NYERI Dr. fajar as sp.AS Sp.An .MSc
NYERIDr. fajar as sp.AS Sp.An .MSc
DEFINISI dan KLAsIFIKASI NYERI• SENSASI
PROTOPATIK (NOXIOUS) EPIKRITIK (NON NOXIOUS)
•SENSASI EPIKRITIK SENTUHAN, TEKANAN, PROPRIOSEPSI, TEMPERATUR RESEPTOR AMBANG RENDAH ( LOW THRESHLOD ) DIHANTARKAN SERABUT SYARAF BESAR BERMYELIN
•SENSASI PROTOPATIK RESEPTOR AMBANG TINGGI (HIGH THRESHOLD) DIHANTARKAN SERABUT SYARAF KECIL, MYELIN
( A DELTA ) & SERABUT SYARAF TIDAK BERMYELIN ( C )
• IASP ( The International Association For Study Of Pain )
→ PENGALAMAN & EMOSI SENSORI YANG TIDAK MENYENANGKAN DIHUBUNGKAN
DENGAN KERUSAKAN JARINGAN ATAU POTENSIAL RUSAK
KLASIFIKASI NYERI - PATOFISIOLOGI
NYERI NOSISEPSI NYERI NEUROPATIK
- ETIOLOGI NYERI POST OPERATIF NYERI KANKER
- LOKASI NYERI KEPALA NYERI PUNGGUNG BAWAH ( NPB )
- KLINIS NYERI AKUT NYERI KRONIS
NYERI NOSISEPSI AKTIFASI ATAU SENSITISASI NOSISEPTOR PERIFER RESEPTOR KHUSUS YANG MENGHANTARKAN STIMULUS NOXIOUS
NYERI NEROPATIK AKIBAT INJURI ATAU ABNORMAL STRUKTUR SYARAF PERIFER ATAU SENTRAL
NYERI AKUT AKIBAT STIMULASI NOKSIUS KARENA INJURI, PRO SES PENYAKIT ATAU FUNGSI OTOT dan VISERA ABNORMAL HAMPIR SELALU NOSISEPSI PROSES FISIOLOGI
1. TRANSDUKSI 2. TRANSMISI 3. MODULASI 4. PERSEPSI
DIHUBUNGKAN DENGAN STRESS NEURO ENDOKRIN
NYERI POSTOPERATIF, NYERI OBSTETRI, PENYAKIT MEDIKAL AKUT (AMI,PANCR.AKUT, Batu ginjal)“SELF LIMITED” ATAU SEMBUH DALAM BEBERAPA HARI ATAU BEBERAPA MINGGU DAPAT MENJADI NYERI KRONIS ADA 2 TYPE :
SOMATIK VISERAL
• NYERI SOMATIK - SUPERFISIAL : KULIT, SUBKUTIS, MEMBRAN MUKUS - DEEP : OTOT, TENDON, JOINT, TULANG
• NYERI VISERAL - PROSES PENYAKIT ATAU FUNGSI ABNORMAL ORGAN INTERNAL (LEURA, PERICARD, PERITONIUM) - TYPE :
1. NYERI VISERAL TERLOKALISIR 2. NYERI PARIETAL TERLOKALISIR 3. NYERI PARIETAL REFERAL 4. NYERI VISERAL REFERAL
• NYERI KRONIS - NYERI PERSISTEN SETELAH AKUT ATAU PENYEMBUH AN NYERI AKUT TIDAK TERJADI, DALAM WAKTU 1 - 6 BULAN - NOSISEPSI NEROPATIK ATAU KOMBINASI - FAKTOR PSIKOLOGIS DAN LINGKUNGAN SANGAT BERPERAN - NEUROENDOKRIN ( - )
Activation of the Central Nervous System
at the Spinal Cord Level
Tissue Damage Activation 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.
Nociceptive afferent fiber
Normal Nerve Impulses Leading to Pain
Noxiousstimuli
Descendingmodulation
Ascendinginput
Spinal cord
Perceived pain
Activation
External
Stimuli
Heat
Mechanical
Chemical
VR1Ca2+
mDEG
P2X3
Generator potentialsaction potentials
Voltage gated sodium channels
Pain and auto-sensitization
Woolf & Mitchel, 2001
Transduction
ATP
Na+
Modifikasi Meliala, 2003
ACTION POTENTIALACTION POTENTIAL
KERUSAKAN JARINGAN
INFLAMASI
SSA MI NOSSENSITISASI
AKTIFASIECT. DISC.
