Pemantauan dan Penanganan

Nyeri Pasca Bedah

Dr. Harold F. Tambajong SpAn.

 Introduction
Surgical procedures become increasingly
complex and were performed on sicker patients
The period in PACU is characterized by
relatively high incidence of potentially life-
threatening respiratory and circulatory
complications.
Postoperative pain management: minimises
patient suffering, reduce morbidity and facilitate
rapid recovery and early discharge from hospital
 PACU
Near the operating rooms
Proximity to radiographic, laboratory, and
other intensive care facilities
Open ward design
Pulse oxymetry, EKG, blood pressure
monitors, capnography, thermometer etc
Emergency equipment
Respiratory therapy equipment
 Speed of Emergence
Inhalation anesthetic: depend on alveolar
ventilation, agents blood solubility, duration of
anesthesia
The most frequent cause of delayed emergence
from inhalation anesthesia is hypoventilation
IV anesthetic: function of its pharmacokinetics.
Preoperative medications, age, renal or hepatic
disease
 Delayed Emergence
Fails to regain consciousness 60-90 minutes following
general anesthesia
The most frequent cause: residual anesthetic, sedative,
and analgesic drug effect
Occur as a result of drug overdose, or potentiation of
anesthetic agents by prior drug ingestion (alcohol).
Naloxone (0.2 mg increments) and flumazenil (0.5 mg
increments): reverses and can exclude the effects of an
opioid and benzodiazepine, respectively.
Physostigmine 1-2 mg may partially reverse the effect of
other agents.
A nerve stimulator can be used to exclude significant
neuromuscular blockade.
 Delayed Emergence
Less common causes:
hypothermia
marked metabolic disturbances
perioperative stroke.
Hypoxemia and hypercarbia are readily
excluded by blood gas analysis.
Rare causes: hypercalcemia,
hypermagnesemia, hyponatremia, and hypo-
and hyperglycemia
Perioperative stroke is rare except following
neurologic, cardiac, and cerebrovascular surgery
 RECOVERY
Vitalsigns and oxygenation should be checked
immediately on arrival.
BP, PR, and RR every 5 min for 15 min or until
stable, and every 15 minutes thereafter.
Pulse oximetry should be monitored
continuously in all patients recovering from
general anesthesia, at least until they regain
consciousness.
All patients recovering from general anesthesia
should receive 30-40% oxygen
 Discharge Criteria
Observed for respiratory depression for at least
30 minutes after the last dose of parenteral
narcotic.
Minimum discharge criteria for patients
recovering from general anesthesia:
(1) Easy arousability
(2) Full orientation
(3) The ability to maintain and protect the airway
(4) Stable vital signs for at least 1 hour
(5) The ability to call for help if necessary
(6) No obvious surgical complications (such as
activebleeding).
Postanesthetic recovery
score. (Ideally, the
patient should be
discharged when the
total score is 10.)

'Based on Aldrete JA,

Kronlik D: A postanesthetic
recovery score. Anesth
Analg 1970;49:924.
Penanganan Nyeri Pasca
Operatif
 The Goals of Pain Management

