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CURRICULUM VITAE
Name : dr.M. Ramli Ahmad, Sp.An-KAP,KMN
Address : Jl. A.P.Pettarani Blok GA 7/9
Job : Dosen FK UNHAS
Education : - FK UNHAS
- Anestesiologi FK UNAIR
Organization : - IDI
- Ketua PERDATIN SUL-SEL
FROM PREEMTIVE TO PREVENTIVE
ANALGESIA
Muhammad. Ramli Ahmad
Department of Anesthesiology Faculty of Medicine
Hasanuddin University
Makassar
0%
20%
40%
60%
Severe Pain Moderate Pain
31%
47%
To breath, cough and
move easier
INTRODUCTION
Surgery with
Pain Control
Better pathophysiology &
pharmacology at the end
1990-s
butMost patients still worried about post operative pain
Apfelbaum JL, Chen C, Mehta SS, Gan TJ.
Postoperative pain experience: results from a national
survey suggest postoperative pain continues to be
undermanaged. Anesth Analg. 2003
Introduction
Optimal Postoperative Pain Management
Progress in
medical fields
WHO (2005)  Pain : 5th vital sign
Postoperative Pain Management
Introduction
Preemptive Analgesia
Before incision Surgery Post operative
Begin in early of 1920’s by Crile & Lower
Incision
(Noxious signal)
Preemptive
Analgesia Note :
Pain modulation by CNS takes a place before perception
Central nervous system (CNS) protection until post operative period
Preemptive Analgesia
Pre - Incision Surgery Post operative
Incision
(Noxious Signal)
• Prevent acute pain
• Prevent chronic pain as
a result of untreated
acute pain
Preemptive
Analgesia
Combination of Local-
Regional blockade &
General Anesthesia
Pain stimuli :
Central Sensitization & “Wind-
Up”
• Prevent central
sensitization
•  hyperalgesia
PREEMPTIVE ANALGESIA
Preemptive therapy (administration of drugs at pre-incision) was
consider :
 Prevent central sensitization
  hyperalgesia incidence
  severity of postoperative pain
but
Since the end of 1980-s, hundreds study (with various quality) failed to proved
effectively of pain management at pra-incision compared to post-incision
Clinical study contradictory
New insight
Kissin I, Preemptive Analgesia at the Crossroad,Anesth Analg 2005,100:754-756
Preemptive Analgesia
Preemptive analgesia problem is no more about timing (pre
or post), but what is more important issues are:
1. Duration of PreemptiveAnalgesia , must include not only
tissue injury phase but also phase of inflammatory
process
2. Completeness of nociceptive blockade during both
phases above
Kissin I, Preemptive Analgesia at the Crossroad,Anesth Analg 2005,100:754-756
Preventive Analgesia
Pre - Incision Surgery Post operative
Incision
(Noxious signal )
Preventive
Analgesia
Duration of action from the agent is longer than preemptive target
Preventive
Analgesia
or
Duration of action from the agent covering
entire perioperative period
Broader definition of preemptive
Preventive
Analgesia
Preventive Analgesia
Pre- Incision Surgery Post operative
Incision
(Noxious Signal)
Analgesic effect must covers entire perioperative period,
whenever the drug was administered
MultimodalAnalgesia
Target of Preventive Analgesia
Perioperative period
Preoperative Intraoperative Postoperative
Peripheral & central sensitization
Definition
Preventive Analgesia
Preventive analgesia is prevention
Prevent before central sensitization occur
Analgesic given prior to the surgery
 A preventive approach that aims to block
transmission of the primary afferent injury barrage
before, during, and after surgery
Targets of a preventive Analgesia
Perioperative period
 Preoperative (days before surgery and just
minutes before skin incision)
 Intraoperative (after incision to those initiated just
prior to the end of surgery)
 Postoperative (after the end of surgery and may
extend for days thereafter
Preemptive to Preventive Analgesia
Earlier Definition:
Preemptive Analgesia has been defined as:
1. Antinociceptive treatment starting before surgery
2. Antinociceptive treatment that prevents central
sensitization
New Definition:
3. Preventing centra sensitization induced byTISSUE
INJURY and INFLAMANTORY INJURY (extending the
period beyond the initial postoperative period)
Preemptive means “ preventive” but this not simply just
“before incison”
CENTRAL
SENSI-
TIZATION
P A I N
Initial
Noxious
Stimulus
Changes in
Dorsal Horn
(e.g.
surgical
incision)
Preemptive Analgesia
PREVENTIVE ANALGESIA AS IMPROVEMENT OF
PREEMPTIVE ANALGESIA
Preventive AnalgesiaTo
CENTRAL
SENSI-
TIZATION
P A I N
Another Noxious
Stimulus
(intraoperative
manipulation)
Postoperative
Inflammation
Pain Management
Also applied intra-
& postoperative
Cousins MJ. Physiology and Psychology of acute pain. In Acute Pain Management: Scientific Evidence. Second Edition. Australian and Newzealand Collage of Anesthetists.
