Acute Pain Management

an introduction
Noroyono Wibowo
Fetomaternal Division
Department Obstetrics & Gynecology
FMUI - Dr CMGH
Jakarta
Pain: The Fifth Vital Sign
1.Pulse
2.Blood pressure
3.Temperature
4.Respiratory rate
Pain:
The Fifth
Vital Sign
1
*
1
American Pain Society Web site.
*Trademarks are the property of their respective owners.

Treatment of Pain: an Unmet Medical Need
Inadequately treated pain can have many negative effects
on patients
1
There is an urgent need for patient education about
pain management
Pain management is moving toward new treatments to
meet physician and patient needs
New guidelines from associations such as Europe Against
Pain (EAP) and the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) underscore the need
for better pain management
2,3

1
Cousins M et al. Textbook of Pain. 1999:447-491.
2
European Federation of IASP Chapters. Europe Against Pain Web site. Available at: http://www.efic.org/eap.htm. Accessed October 31, 2003.
3
Phillips DM. JAMA. 2000;284:428-429.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
P
a
t
i
e
n
t
s
.
Pain Continues to be Undertreated

Postoperative pain U.S., 1996 and 1999
1,2

Adapted from Apfelbaum J et al. Anesth Analg. 2003;97:534-540.
Any
Pain
Slight
Pain
Moderate
Pain
Severe
Pain
Extreme
Pain
1993 (n=135)
1999 (n=250)
77%
82%
19%
13%
49%
47%
23%
21%
8%
18%
Potential Consequences of Poor
Pain Management
Decreased motion
1
Prolonged rehabilitation
Muscle atrophy
Pneumonia
Prolonged hospitalization
1,2

Increased cost
1,2

Greater hospital resource utilization

Psychological impact
1

Poor patient satisfaction
1

1
Cousins et al. Textbook of Pain. 1999:447-491.
2
Zimberg SE. Manag Care Q. 2003;11:34-36.
65%
45%
26%
40%
24%
13%
0%
10%
20%
30%
40%
50%
60%
70%
24 hours 48 hours Day 7
Time After Discharge
P
a
t
i
e
n
t
s

(
%
)
1
Beauregard L et al. Can J Anaesth. 1998;45:304-311.

Worst Pain: Moderate to Severe
Average Pain: Moderate to Severe
Incidence of Postoperative Pain:
Outpatient Surgery
1
Clinical Significance
of the Basic Science of Pain
Not all pains are the same
Not all patients have the same pain sensitivities
Not all patients have the same pain relief from opioids
Not all patients have the same side effects of opioids
Not all opioids are the same
Not all opioid receptors are the same
Not all mu opioid receptors are the same


Pasternak, 2001
The Goals of Emergency Medicine
Pain Management
1
Meet the humanitarian need for pain
relief
Provide rapid diagnosis for immediate
intervention
Provide rapid relief without complicating
diagnosis or limiting further treatment
options
1
Cousins N, Power I. Acute and postoperative pain. In: Wall PD, Melzack R, eds. Textbook of Pain. 4
th
ed. Edinburgh,
UK: Churchill Livingstone; 1999:447-491.
Pain Sensitization

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1980.
P
a
i
n

I
n
t
e
n
s
i
t
y

10

8

6

4

2

0
Stimulus Intensity
Normal
Pain
Response
Allodynia
Hyperalgesia
Hyperalgesia
heightened sense of
pain in response to
noxious stimuli
Allodynia pain
resulting from normally
painless stimuli
Injury
1
Samad TA et al. Nature. 2001;410:471-475.
2
Smith CJ, Zhang Y, Koboldt CM, et al. Pharmacological analysis of cyclooxygenase-1 in inflammation. Proc Natl Acad Sci USA. 1998; 95:13313-13318.
Peripheral
Trauma / inflammation
Release of arachidonic acid
induction of COX-2
Prostaglandins
Sensitivity of
peripheral nociceptors
Central sensitization
Pain
Central
PLA
2
IL-1

