Dr. Tinni T. Maskoen is the Head of Intensive Care at Hasan Sadikin Hospital in Bandung and Chair of the Intensive Care Education Program at Padjadjaran University Medical School. She discusses the importance of effective pain relief after surgery and outlines the World Health Organization analgesic ladder for treating surgical pain. She advocates for a multimodal approach using combinations of paracetamol, NSAIDs, opioids, and other adjuvants to provide enhanced pain relief with reduced side effects.

1. Curriculum Vitae
Nama : Dr. Tinni T. Maskoen, dr., SpAnKIC,KMN
Jabatan : Kepala Perawatan Intensif RS. Hasan Sadikin Bandung
Ketua Program Studi Pendidikan Konsultan Intensive Care
(KIC) Fakultas Kedokteran Universitas Padjadjaran/RS.
Hasan Sadikin Bandung
Alamat : Departemen Anestesiologi & Terapi Intensif Fakultas
Kedokteran Universitas Padjadjaran/RS. Hasan Sadikin
Jalan Pasteur no. 38 Bandung 40161
Telp : 022-2038285/08122369670
Fax : 022-2038306
E-mail : ttmaskoen@yahoo.co.id

2. ANALGESIC NSAID’S IN
WFSA LADDER
TINNI T MASKOEN
MEDICAL FACULTY UNPAD – HASAN SADIKIN HOSPITAL
BANDUNG
Makasar, November 2,2012

3. INTRODUCTION
 The effective relief of pain is of paramount
importance to anyone treating patients
undergoing surgery.
 There is now evidence that pain relief has
significant physiological benefit.
 Earlier discharge from hospital.
 Reduce the onset of chronic pain syndromes.
Makasar, November 2,2012

4. Pain
 Pain serves a biological function.
 It signals the presence of damage or
disease within the body.
 In the case of postoperative pain it is the
result of the surgery
Makasar, November 2,2012

5. 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.

6. Nociception
Spinothalamic
tract Peripheral
nerve
Dorsal Horn
Dorsal root
ganglion
Pain
Modulation
Transduction
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.
Perception
Transmission

7. Prostaglandins
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 cell
Blood vessel
Bradykinin
Nociceptor
Substance P
2
3
1
Inflammation Tissue

8. Surgical pain
Review Multimodal strategies to improve surgical outcome
The American Journal of Surgery 183 (2002) 630–641

9. WHO Analgesic Ladder

10. Pain management
Pain symptom
intensity
Drug selection
Constant moderate to
severe pain
Intermittent pain
Long acting analgesics +prn
short acting analgesics
prn short acting
analgesics
Mild
Moderate
severe

11. Surgical pain
Minor surgery
Herniotomy
Varicose vein
Gynecological
laparotomy
Moderate surgery
Hip replacement
Hysterectomy
maxillofacial
Major surgery
Thoracotomy
Major abdominal
surgery
Knee surgery
Paracetamol /NSIADs
/ weak opiods
Wound infiltration
Peripheral nerve block
Paracetamol /NSIADs
+Wound infiltration
Peripheral nerve block
Systemic opioids
PCA
Paracetamol /NSIADs
Epidural anesthesia
systemic opioids
PCA
Treatment modality
Surgical procedure

12. The Continuum of Pain
<1 month
Time to resolution
3-6 months
Acute
Pain
Chronic
Pain
•Usually obvious tissue damage
•Increased nervous system
activity
•Pain resolves upon healing
•Serves a protective function
•Pain for 3-6 months or more2
•Pain beyond expected period of
healing2
•Usually has no protective
function3
•Degrades health and function3
1. Cole BE. Hosp Physician. 2002;38:23-30.
2. Turk and Okifuji. Bonica’s Management of Pain. 2001.
3. Chapman and Stillman. Pain and Touch. 1996.
Insult

14. WFSA Analgesic Ladder

15. Factors influencing analgesic
requirements
 Age
 Pre-operative analgesic use.
 Coexisting medical conditions
 Cultural factors and personality
 Preoperative patient education
 Past history of poor pain management
 Site of operation

16. Treatment …
Pharmacologic
• Opioid
• Non opioid
- Aspirin
- Acetaminophen
- NSAID’s
• Adjuvant

17. NSAID
Side effects Therapeutic effects
TXA2
PGE2
PGI2 PGI2

18. Contraindication of NSIAD
 Pre-existing renal impairment (Cr)
 Cardiac failure
 Severe liver dysfunction
 Uncontrolled hypertension
 Aspirin-induced asthma
 History of GI bleeding
 Known hypersensitivity

19. NSIAD used with caution
 High risk of intraoperative hemorrhage
 Diabetes
 Bleeding or coagulation disorders.
 Pregnant and lactating woman
 Children or advanced age
 Concurrent used other NSIAD ,ACEI ,
cyclosporin, methotrexate

20. Non Opioid
Non Selective NSAIDs
 Aspirin
 Ibuprofen
 Naproxen
 Fenoprofen
 Indomethacin
 Ketorolac
COX-2 Selective inh
• Rofecoxib
• Celecoxib
• Valdecoxib
Others
• Acetaminophen
• Clonidine
• Ketamin

21. Potential side effects of NSAID
REVIEW ARTICLE WHITE ANESTH ANALG
NON-OPIOID ANALGESICS AND ACUTE POSTOPERATIVE PAIN 2005;101:S5–S22
-Operative site bleeding
- GI bleeding
- Renal tubular dysfunction
- Allergic reaction
- Bronchospasm
- Hypertension
- Pedal edema

22. Pain management
 Preemptive analgesia & Multimodal
analgesia
 ⇩ doses of each analgesic
 Improved actinociception due to
synergistic/additive effects
 may⇩ reduce severity of side effect of each
drugs

23. Potentiation
• Reduced doses of each
analgesic
• Improved pain relief due to
synergistic or additive
effects
• May reduce severity of side
effects of each drug
Benefits of Multimodal Pain Therapy
1
1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.
Morphine
NSAIDs,
acetaminophen,
nerve blocks

24. Multimodal Therapy Can Provide
Enhanced Analgesia
1Crews JC. JAMA. 2002;288:629-632.
2Samad TA et al. Trends Mol Med. 2002;8:390-396.
3Atcheson R et al. Management of Acute and Chronic Pain. London, England: BMJ Books; 1998:23-50.

25. Resume
 Pain relief has significant physiological benefit, such
as earlier discharge from hospital and reduce the
onset of chronic pain syndrome.
 Surgical pain produce complexity neurohumoral,
infammation and amplifying responses and should be
treated according to WFSA Analgesic Ladder
• Multimodal Pain Therapy should be done to reduced
doses of each analgesic, improved pain relief due to
synergistic or additive effects and reduce severity of
side effects of each drug