Australia 2005. 1-17
Moiniche SM, Kehlet H, Dahl JB. A Qualitative and Quantitative Systemic Review of Preemptive Analgesia for Postoperative Pain Relief. Anesthesiology 2002; 96:725-41
Kissin I. Preemptive Analgesia at the Crossroad. Anesth Analg 2005; 100:754-6
Pain Management
Before Initial
Stimulus
 TARGET
 POSTOPERATIVE HYPERALGESIA
 PERIODS : PRE (Pre emptive analgesia, pre emptive anti hyperalgesia)
INTRA
POSTOPERATIVE (general as well regional anesthesia)
 DRUG MECHANISMS :
 PRIMARY SENSITIZATION (PERIPHERY)
 AINS
 Local anesthetics
 SECONDARY SENSITIZATION (CENTRAL)
 NMDA receptors
 Kétamine, Dextromorphan …
 Voltage gated calcium channels (anti hyperalgesic drugs)
 Gabapentine, gabapentinoids, Nefopam…
 a2 adrenegic drugs descending inhibiting pathways)
 Clonidine
PHARMALOGICAL CONTROL OF POSTOPERATIVE
HYPERALGESIA
CONTROL OF HYPERALGESIA
Primary Secondary
BULBO-SPINAL
DESCENDING
INHIBITORY
CONTROLS
MORPHINE
a2 ADRENERGICS
(Clonidine)
N.S.A.I.D
s
“Inflammatory soup”
Histamin
Serotonin
Bradykinin
Prostaglandins
.......................
Susbtance (SP)
Neuropeptides
CGRP
Excitatory A.A.
....................……
• NMDA Receptors
• Voltage gated
calcium channels
Péripheral
NMDA RECEPTOR
Kétamine
Dextromorphan
Central
LOCAL
ANAESTHETICS
Protein
kinases
Protooncogen
- C Fos
- C Jun
Second messengerr
+
+
+
WIND.UP
Axon Reflex
5HT
N.E.
Synapse
PRE
POST
+
VOLTAGEGATED
CALCIUM
CHANNELS
. Nefopam
. Gabapentine
Clinical Applications of Preemptive
Analgesia
Pro-Contra
Pre - Incision Post - Incision
Preemptive
Analgesia
Post incisional
Analgesia
• NSAIDs
• EpiduralAnalgesics
• LocalAnesthetic Infiltration
• Opioid
• NMDA antagonist
RCTSs Review, Moiniche dkk.,
• Pain intensity
• Onset rescue analgesic 
• Total analgesic requirement
PREEMPTIVE ANALGESIA
Moiniche et al
Ong et al
Controversial
80 RCT
Evaluated preemptive
analgesia of NSAID, epidural,
wound infiltration, opiate,
NMDA antagonist
No difference in effectifity
between preemptive analgesia
and post-incision analgesia
66 RCT
Evaluated preemptive analgesia of
NSAID, epidural, wound
infiltration, opiate, NMDA
antagonist
Epidural analgesia preemptive:
 Pain intensity in 24-48 hours
post-operative, onset of first
rescue analgesia, &  total
supplement analgesic
Local infiltration, NSAID, opiate, &
NMDA antagonist preemptive: 
total supplement analgesic ,onset
of first rescue analgesia & failed to
improved pain intensity
CLINICAL APPLICATIONS OF PREEMPTIVE
ANALGESIA
NON STEROIDANTI INFLAMMATIONS DRUGS (NSAID)
Pra-Incision Post-incision
 duration of analgesia
 Opiate consumption in 24 hours
 Incidental pain score
Ruben et al
No benefict effect
Moniche et al
 Analgesic consumption
 Onset of First analgesic administration
Not improved pain score
Ong et al
CLINICAL APPLICATIONS OF PREEMPTIVE
ANALGESIA
NMDA RECEPTORANTAGONISTS
Pra-Incision Post-incision
Positive effect of preemptive
analgesic, uncertain dose response
McCartney et al
Analgesic effect not consistent
 Analgesic consumption (67%)
 pain score (58%)
Ong et al
Activation of NMDA receptor has important role in central sensitization
On focus in preventive & preemptive analgesia
CLINICAL APPLICATIONS OF PREEMPTIVE
