Mengenal nyeri untuk peserta ipm ke dua 7 nov 2017 di makassar
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Nyeri adalah penggabungan perasaan sensorik dan emosional yang dipengaruhi oleh berbagai faktor. Nyeri memiliki dua dimensi yg jelas, dimensi inderawi dan emosional Peran dimensi emosional lebih dominan dibanding inderawi utamanya pada nyeri kronik.
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Mengenal nyeri untuk peserta ipm ke dua 7 nov 2017 di makassar
- 1. Mengenal Nyeri Andi Husni Tanra Ketua Program Studi Sp2 Ilmu anestesi Fakultas Kedokteran Universitas Hasanuddin Makassar Kuliah perdana bagi peserta IPM ke-dua 7 Nov 2017 di Makassar
- 2. Pembahasan meliputi: 1. Sejarah singkat Anestesi dan IPM 2. Klasifikasi Nyeri 3. Apa itu Nyeri ? Pain perception? 4. Penutup
- 3. 1. Short History of Anesthesia & IPM
- 4. Anesthesia was the first applied science in the world Before Eva was created from Adam’s rib, Adam was put into sleep by Jibril Drawn by Prof. Hyodo Leader of pain clinic in Japan
- 5. First Ether Anesthesia in 1846 at Massachusetts Hospital William T, Morton (left) holding globe inhaler John C Warren the Surgeon Gilber Abbot the Patient
- 6. Di batu nisan Thomas, William G. Morton di Massachusetts, Amerika Serikat tertulis, disinlah berbaring: • Penemu anestetik inhalasi. • Atas jasanya, nyeri pembedahan dapat diatasi • Sejak itu ilmu-pengetahuan telah mengontrol nyeri. • Sebelum dia, pembedahan sebagai penderitaan yang luar biasa. Charles Darwin pernah ditanyak, penemuan apa yang terbesar diabad 19? “Painless surgery” jauh lebih bermanfaat dari mesin uap atau telegaram yg ditemukan pd abad yg sama
- 7. What is Anesthesiology? Anesthesiology is the practice of medicine dedicated to the pain relief and total care of the surgical patient before, during and after surgery. Who is Anesthesiologist? Anesthesiologists is a physician who focus on surgical patient and pain relief. ( perioperative pain management doctor)
- 8. 1. Life Saving 2. Alleviate suffering Two main role of anesthesiologists are:
- 9. History of Pain Management and Critical Care Medicine 1960 an 1980an
- 10. History of Pain Management John Bonica (1917-1994) Founding Father of Pain Management from Seattle 2010 First edition 1953
- 11. “Brian Ready “ pencetus Acute Pain Service dari “Washington University” , Seattle USA 1988 He is Anesthesiologist from Washington University’s Hospital in Seattle
- 12. First Anesthesiologist who practice pain management in US. In 1990 Founder the Society for Pain Practice Management (SPPM). One of the leader of Intervention Pain Management. Steven D. WALDMAN
- 13. ANESTHESIOLOGIST is a superman Doctor IS NOT JUST IN THE OPERATING ROOM • Operating room hospital surgical center • Labor & delivery suite • Other procedural areas • Intensive care unit (ICU) • PACU • Pain management acute pain chronic/ cancer pain o Emergency Medicine • “Code Blue” team • Respiratory therapy • Administration operating room hospital medical school • Education health professionals public • Research • Managers Copyright © 2003 American Society of Anesthesiologists. All rights reserved
- 14. KepMenkes 779/Menkes/Sk/VIII/2008 ttg standar pelayanan anestesiologi dan reanimasi di rumah sakit
- 15. PERDATIN Perhimpunan dokter spesialis Anestesi dan terapi intensif Perhimpunan dokter spesialis Anestesi, Terapi Intensif dan Menejemen Nyeri
- 16. 2. Classification of Pain
- 17. Pain Tissue damage - inflammation or nociceptive pain Nerve damage - neuropathy Headache/period Central pain Cancer pain Co-existence Acute Chronic Most accepted classification: 1. Nociceptive pain (Acute pain) 2. Inflammation Pain 3. Patological Pain
- 18. According to neuropathology, pain can be devided into 3 type (by Cliford Woolf 2010) PAIN Nociceptive Pain Inflammatory Pain Pathological Pain Neuropathic Pain Dysfunctional Pain
- 19. 1.Nociceptive Pain According to Neuropathology Pain can be Divided into 3 type • Due to potential tissue damage • To protect further damage • E.g. touching something to hot, cold or sharp • Also called physiological pain withdrawal reflex • Activation of nociceptor by noxious stimulus nociceptive pain • Adaptive and protective pain
- 20. Potential tissue damage Nociceptive pain withdrawal reflex protective mechanism
