Time to Resolution Acute Pain Chronic Pain
Total Page：16
File Type：pdf, Size：1020Kb
CURICULUM VITAE Dr. dr. I Putu Eka Widyadharma, M.Sc, Sp.S(K) Pendidikan : S1 : Universitas Udayana Denpasar Tahun 1997 Profesi : Universitas Udayana Denpasar Tahun 1999 S2 –Clinical Medicine : Universitas Gadjah Mada Yogyakarta Tahun 2009 Spesialis Saraf : Universitas Gadjah Mada Yogyakarta Tahun 2009 Konsultan Nyeri : Kolegium Neurologi Indonesia Tahun 2014 S3 : Universitas Udayana Tahun 2018 Pekerjaan : Staf Divisi Nyeri dan Nyeri kepala Departemen/KSM Neurologi FK UNUD/RSUP Sanglah Denpasar Pelatihan/Workshop : •Neuropathic pain Management,Manila, Philippine, 2011 • Pain Management,Mumbai, India, 2012 • DiabeticNeuropathy Workshop, , Manila, Philippine, 2012 • USG for Neurologist, Jakarta, 2012 • Neuropathic pain workshop, Milan, Italy2012 • USG Guidance for Interventional Pain management,Bandung 2012 • Pain Management Camp, Singapore 2013 • Interventional Pain Management,Medan 2013 • USG Guidance In Pain management,Yogyakarta 2014 • Asia Facific Pain Summit, Denpasar 2016 • Neuropathic Pain, Yokohama, Jepang 2016 • Dry Needling, Perth, Australia, 2017 THE MANAGEMENT OF “BEAUTIFUL PAIN” I PUTU EKA WIDYADHARMA DIVISI NYERI DAN NYERI KEPALA, DEPARTEMEN/KSM NEUROLOGI FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA/RSUP SANGLAH DENPASAR INDAAC, BALI, 14 MARET 2019 What is pain? An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Study of Pain (IASP) 2011 International Association for the Study of Pain. IASP Taxonomy. Available at: http://www.iasp- pain.org/AM/Template.cfm?Section=Pain_Definitions. Accessed: July 15, 2013. Pain Is the 5th Vital Sign Respiration Pulse Blood pressure Temperature Pain Phillips DM. JAMA 2000; 284(4):428-9. Overview of Pain ProteCtive role: vital early warninG system • Senses noxious stimuli • Triggers withdrawal reflex and heightens sensitivity after tissue damage to reduce risk of further damage Unpleasant experienCe: • Suffering – physical, emotional and cognitive dimensions • Continuous unrelieved pain can affect physical (e.g., cardiovascular, renal, gastrointestinal systems, etc.) and psychological states Maladaptive response: • Neuropathic and central sensitization/dysfunctional pain • Not protective • Lessens quality of life Costigan M et al. Annu Rev Neurosci 2009; 32:1-32; Wells N et al. In: Hughes RG (ed). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality; Rockville, MD: 2008; Woolf CJ et al. Ann Intern Med 2004; 140(6):441-51. The Pain Continuum Insult Time to resolution Acute pain ChroniC pain Normal, time-limited response Pain that has persisted beyond to ‘noxious’ experience normal tissue healing time (less than 3 months) (usually more than 3 months) • Usually obvious tissue damage • Usually has no protective function • Serves a protective function • Degrades health and function • Pain resolves upon healing Acute pain may become chronic Chapman CR, Stillman M. In: Kruger L (ed). Pain and Touch. Academic Press; New York, NY: 1996; Cole BE. Hosp Physician2002; 38(6):23-30; International Association for the Study of Pain. Unrelieved Pain Is a Major Global Healthcare Problem. Available at: http://www.iasp-pain.org/AM/Template.cfm?Section=Press_Release&Template=/CM/ContentDisplay.cfm&ContentID=2908. Accessed: July 24: 2013; National Pain Summit Initiative. National Pain Strategy: Pain Management for All Australians. Available at: http://www.iasp-pain.org/PainSummit/Australia_2010PainStrategy.pdf. Accessed: July 24, 2013; Turk DC, Okifuji A. In: Loeser D et al (eds .). Bonica’s Management of Pain. 3rd ed. Lippincott Williams & Wilkins; Hagerstown, MD: 2001. Nociceptive Pain SomatiC VisCeral Trauma Musculoskeletal injury Ischemic, e.g., myocardial Abdominal colic infarction Post-operative pain Burn pain Infection, e.g., pharyngitis Dysmenorrhea Fishman SM et al (eds). Bonica’s Management of Pain. 4th ed. Lippincott, Williams and Wilkins; Philadelphia, PA: 2010. Nociception: Neural Process of Encoding Noxious Stimuli Somatosensory cortex Thalamus PerCeption Noxious stimuli DesCendinG modulation AsCendinG TransduCtion Conduction Transmission input NoCiCeptive afferent fiber Spinal Cord Consequences of encoding may be autonomic (e.g., elevated blood pressure) or behavioral (motor withdrawal reflex or more complex nocifensive behavior). Pain perception is not necessarily implied. Scholz J, Woolf CJ. Nat Neurosci 2002; 5(Suppl):1062-7. “BEAUTIFUL PAIN” • The embodiment of pain in women who undergo aesthetic procedures • The pain induced not for medical reasons but for aesthetic ones Bendelow, 1993; Johansson, et. al., 1999 