ANALGESIA
LOCAL ANESTHETICS
Pra-Incision Post-incision
No epidural regiment that improve
postoperative pain control,
Wound Infiltration, peripheral nerve block,
and intraperitoneal infiltration regiment
had no benefit effect
Moniche et al
Wound Infiltration regiments decreased analgesic drugs
consumption & extend duration of analgesia, but no effect
on pain score
Ong et al
Epidural regiment :
Improve pain intensity
Long duration of action
Ong et al
Had more advantages than
Katz & McCartney
Its imporatant to give multimodal analgesic therapy
at all perioperative periode
CLINICAL APPLICATIONS OF PREVENTIVE ANALGESIA
Central Sensitization & Neuroplasticity of Nocisepsy Input
Pra-Incision Intraoperative Intraoperative
More extent than preemptive analgesia, involved all perioperative pain
control regiment
From Preemptive to Preventive analgesia
Clinical Implication
A QUALITATIVE SYSTEMATIC REVIEW OF THE ROLE OF N-METHYL-D-
ASPARTATE ANTAGONISTS IN PREVENTIVE ANALGESIA
Mc CARTNEY C.J.L., SINHA A., KATZ J. Anesth Anal 2004;98:1385-400
META ANALYSIS
 USINGA MEDLINE (1966 - 2003) AND EMBASE
(1985-2003) SEARCH
 FORTY ARTICLES MEETINGTHE INCLUSION CRITERIA
 OUTCOMES :
 Primary reduction of pain, analgesic cunsumption
 Secondary : time for first analgesic request,
adverse effects
 PREVENTIVE EFFECTS OF :
 Dextromorphan (12 articles) = 67 %
 Ketamine (24 articles) = 58 %
 Magnesium ( 4 articles) = none
Clinical Implication
Clinical Implication (cont.)
Clinical Implication (cont.)
Korean J Anesthesia 2005:48:S 21-5
British Journal of Anaesthesia 100 (2): 256–62
(2008)
Reg Anesth Pain Med
2008;33:44-51.
Coll. Antropol. 31 (2007) 4: 1071–1075
Original scientific paper
Summary of studies of preemptive and
preventive analgesia according to
target agent administered
Agents
No. of
studies
Preemptive effects(%) Preventive effects(%) Opposite
effects(%)
Total No.
effects(%)Positive Negative Positive Negative
Local
anesthetics
65 8(10.7) 16(21.3) 27(36.0) 18(24.0) 6(8.0) 75(100)
Opioids 25 7(25.0) 5(17.9) 10(35.7) 3(10.7) 3(10.7) 28(100)
NSAIDs 25 3(11.5) 12(46.2) 1(3.8) 8(30.8) 2(7.7) 26(100)
NMDA
anatgonists
31 5(13.2) 6(15.8) 19(50.0) 7(18.4) 1(2.6) 38(100)
Clonidine 2 0(0.0) 0(0.0) 2(100.0) 0(0.0) 0(0.0) 2(100.0)
Local
anesthetics
and opioids
21 4(17.4) 5(21.7) 7(30.4) 6(26.1) 1(4.3) 23(100)
Multimodal 6 2(25.0) 0(0.0) 2(25.0) 3(37.5) 1(12.5) 8(100)
Total 175 29(14.5) 44(22.0) 68(34.0) 45(22.5) 14(7.0) 200(100)
• Katz J, Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE,
Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154-
99.
• Katz J, Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE,
Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154-
99.
Katz J, Kavanagh BP, Sandler AN et al. Preemptive analgesia. Clinical evidence of neuroplasticity contributing
to postoperative pain.Anesthesiology. 1992; 77: 439–46.
• Katz J, Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE,
Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154-
99.
• Katz J, Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE,
Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154-
99.
PREVENTIVE ANALGESIA
PREVENTIVE ANALGESIA
Summary
Thank you!