- 21. According to Neuropatology Pain can be Devided into 3 type 2. Inflammatory Pain • Due to tissue damage and infiltration of immune calls. • To pro more healing by causing pain hypersensitivity until healing occurs. • Pain is one of the coordinal features of inflammatory. • Adaptive and protective pain
- 22. 2. INFLAMMATION PAIN Clinical Signs: • Calor (heat) • Dolor (pain) • Rubor (redness) • Tumor (swelling) • Functio laesa (loss of function) Bimolecular changes in inflammation Pain may occur without noxious stimuli
- 23. Prostaglandin threshold nyeri EP receptor PKA PKC Increased neuronal membrane excitability PGE2 NaV1.8 TTx-resistant sodium channel Neuron firing threshold decreases Tissue injury COX-2 expressed P
- 24. Spinal cord Adaptive, high-threshold pain Early warning system ( (protective)) Adaptive, low-threshold pain Tenderness promotes repair (protective) Peripheral Inflammation Positive symptoms Nociceptionr Sensory neuron Heat Cold Intense mechanical force Chemical irritants Macrophage Mast cell Neutrophil Granulocyte Inflammation Tissue damage Noxious stimuli Inflammatory pain Nociceptive painA B Pain Autonomic response Withdrawal reflex Spontaneous pain Pain hypersensitivity Modify by: AHT
- 25. Rational use of NSAID or Steroid
- 26. Pathological Pain According to Patophysiology Pain can be Devided into 3 type • Maladaptive pain and non protective pain • This is not a symptom or protective pain but a disease state Due to damage of nervus system Neuropathic Pain Dysfunctional Pain No damage of the NS • Panthom pain • Herpetic neuralgesia • Trigemeanial neuralgesic • Diabetic neurophatic • Fibromyolgia • IBS tension • Head achl • TMJ disease
- 27. Pathological Pain Neuropathic Pain • After damaging of the nervous system Post limb amputation Post herpetic neuralgia Trigeminal neuralgia Diabetic neuropathic etc Dysfunctional Pain • No such damaging of the nervous system Fibromyalgia Irritable bowel synd. Tension headache TMJD, Interstitial cystitis etc. WRAMC Feb1, 2005 Is not a symptom but a disease of the nervous system
- 28. Abnormal Central processing Maladaptive, low-threshold pain Disease state of nervous system Peripheral Nerve damage Neural lesion Positive and negative symptoms Neuropathic pain Spontaneous pain Pain hypersensitivity Injury Stroke Modified by AHT . Nyeri neuropatik; Adalah nyeri yang terjadi akibat adanya kerusakan pada saraf, baik saraf perifer atau saraf sentral. Jadi nyeri akibat terjadinya disfungsi saraf baik perifer maupun sentral. 3. Nyeri Neuropatik
- 29. Burning, feeling like the feet are on fire Stabbing, like sharp knives Lancinating, like electric shocks Freezing, like the feet are on ice, although they feel warm to touch Modified by Meliala 2006 Gejala nyeri nya lain dari biasanya
- 30. Stimulus-Response dari ke 3 jenis nyeri Nociceptive pain Inflammatory pain Neuropathic pain No stimulus No stimulus No stimulus Response duration Response duration Response duration PainPainPain touch touch touch
- 31. NYERI NOSISEPTIF NYERI INFLAMASI NYERI PATOLOGIS ? Air Hangat Api Tanpa rangsangan Analogi
- 32. Klasifikasi Nyeri • 1. Menuru neurobiologinya dibagia atas 1.1. Nyeri nosisptif 1.2. Nyeri inflamasi 1.3. Nyeri patologik - Nyeri neuropatik - Nyeri disfungtional • 2. Menurut durasinya dibagi; Akut dan Kronik CJ. Woolf, J Clin Invest. 2010 Kesimpulan akademiknya
- 33. Dalam klinik nyeri hanya dibagi atas : 1. Menuru Jenisnya (Type nyeri) 1. Nyeri nosisptif 2. Nyeri neuropatik 2. Menurut durasinya dibagi; Akut dan Kronik 3. Menurut intensitasnya : 1. Nyeri ringan (mild pain) 2. Nyeri sedang (moderate) 3. Nyeri berat (seveare pain) Kesimpulan klinik
- 35. Apakah orang ini merasa nyeri? • Ada Rangsang kuat • Ada Kerusakan jaringan • wajahnya tidak memperlihatkan kalau dia nyeri. Tidak nyeri. Bagm. menerangkannya? Nociception without pain,There is a nociception but no Pain
- 36. Apakah pasien ini merasa nyeri? Tanpa suatu stimulus Pain without nociception no nociception but pain CRPS. (Complex Regional Pain Syndrome) Allodynia Hiperlagesia
- 37. Bagaimana dengan pasien ini? Wajahnya sangat nyeri Tak ada lagi jaringan rusak. Sudah sembuh. PHN Post Herpetic NeuralgiaVery painful, allodynia & Hiperalgesia
- 38. Pentingnya Nyeri Nosisepsi • Pentingnya nyeri nosiseptif dalam kehidupan manusia sebagai alat proteksi dapat kita bayangkan dengan melihat penderta ini. Hidupnya tidak bisa panjang karena tidak bisa merasa nyeri. Congenital insensitivity to pain ( chennelopathy) Nyeri adalah suatu rahmat, tanpa sensasi nyeri, kita mudah mencederai diri kita tanpa sadar.