Post-operative Pain 80% of patients undergoing surgery experience post-operative pain 10–50% develop <50% report adequate pain relief chronic pain* 88% of these report the pain is For 2–10% of these, moderate, severe or extreme pain is severe Pain accounts for 38% of unanticipated admissions and readmissions following ambulatory surgery *DependinG on type of surGery Coley KC et al. J Clin Anesth 2002; 14(5):349-53; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press; Washington, DC: 2011. Consequences of Unrelieved Pain Acute pain Impaired physical Extended recovery Increased risk Dependence function time of developing chronic pain Reduced mobility On medication Hospital readmissions Disturbed sleep On family members/other Economic costs caregivers Immune impairment Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press; Washington, DC: 2011. Acute Pain Evaluation and Treatment Patient presenting with acute pain Perform diagnostic evaluation Perform assessments Yes Pain is severe/disabling: requires opioids Refer to specialist No Treat appropriately Re-evaluate and adjust treatment if indicated Ayad AE et al. J Int Med Res 2011; 39(4):1123-41. Ideal Characteristics for Acute Analgesic Therapy • Ideal drug characteristics for acute pain therapy: Rapid onset Limited LonG duration adverse EffeCtive analGesia effects Baumann TJ. In: DiPiro JT et al (eds). Pharmacotherapy: A Pathophysiologic Approach. 5th ed. McGraw-Hill; New York, NY: 2002. Why should we treat acute pain? If aCute pain IS NOT treated effeCtively: • It may cause severe suffering, loss of quality of life, loss of productivity, have economic considerations • Is associated with morbidity and even mortality • May develop into chronic pain Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 3rd ed. ANZCA & FPM; Melbourne, VIC: 2010. So how do we treat acute pain? Treat according to pain mechanisms involved Multimodal analgesia Voscopoulos C, Lema M. Br J Anaesth 2010; 105(Suppl 1):i69-85. Multimodal or Balanced Analgesia Opioid • Improved analgesia • ⇓ doses of each analgesic Potentiation • ⇓ severity of side effects of each drug Acetaminophen nsNSAIDs/Coxibs α2δ ligands Ketamine Clonidine Nerve bloCks Coxib = COX-2 inhibitor; nsNSAID = non-speCifiC non-steroidal anti-inflammatory druG Kehlet H, Dahl JB. Anesth Analg 1993; 77(5):1048-56. Analgesics Should Be Given at Regular Intervals During Acute Pain Episodes Sutters KA et al. Clin J Pain 2010; 26(2):95-103. Mechanism-Based Pharmacological Treatment of Nociceptive/Inflammatory Pain Brain α2δ ligands PerCeption Acetaminophen Opioids Antidepressants nsNSAIDs/coxibs Noxious Opioids stimuli nsNSAIDs/coxibs Local anesthetics Local anesthetics DesCendinG AsCendinG TransduCtion Transmission modulation input NoCiCeptive afferent fiber Inflammation Spinal Cord Peripheral sensitization Central sensitization nsNSAIDs/coxibs, opioids Coxib = COX-2 inhibitor; nsNSAID = non-speCifiC non-steroidal anti-inflammatory druG Scholz J, Woolf CJ. Nat Neurosci 2002; 5(Suppl):1062-7. What are NSAIDs (nsNSAIDs/coxibs)? NSAID = Non-Steroidal Anti-Inflammatory Drug • Analgesic effect via inhibition of prostaglandin production • Broad class incorporating many different medications: Examples of nsNSAIDs: Examples of Coxibs: – Diclofenac – Celecoxib – Ibuprofen – Etoricoxib – Naproxen – Parecoxib Coxib = COX-2-speCifiC inhibitor; nsNSAID = non-speCifiC nonINDAAC BALI 2019-steroidal anti-inflammatory druG Brune K. In: Kopf A et al (eds). Guide to Pain Management in Low-Resource Settings. International Association for the Study of Pain; Seattle, WA: 2010. How do nsNSAIDs/coxibs work? AraChidoniC aCid COX-2 (induced by COX-1 (constitutive) inflammatory stimuli) Coxibs BLOCK BLOCK nsNSAIDs BLOCK Prostaglandins Prostaglandins Gastrointestinal cytoprotection, Inflammation, pain, fever platelet activity Coxib = COX-2-speCifiC inhibitor; NSAID = non-steroidal anti-inflammatory druG Pain relief nsNSAID = non-speCifiC non-steroidal anti-inflammatory druG Gastrosource. Non-steroidal Anti-inflammatory Drug (NSAID)-Associated Upper Gastrointestinal Side-Effects. Available at: http://www.gastrosource.com/11674565?itemId=11674565. Accessed: December 4, 2010; Vane JR, Botting RM. Inflamm Res 1995;44(1):1-10. Adverse Effects of nsNSAIDs/Coxibs All NSAIDs: • Gastroenteropathy – Gastritis, bleeding, ulceration, perforation • Cardiovascular thrombotic events • Renovasculareffects – Decreased renal blood flow – Fluid retention/edema – Hypertension • Hypersensitivity Cox-1-mediated NSAIDs (nsNSAIDs): • Decreased platelet aggregation Coxib = COX-2-speCifiC inhibitor; NSAID = non-steroidal