep salah: Anestesiologi = pembiusan

KONSEP BENAR: ANESTESIOLOGI = LIFE SUPPORT + Pain & stress management

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Pain management harus dikaji dalam konteks “primum non nocere”

• Pasien nyeri hebat pasca bedah, mengapa tidak diteruskan saja memberi anestesi selama 48 jam sampai tingkat nyeri akan menurun dengan sendirinya?

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Pain management sebaiknya:

• “ Non invasive” atau “minimally invasive”• Tidak menambah risiko yang sudah ada

dengan risiko anafilaksis, GI bleeding, gg. bone marrow, gg. faal ginjal, gagal nafas

• Tidak berisiko tambahan terlalu banyak ( < 1: 15,000)

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Apakah semua ini terlalu merepotkan “kerja-bius” kita?

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Anesthesiologists, CRNAs Spar Over Chronic Pain Reimbursement

Nancy A. Melville Oct 24, 2012

• A proposal by the Centers for Medicare and Medicaid Services (CMS) that certified registered nurse anesthetists (CRNAs) be reimbursed for chronic pain management services has reignited a turf war of sorts between CRNAs and anesthesiologists, with both sides arguing patient care as their top priority.

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If we don’t want to do it, somebody else will

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Itches“gatal”

Dull pain“kemeng”

Burning pain& Colicky

Delivery pain & Post-op pain

Surgical pain

Neuropathic Pain & intractables

Anesthesiologists daily work

Too busy OK …..Too busy OK …..

M U

S T

M U

S T

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Postoperative pain is a complex of unpleasant sensory, emotional,

and mental experiences associated with autonomic, psychological,

and behavioral responses precipitated by the surgical injury.

Henrik Kehlet, ACS Surgery 2003.

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Is pain a useless happening we need to abolish completely?

• Pain gives off warning, that something is Pain gives off warning, that something is going wrong inside your bodygoing wrong inside your body

• Pain gives off warning, to what limit one Pain gives off warning, to what limit one may do or proceed tomay do or proceed to

• Pain becomes a nuisance if it exceeds Pain becomes a nuisance if it exceeds tolerable limit (say, VAS of 3-4)tolerable limit (say, VAS of 3-4)

• Pain becomes agony if it becomes Pain becomes agony if it becomes excruciating (say, VAS of 7-10)excruciating (say, VAS of 7-10)

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Pain-less or Less Pain?

Pain-lessPain-less• Very comfortable from

pain view-point• High dose opioids• Multimodal with more

possible complications

Less painLess pain• Still partially

uncomfortable• Lower dose options

besides opioids• Less dose-related

complications

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Pain is always subjectivePain is always subjective

“If one regards his experience as pain, then it should be accepted as pain.”

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• pain is always subjective– listen to complaints

• Ask, Listen, Look– “Pak, apakah lukanya sakit? Coba gerakkan sedikit ..”– “zuster, lukanya sakit ……..”– grimace, body stiffness, eyebrows, cry ….

talkingtalkingre-assurancere-assurance

some some medicationmedication+ + consolationconsolation

strongstrongmedication medication

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Pain control is the hallmark of a civilization

• Proceed to relieve pain without asking the patient for a pain ONLY when– Patient is obviously in pain. – Patient is not focused to learn to communicate

his pain– Patient is unable to mention the pain

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Individuals differ considerably in how they respond to noxious stimuli; much of this variance is accounted much of this variance is accounted for by psychological factors.for by psychological factors. Cognitive, behavioral, or social interventions Cognitive, behavioral, or social interventions should be used in combination with pharmacologic should be used in combination with pharmacologic therapies to prevent or control acute pain, therapies to prevent or control acute pain, with the goal of such interventions being to guide the patient toward self-control of pain

Terapi nyeri akan lebih mudahjika dibantu pendekatan psikologis

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Trauma asExternal Stressor

Stress on physical body Stress on MIND

• NyeriNyeri• Takut infeksi• Takut amputasi• Takut biaya operasi

• Catecholamine release• Tensi naik, Nadi naik

X morfin iv

komunikasi

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• Dr Goucke, – a former dean of the Faculty of Pain Medicine.

• Dr Wayne Morriss

Januari 2013, di Surabaya

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Peran operasional

• Nyeri postoperatif, semua• Nyeri preoperatif pada trauma

– Perhatian utama pada trauma akan amputasi, • mulai nerve blok dini utk mengurangi risiko

timbulnya nyeri phantom limb

• Nyeri kanker– Oral morphine– Block diagnostik– Neurolysis

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Take home message(s)1. SpAn harus memberi waktu untuk pengelolaan

nyeri2. SpAn harus mampu mengelola nyeri dengan

memilih cara yang paling aman, paling efektif dan paling ekonomis

3. Berperan aktif pada acute pain4. Berperan, minimal partisipatif, dalam chronic

pain5. Berperan utama pada interventional pain

management

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Wassalamualaikum wr wb