- 39. Kita tidak mengenal lagi istilah Rangsang nyeri • Yang ada hanyalah: Rangsang kuat (Noxious Stimulus) dan Rangsang lemah (innocuous Stimulus)
- 40. Cortex Thalamus Midbrain Projection To PGA Brainstem Reticular formation Spinothalamic tract Spinoreticular tract Dorsal horn Of spinal cord Cell body in DRG Noxious stimulus Sensory Location, intensity Nociceptors C fiber A fiber Nyeri Memiliki dua dimensi (inderawi dan psikologis). Pain perception Limbic System Emotional Fear, anxiety
- 41. Nyeri Merupakan Output dari Otak • Pain does not exist until the brain determines it does. • Nyeri tidak akan dirasakan hingga otak mempersepsi bahwa ada nyeri Otak menggunakan peta virtual untuk mengarahkan output nyeri ke daerah yang dicurigai dalam bahaya. Proses ini merupakan komunikasi antara otak dan jaringan tubuh sebagai pertahanan terhadap kerusakan
- 44. So far what we know is : • We know that pain is processed in the Brain. • How it processes, not clear yet. • Do we have pain center in the Brain? also not clear.
- 45. • Brain areas and structures that are involved in pain processing What happen in the brain? (Dillworth et al., 2012) SomatoSensory Cortices (SSC1&2) Insular Cortex (IC) PreFrontal Cortex (PFC) Anterior Cingulate Cortex (ACC) Thalamus Hippocampu s Amygdala
- 46. Pain is Integrating of Sensory and Emotional experiences Thalamus Pre Frontal cortex (PFC) Hippocampus Insular cortex (IC) Somatosensory Cortex (S1 & S2) Anterior Cingulated Cortex (ACC) Amygdala
- 47. Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Signals from periphery and spinal cord Hippocampus Amygdala
- 48. Somatosensor y Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus • Thalamus –Primary relay center for transmission to somato-sensory and emotional signals Hippocampu s Amygdala Signals from periphery and spinal cord
- 49. • Anterior Cingulate Cortex (ACC) – Affective/ emotional component • (e.g. sense of suffering) Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 50. • Prefrontal Cortex – Cognitive aspects of pain • Meaning of pain, what to do about the pain Somatosensor y Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampu s Amygdala Signals from periphery and spinal cord
- 52. • Somatosensory Cortices – Primary (S1): Location of pain – Secondary (S2): intensity of pain Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampu s Amygdala Signals from periphery and spinal cord S1 S2
- 53. • Insular Cortex – Survival instinct – Active with the presence of threat • Lack of oxygen, pain, low blood sugar Somatosensory Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 54. • Hippocampus (kuda Laut) – Aversive input pain memory, menyimpan emosional memory. Somatosensor y Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 55. • Amygdala (almon) (penjaga emosi, perintahnya membuat kita tidak rasional, membajak otak) – Excecution decision, what to do due to pain – Emotional reaction to pain Somatosensor y Cortices Insular Cortex Prefrontal Cortex Anterior Cingulate Cortex Thalamus Hippocampus Amygdala Signals from periphery and spinal cord
- 56. Pain : From simplicity to complexity Rene Descartes 1649 Emotional Sensory Cognitive Tracey & Mantyh 2007
- 57. 16th Century 21st Century Prior experiences Attention Mood (Psychological state) Ecpectation The meaning of pain Pain Experience Noxious stimulus
- 58. Attention
- 59. Attention
- 61. Expectation
- 62. Reagan Was shot 21” before taken this picture
- 63. The meaning of pain
- 65. Penutup • Nyeri adalah penggabungan perasaan sensorik dan emosional yang dipengaruhi oleh berbagai faktor. • Nyeri memiliki dua dimensi yg jelas, dimensi inderawi dan emosional • Peran dimensi emosional lebih dominan dibanding inderawi utamanya pada nyeri kronik.