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FROM PREEMTIVE TO PREVENTIVE ANALGESIA - Muhammad. Ramli Ahmad

  • 1. CURRICULUM VITAE Name : dr.M. Ramli Ahmad, Sp.An-KAP,KMN Address : Jl. A.P.Pettarani Blok GA 7/9 Job : Dosen FK UNHAS Education : - FK UNHAS - Anestesiologi FK UNAIR Organization : - IDI - Ketua PERDATIN SUL-SEL
  • 2. FROM PREEMTIVE TO PREVENTIVE ANALGESIA Muhammad. Ramli Ahmad Department of Anesthesiology Faculty of Medicine Hasanuddin University Makassar
  • 3. 0% 20% 40% 60% Severe Pain Moderate Pain 31% 47% To breath, cough and move easier INTRODUCTION Surgery with Pain Control Better pathophysiology & pharmacology at the end 1990-s butMost patients still worried about post operative pain Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003
  • 4. Introduction Optimal Postoperative Pain Management Progress in medical fields WHO (2005)  Pain : 5th vital sign Postoperative Pain Management
  • 6. Preemptive Analgesia Before incision Surgery Post operative Begin in early of 1920’s by Crile & Lower Incision (Noxious signal) Preemptive Analgesia Note : Pain modulation by CNS takes a place before perception Central nervous system (CNS) protection until post operative period
  • 7. Preemptive Analgesia Pre - Incision Surgery Post operative Incision (Noxious Signal) • Prevent acute pain • Prevent chronic pain as a result of untreated acute pain Preemptive Analgesia Combination of Local- Regional blockade & General Anesthesia Pain stimuli : Central Sensitization & “Wind- Up” • Prevent central sensitization •  hyperalgesia
  • 8. PREEMPTIVE ANALGESIA Preemptive therapy (administration of drugs at pre-incision) was consider :  Prevent central sensitization   hyperalgesia incidence   severity of postoperative pain but Since the end of 1980-s, hundreds study (with various quality) failed to proved effectively of pain management at pra-incision compared to post-incision
  • 10. New insight Kissin I, Preemptive Analgesia at the Crossroad,Anesth Analg 2005,100:754-756
  • 11. Preemptive Analgesia Preemptive analgesia problem is no more about timing (pre or post), but what is more important issues are: 1. Duration of PreemptiveAnalgesia , must include not only tissue injury phase but also phase of inflammatory process 2. Completeness of nociceptive blockade during both phases above Kissin I, Preemptive Analgesia at the Crossroad,Anesth Analg 2005,100:754-756
  • 12. Preventive Analgesia Pre - Incision Surgery Post operative Incision (Noxious signal ) Preventive Analgesia Duration of action from the agent is longer than preemptive target Preventive Analgesia or Duration of action from the agent covering entire perioperative period Broader definition of preemptive Preventive Analgesia
  • 13. Preventive Analgesia Pre- Incision Surgery Post operative Incision (Noxious Signal) Analgesic effect must covers entire perioperative period, whenever the drug was administered MultimodalAnalgesia
  • 14. Target of Preventive Analgesia Perioperative period Preoperative Intraoperative Postoperative Peripheral & central sensitization
  • 16. Preventive Analgesia Preventive analgesia is prevention Prevent before central sensitization occur Analgesic given prior to the surgery  A preventive approach that aims to block transmission of the primary afferent injury barrage before, during, and after surgery
  • 17. Targets of a preventive Analgesia Perioperative period  Preoperative (days before surgery and just minutes before skin incision)  Intraoperative (after incision to those initiated just prior to the end of surgery)  Postoperative (after the end of surgery and may extend for days thereafter
  • 18. Preemptive to Preventive Analgesia Earlier Definition: Preemptive Analgesia has been defined as: 1. Antinociceptive treatment starting before surgery 2. Antinociceptive treatment that prevents central sensitization New Definition: 3. Preventing centra sensitization induced byTISSUE INJURY and INFLAMANTORY INJURY (extending the period beyond the initial postoperative period) Preemptive means “ preventive” but this not simply just “before incison”