Si-Na+
KORNU DORSALIS
PgB5HTAdenosin
PengalamanKognitifBehaviourPsikologik
Inhibisi desenden
OTAK
PAIN – NO PAIN
R-NE
Nociception
Spinothalamictract Peripheral
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
Dorsal HornDorsal root
ganglion
Peripheral sensoryNerve fibers
A
A
C
Largefibers
Smallfibers
There are Two Sensory Afferent Neurons1. Large myelinated A fibers
• Very fast conduction velocity • Respond to innocuous stimuli
2. Small myelinated A & C unmyelinated fibers• Slow conduction velocity • Respond to noxious stimuli
PAIN PATHWAYSADA 3 NEURON
1. FIRST ORDER NEURON2. SECOND ORDER NEURON3. THIRD ORDER NEURON
FISIOLOGI NOSISEPSI
1. NOSISEPTOR FREE NERVE ENDING ( SUHU, MEKANIK DAN KIMIA JARINGAN RUSAK ) TYPE :
1. MEKANO NOSISEPTOR 2. SILENT NOSISEPTOR 3. POLIMODAL MEKANO HEAT NOSISEPTOR
1. MEKANO NOSISEPTOR : → SENTUHAN , TUSUKAN 2. SILENT NOSISEPTOR : → INFLAMASI 3. POLIMODAL MEKANOHEAT NOSISEPTOR : - TEKANAN KUAT
- SUHU ↑ ( > 42º C dan < 18º C ) - ALLOGENS ( PAIN PRODUCING SUBSTANCE ) SEPERTI : BRADIKININ, HISTAMIN, SEROTONIN, H+, K+, PROSTAGLANDIN dan ATP
2. MEDIATOR KIMIA / NYERI → SUBSTANS P ( SP ) dan CALCITONIN GENE RELATED PEPTIDE ( CERP ) → GLUTAMAT
3. MODULASI NYERI → MODULASI PERIFER :
1. HIPERALGESIA PRIMER 2. HIPERALGESIA SEKUNDER
→ MODULASI SENTRAL A. FASILITAS B. INHIBISI
4. ANALGESI PREEMPTIF → ANALGESI EFEKTIF SEBELUM TRAUMA PEMBEDAHAN → INFILTRASI DENGAN ANESTESI LOKAL → BLOKADE NEURAL SENTRAL → PENGGUNAAN OPIOID DOSIS EFEKTIF → PENGGUNAAN KETAMIN → EFEKTIF MELEMAHKAN SENSITISASI PERIFER dan SENTRAL
PATOFISIOLOGI NYERI KRONIS• MEKANISME PERIFER, SENTRAL dan PSIKOLOGIS• SENSITISASI NOSISEPTOR MEMEGANG PERANAN BESAR • MEKANISme PERIFER SENTRAL dan SENTRAL KOMPLEK → LESI NERVUS PERIFER, GANGLION, RADIX DORSA LIS, RADIX NERVUS dan STRUKTUR SENTRAL
NYERI KRONIK- NEUROENDOKRIN STRESS RESPON (-)-- NYERI DIHUBUNGKAN DG PARAPLEGIA- GANGGUAN TIDUR- DEPRESI-GANGGUAN NAFSU MAKAN
EVALUASI PASIEN DENGAN NYERI- BEDAKAN NYERI AKUT dan KRONIS- NYERI AKUT →TERAPEUTIK- NYERI KRONIK → INVESTIGATIVE MEASURE
RESPON SISTEMIK TERHADAP NYERINYERI AKUT :• EFEK KARDIOVASKULER :
- TAKHIKARDI - HIPERTENSI - PENINGKATAN IRITABILITAS JANTUNG - PENINGKATAN RESISTENSI VASKULER SISTEMIK - CARDIAC OUTPUT MENINGKAT
• EFEK RESPIRASI - KONSUMSI OKSIGEN TUBUH TOTAL MENINGKAT - PRODUKSI KARBONDIOKSIDA MENINGKAT - MINUTE VENTILATION MENINGKAT
• EFEK GASTROINTERSTINAL dan URINARY : - TONUS SPINKTER ↑ - ↓ MOTILITAS INTERSTINAL dan URINARY
- ↑ ILLEUS - RETENSI URIN - STRESS ULCER - ASPIRASI - MUAL MUNTAH
• EFEK ENDOKRIN - ↑ HORMON KATABOLIK (KATEKOLAMIN, KORTISOL,GLUKAGON) - ↓ HORMON ANABOLIK ( INSULIN dan TESTOSTERON)
• EFEK IMUN - LEKOSITOS - LYMPHOPENIA - MUDAH INFEKSI
• LAIN – LAIN - ANSIETAS - GANGGUAN TIDUR
Terapi
Prostaglandin 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
TreatmentMethods
Drug therapyRemove the causeof pain
Regionalanalgesia
Physicalmethods
Psychologicalapproaches
• Surgery• Splinting
Non-opioid• Aspirin & other NSAIDs• Paracetamol• Combinations
Opioid• Morphine• Others
High-tech• Epidural infusion• Local anaesthetic + opioid
Low-tech• Nerve bloks• Local anesthetic + opioid
• Physiotherapy• Manipulation• TENS• Acupunture• Ice
• Psychoprophylaxis• Relaxation• Hypnosis
Acute pain interventions
McQuary, 2000 An evidence-based resource for pain relief,
Multimodal Pain ManagementCoordinated use of medication & non medication to control the painConsider the psycho-socio-cultural-spiritual aspects