Induction of COX-2
Pathophysiologic conditions
(eg, hypoxia, ischemia) or
inflammatory stimuli
Prostaglandins
Abnormal pain sensitivity
IL-6?
Pain Mechanisms: Peripherally and
Centrally Induced COX-2
1,2


Pain Transmission
Spinothalamic
tract
Peripheral
nerve
Dorsal Horn
Dorsal root
ganglion
Pain

COX-2



COX-2

Ascending
input
Descending
modulation
Peripheral
nociceptors
Trauma
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
Treatment Options for Acute
and Chronic Pain
NSAIDS
Nonspecific
COX-2 specific
Opioids
Local anesthesia
Adjunctive therapy
Other

Flufenamic Acid
Mefenamic Acid
Meclofenamate
Klasifikasi NSAIDs berdasarkan Struktur Kimia
Indomethacin
Sulindac
Tolmetin
Acemethacin
Zidomethacin
Etodolac
Carboxylic acid
Salicilic and
Ester Acids
Phenylacetic
Acid
Indolacetic
Acid
Propionic Acid Phenamic
Acid
Aspirin
Diflunisal
Diclofenac
Aceclofenac
Fenclofenac
Ionacolac
Metizinic
Ibuprofen
Naproxen
Flurbiprofen
Fenbrufen
Benoxaprofen
Fenoprofen
Indoprofen
Ketoprofen
Pirprofen
Tiaprofenic Acid
Acid 6 MNA
Alkanos
Naphtylalkanone
Nabumetone
Sulphonanilide
Methan
Sulphonanilide

Nimesulide
Oxyphenbutazone
Phenylbutazone
Feprazone
Oxicams
Enolic Acid
Pyrazolones
Piroxicam
Tenoxicam
1
Coxib
Celexocib
Refexocib
Valdecoxib
Parecoxib
Eterocoxib
Commonly Used Pain Medications:
Nonspecific NSAIDs
Inhibition of COX-1 and
COX-2 isoenzymes
inhibits prostaglandin
synthesis
1
Anti-inflammatory
analgesic
1
Non-narcotic safety
profile
1
Effective relief of pain
on movement
1

Multimodal efficacy
1

Risk of GI and
antiplatelet adverse
events
1
Ceiling effect
2
Use with caution in
patients with impaired
renal function and/or
considerable
dehydration
2

1
Power I et al. Surg Clin North Am. 1999;79(2):275-295.
2
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.

Mechanism of Action Benefits Prescribing
Considerations
Enhanced
analgesic effect
Further Considerations in Prescribing
Nonspecific NSAIDs

Gastrointestinal
1,2
Peptic ulceration; gastrointestinal hemorrhages
Esophagitis and strictures
Small and large bowel erosive disease

Inhibition of platelet aggregation
Increased risk of bleeding

Reversible acute renal failure
Fluid and electrolyte disturbance/edema
Chronic renal failure and interstitial fibrosis
Interstitial nephritis
Nephrotic syndrome
Exacerbation of
Hypertension
Congestive heart failure
Angina
1
Brooks P. Am J Med. 1998;104(suppl 3a):9S-13S.
2
Girgis L et al. Drugs Aging. 1994;4(2):101-112.
3
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.

Hematologic
3

Cardiorenal
1

Commonly Used Pain Medications: Opioids
Bind to opioid
receptors, producing
agonist action that
inhibits pain impulses
1
Effective in severe pain
1
Not associated with GI
bleeding
1
Generally, no
ceiling effect
2
Serious risks
associated with
opioid side effects
2,3
Risk of tolerance
and dependency
3