  • 19. CENTRAL SENSI- TIZATION P A I N Initial Noxious Stimulus Changes in Dorsal Horn (e.g. surgical incision) Preemptive Analgesia PREVENTIVE ANALGESIA AS IMPROVEMENT OF PREEMPTIVE ANALGESIA Preventive AnalgesiaTo CENTRAL SENSI- TIZATION P A I N Another Noxious Stimulus (intraoperative manipulation) Postoperative Inflammation Pain Management Also applied intra- & postoperative Cousins MJ. Physiology and Psychology of acute pain. In Acute Pain Management: Scientific Evidence. Second Edition. Australian and Newzealand Collage of Anesthetists. Australia 2005. 1-17 Moiniche SM, Kehlet H, Dahl JB. A Qualitative and Quantitative Systemic Review of Preemptive Analgesia for Postoperative Pain Relief. Anesthesiology 2002; 96:725-41 Kissin I. Preemptive Analgesia at the Crossroad. Anesth Analg 2005; 100:754-6 Pain Management Before Initial Stimulus
  • 20.  TARGET  POSTOPERATIVE HYPERALGESIA  PERIODS : PRE (Pre emptive analgesia, pre emptive anti hyperalgesia) INTRA POSTOPERATIVE (general as well regional anesthesia)  DRUG MECHANISMS :  PRIMARY SENSITIZATION (PERIPHERY)  AINS  Local anesthetics  SECONDARY SENSITIZATION (CENTRAL)  NMDA receptors  Kétamine, Dextromorphan …  Voltage gated calcium channels (anti hyperalgesic drugs)  Gabapentine, gabapentinoids, Nefopam…  a2 adrenegic drugs descending inhibiting pathways)  Clonidine PHARMALOGICAL CONTROL OF POSTOPERATIVE HYPERALGESIA
  • 21. CONTROL OF HYPERALGESIA Primary Secondary BULBO-SPINAL DESCENDING INHIBITORY CONTROLS MORPHINE a2 ADRENERGICS (Clonidine) N.S.A.I.D s “Inflammatory soup” Histamin Serotonin Bradykinin Prostaglandins ....................... Susbtance (SP) Neuropeptides CGRP Excitatory A.A. ....................…… • NMDA Receptors • Voltage gated calcium channels Péripheral NMDA RECEPTOR Kétamine Dextromorphan Central LOCAL ANAESTHETICS Protein kinases Protooncogen - C Fos - C Jun Second messengerr + + + WIND.UP Axon Reflex 5HT N.E. Synapse PRE POST + VOLTAGEGATED CALCIUM CHANNELS . Nefopam . Gabapentine
  • 22.
  • 23. Clinical Applications of Preemptive Analgesia Pro-Contra Pre - Incision Post - Incision Preemptive Analgesia Post incisional Analgesia • NSAIDs • EpiduralAnalgesics • LocalAnesthetic Infiltration • Opioid • NMDA antagonist RCTSs Review, Moiniche dkk., • Pain intensity • Onset rescue analgesic  • Total analgesic requirement
  • 24. PREEMPTIVE ANALGESIA Moiniche et al Ong et al Controversial 80 RCT Evaluated preemptive analgesia of NSAID, epidural, wound infiltration, opiate, NMDA antagonist No difference in effectifity between preemptive analgesia and post-incision analgesia 66 RCT Evaluated preemptive analgesia of NSAID, epidural, wound infiltration, opiate, NMDA antagonist Epidural analgesia preemptive:  Pain intensity in 24-48 hours post-operative, onset of first rescue analgesia, &  total supplement analgesic Local infiltration, NSAID, opiate, & NMDA antagonist preemptive:  total supplement analgesic ,onset of first rescue analgesia & failed to improved pain intensity
  • 25. CLINICAL APPLICATIONS OF PREEMPTIVE ANALGESIA NON STEROIDANTI INFLAMMATIONS DRUGS (NSAID) Pra-Incision Post-incision  duration of analgesia  Opiate consumption in 24 hours  Incidental pain score Ruben et al No benefict effect Moniche et al  Analgesic consumption  Onset of First analgesic administration Not improved pain score Ong et al
  • 26. CLINICAL APPLICATIONS OF PREEMPTIVE ANALGESIA NMDA RECEPTORANTAGONISTS Pra-Incision Post-incision Positive effect of preemptive analgesic, uncertain dose response McCartney et al Analgesic effect not consistent  Analgesic consumption (67%)  pain score (58%) Ong et al Activation of NMDA receptor has important role in central sensitization On focus in preventive & preemptive analgesia
  • 27. CLINICAL APPLICATIONS OF PREEMPTIVE ANALGESIA LOCAL ANESTHETICS Pra-Incision Post-incision No epidural regiment that improve postoperative pain control, Wound Infiltration, peripheral nerve block, and intraperitoneal infiltration regiment had no benefit effect Moniche et al Wound Infiltration regiments decreased analgesic drugs consumption & extend duration of analgesia, but no effect on pain score Ong et al Epidural regiment : Improve pain intensity Long duration of action Ong et al
  • 28. Had more advantages than Katz & McCartney Its imporatant to give multimodal analgesic therapy at all perioperative periode CLINICAL APPLICATIONS OF PREVENTIVE ANALGESIA Central Sensitization & Neuroplasticity of Nocisepsy Input Pra-Incision Intraoperative Intraoperative More extent than preemptive analgesia, involved all perioperative pain control regiment
  • 29. From Preemptive to Preventive analgesia
  • 31. A QUALITATIVE SYSTEMATIC REVIEW OF THE ROLE OF N-METHYL-D- ASPARTATE ANTAGONISTS IN PREVENTIVE ANALGESIA Mc CARTNEY C.J.L., SINHA A., KATZ J. Anesth Anal 2004;98:1385-400 META ANALYSIS  USINGA MEDLINE (1966 - 2003) AND EMBASE (1985-2003) SEARCH  FORTY ARTICLES MEETINGTHE INCLUSION CRITERIA  OUTCOMES :  Primary reduction of pain, analgesic cunsumption  Secondary : time for first analgesic request, adverse effects  PREVENTIVE EFFECTS OF :  Dextromorphan (12 articles) = 67 %  Ketamine (24 articles) = 58 %  Magnesium ( 4 articles) = none
  • 35. Korean J Anesthesia 2005:48:S 21-5
  • 36. British Journal of Anaesthesia 100 (2): 256–62 (2008)
  • 37. Reg Anesth Pain Med 2008;33:44-51.
  • 38. Coll. Antropol. 31 (2007) 4: 1071–1075 Original scientific paper
  • 39. Summary of studies of preemptive and preventive analgesia according to target agent administered Agents No. of studies Preemptive effects(%) Preventive effects(%) Opposite effects(%) Total No. effects(%)Positive Negative Positive Negative Local anesthetics 65 8(10.7) 16(21.3) 27(36.0) 18(24.0) 6(8.0) 75(100) Opioids 25 7(25.0) 5(17.9) 10(35.7) 3(10.7) 3(10.7) 28(100) NSAIDs 25 3(11.5) 12(46.2) 1(3.8) 8(30.8) 2(7.7) 26(100) NMDA anatgonists 31 5(13.2) 6(15.8) 19(50.0) 7(18.4) 1(2.6) 38(100) Clonidine 2 0(0.0) 0(0.0) 2(100.0) 0(0.0) 0(0.0) 2(100.0) Local anesthetics and opioids 21 4(17.4) 5(21.7) 7(30.4) 6(26.1) 1(4.3) 23(100) Multimodal 6 2(25.0) 0(0.0) 2(25.0) 3(37.5) 1(12.5) 8(100) Total 175 29(14.5) 44(22.0) 68(34.0) 45(22.5) 14(7.0) 200(100)
  • 40. • Katz J, Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE, Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154- 99.
  • 41.
  • 42. • Katz J, Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE, Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154- 99. Katz J, Kavanagh BP, Sandler AN et al. Preemptive analgesia. Clinical evidence of neuroplasticity contributing to postoperative pain.Anesthesiology. 1992; 77: 439–46.
  • 43. • Katz J, Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE, Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154- 99.
  • 44. • Katz J, Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE, Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154- 99.
  • 47.

Editor's Notes

  1. Cousins MJ. Physiology and Psychology of acute pain. In Acute Pain Management: Scientific Evidence. Second Edition. Australian and Newzealand Collage of Anesthetists. Australia 2005. 1-17 Moiniche SM, Kehlet H, Dahl JB. A Qualitative and Quantitative Systemic Review of Preemptive Analgesia for Postoperative Pain Relief. Anesthesiology 2002; 96:725-41 Kissin I. Preemptive Analgesia at the Crossroad. Anesth Analg 2005; 100:754-6
  2. Preventive lebih efektif
  3. efektif
  4. Antagonis alpha 2 antagonis
  5. GA + Infiltrasi .
  6. Analgesia preventif: Definisi yg lebih luas dari analgesia preemptif Formula analgetik perioperatif yg mampu mengendalikan sensitisasi yang dipicu oleh nyeri Bukan waktu pemberian yg utama, namun durasi dan efektifitas yang lebih penting untuk menurunkan nyeri pasca bedah. Analgesia preventif yg adekuat harus mencakup teknik pendekatan multimodal dan dengan masa tatalaksana yg cukup