1
Moreland LW, St. Clair EW. The use of analgesics in the management of pain in rheumatic diseases. Rheum Dis Clin North Am. 1999;25:153-191.
2
Atcheson R, Rowbotham DJ. Pharmacology of acute and chronic pain. In: Rawal N, ed. Management of Acute and Chronic Pain. London, England: BMJ Books;
1998:23-50.
3
Power I, Barratt S. Analgesic agents for the postoperative period. Nonopioids. Surg Clin North Am. 1999;79:275-295.
Mechanism of Action Benefits Prescribing
Considerations
Further Considerations in Prescribing
Opioid Analgesics
1-3
Chronic use can lead to development of physical
dependence and tolerance
Less able to control pain on movement
Can produce withdrawal syndrome with abrupt
cessation
Many single and combination opioid agents are
short-acting, requiring multiple daily doses
Increased utilization of hospital resources
Special Issues
Respiratory depression
Nausea, vomiting, and constipation
Sedation and cognitive impairment
Urinary retention
Pruritus
Urticaria

Adverse
Effects
1
Moreland LW et al. Rheum Dis Clin North Am. 1999;25:153-191.
2
Power I et al. Surg Clin North Am. 1999;79:275-295.
3
Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.
Commonly Used Pain Medications:
COX-2 Specific Inhibitors
Selective for COX-2
isoenzyme inhibition
1
Anti-inflammatory analgesic
2
No effect on platelet
aggregation
3
Non-narcotic safety profile
2
Effective relief of pain
on movement
2
Multimodal efficacy
2

Enhanced analgesic effect

Lower risk of GI side effects
1
Ceiling effect
4
Use with caution in
patients with impaired
renal function or
considerable
dehydration
4

1
Needleman P et al. J Rheumatol. 1997;24(Suppl 49):6-8.
2
Power I et al. Surg Clin North Am. 1999;79(2):275-295.
3
Noveck RJ et al. Clin Drug Invest. 2001;21(7):465-476.
4
Atcheson R, Rowbotham DJ. Pharmacology of acute and chronic pain. In: Rawal N, ed. Management of Acute and Chronic Pain. London, England: BMJ
Books; 1998:23-50.
Mechanism of Action Benefits Prescribing
Considerations
COX-1 COX-2
COX-1 vs COX-2
1-3

Constitutive in many
tissues
Present in most tissues
Synthesizes PGs
that regulate physiologic
processes
Especially important in
Gastric mucosa
Kidneys
Platelets
Vascular endothelium
Inducible (in most
tissues)
Induced mainly at sites
of inflammation by
cytokines
Synthesizes PGs that
mediate inflammation,
pain, and fever
Constitutive expression
primarily in
CNS
Kidneys

1
Needleman P et al. J Rheumatol. 1997;24(suppl 49):6-8.

2
DuBois RN et al. FASEB J. 1998;12:1063-1073.

3
Samad TA, Moore KA, Saperstein A, et al. Interleukin-1-mediated induction of COX-2 in the CNS contributes to inflammatory pain hypersensitivity.
Nature. 2001;410:471-475.

Cyclooxygenase (COX) in Platelets
1
Platelet (Cox)-1
Inhibitors of
COX-1
Thromboxane A
2
Platelet
aggregation
Increased
bleeding
(-)
1
Noveck RJ et al. Clin Drug Invest. 2001;21(7):465-476.
MEKANISME TIMBULNYA
NYERI PERSALINAN
DAMPAK NYERI
PERSALINAN
THD AKTIFITAS RAHIM DAN
KEMAJUAN PERSALINAN
Kontraksi tidak teratur / menurun
mempengaruhi lama persalinan.
THD JANIN
Mengurangi transfer oksigen dari ibu ke
janin.
Pola detak jantung janin abnormal.

BERBAGAI POSISI SAAT
KALA I
BERBAGAI POSISI SAAT
KALA II
PENDAMPINGAN
PERSALINAN
1. Pendampingan persalinan oleh suami
dapat menurunkan tingkat kecemasan
secara bermakna ( p = 0,000 ).
2. Skor nyeri VAS pada kala I fase aktif
menurun bermakna ( p = 0,028 ),
sedangkan pada kala II menurun tidak
bermakna ( p = 0,054 ).
PENDAMPINGAN
PERSALINAN
3. Pendampingan persalinan oleh suami
dapat menurunkan secara bermakna
sekresi hormon kortisol ( p = 0,025 ).