Improve quality of life for the patient

Facilitate rapid recovery and return to full
function
Reduce morbidity
Allow early discharge from hospital
Pain: "An unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage."
(IASP 1979)
 Physiology of pain
There is individual variation in response to pain,
which is influenced by genetic makeup, cultural
background, age and gender.
Certain patient populations are at risk of
inadequate pain control and require special
attention.
Paediatric patients
Geriatric patients
Patients with difficulty in communicating ( critical
illness, cognitive impairment or language barriers)
 Physiology of pain
Postoperative pain can be divided into acute
pain and chronic pain:
Acute pain is experienced immediately after
surgery (up to 7 days)
Pain which lasts more than 3 months after the
injury is considered to be chronic pain
 Physiology of pain
The type of pain:
somatic (from skin, muscle, bone)
visceral (from organs within the chest and
abdomen)
neuropathic (damage or dysfunction in the
nervous system).
Patientsoften experience more than one
type of pain
 Positive role of pain
Providing a warning of tissue damage
Inducing immobilisation to allow
appropriate healing
 Negative effects of pain
Short term negative effects of acute pain:
Emotional and physical suffering for the patient
Sleep disturbance (with negative impact on mood and
mobilisation)
Cardiovascular side effects ( hypertension, tachycardia)
Increased oxygen consumption (negative impact in CAD)
Impaired bowel movement (opioids induce constipation or
nausea, pain may also be an important cause of impaired
bowel movement or PONV)
Negative effects on respiratory function (leading to
atelectasis, retention of secretions and pneumonia)
Delays mobilisation and promotes thromboembolism (post
operative pain on mobilisation is one of the major causes
for delayed mobilisation)
 Principles of successful pain
assessment
Assess pain both at rest and on movement to evaluate
the patient's functional status.
The effect of a given treatment is evaluated by assessing
pain before and after every treatment intervention.
In the surgical Post Anaesthesia Care Unit (PACU) or
other circumstances where pain is intense, evaluate,
treat, and re-evaluate frequently (e.g. every 15 min
initially, then every 1-2 h as pain intensity decreases).
On the surgical ward, evaluate, treat, and re-evaluate
regularly (e.g. every 4-8 h) both the pain and the
patient's response to treatment.
 Principles of successful pain
assessment
Define the maximum pain score above which pain relief
is offered the intervention threshold). For example,
verbal ratings score of 3 at rest and 4 on moving, on a
10-point scale.
Pain and response to treatment, including adverse
effects, are documented clearly on easily accessible
forms, such as the vital sign sheet.
Patients who have difficulty communicating their pain
require particular attention. (cognitively impaired,
severely emotionally disturbed, children, patients who do
not speak the local language, and patients whose level
of education or cultural background differs significantly
from that of their health care team).
 Principles of successful pain
assessment
Unexpected intense pain, particularly if
associated with altered vital signs (hypotension,
tachycardia, or fever) is immediately evaluated.
New diagnoses, such as wound dehiscence,
infection, or deep venous thrombosis, should be
considered.
Immediate pain relief without asking for a pain
rating is given to patients in obvious pain who
are not sufficiently focused to use a pain rating
scale.
Family members are involved when appropriate.
 Specific tools for pain
assessment
Facial expressions: a pictogram of six faces with
different expressions from smiling or happy through to
tearful. This scale is suitable for patients where
communication is a problem,
Verbal rating scale (VRS): the patient is asked to rate
their pain on a five-point scale as "none, mild,
moderate, severe or very severe".
Numerical rating scale (NRS): This consists of a simple
0 to 5 or 0 to 10 scale which correlates to no pain at
zero and worst possible pain at 5 (or 10).
Visual analogue scale (VAS): This consists of an
ungraduated, straight 100 mm line marked at one end
with the term " no pain" and at the other end "the worst
possible pain".
 Documentation
The nurse responsible for the patient reports the
intensity of pain and treats the pain within the
defined rules of the local guidelines.
The physician responsible for the patient may
need to modify the intervention if evaluation
shows that the patient still has significant pain.
The treatment strategy to be continued is
discussed by the physician responsible for the
patient in conjunction with the ward nurses.
The physician and nurses pay attention to the
effects and side effects of the pain treatment.
 Treatment options
a. Pharmacological methods of pain treatment: step-
wise and balanced
1. Balanced (multimodal) analgesia
Uses two or more analgesic agents that act by different
mechanisms to achieve a superior analgesic effect
without increasing adverse events compared with
increased doses of single agents. (e.g. epidural opioids
+ epidural local anaesthetics; intravenous opioids can +
NSAIDs.
Balanced analgesia is therefore the method of choice
wherever possible, based on paracetamol and NSAIDs
for low intensity pain with opioid analgesics and/or local
analgesia techniques being used for moderate and
high intensity pain as indicated
2. Opioids
3. Non Opioid
 4. Adjuvants

In
addition to systemic administration of
NSAIDs or paracetamol, weak opioids and
non-opioid analgesic drugs may be
administered "on request" for moderate or
severe pain. These include ketamine (oral,
im, iv) and clonidine (oral, iv or
perineurally in combination with local
anaesthetics). However, the side effects
could be significant.
 5. Regional analgesia

Continuous Central Neuraxis Blockade (CCNB)

Continuous epidural analgesia: first choice
Continuous Peripheral Nerve Blockade (CPNB)
Continuous Infusion (CI)
Intermittent Top-up:
Patient-Controlled Epidural Analgesia (PCEA):

Continuous spinal analgesia - selected cases only

(less experience with this technique)
Continuous Peripheral Nerve Blockade (CPNB)
Infiltration blocks
b. Non-pharmacological methods of pain treatment
Acute pain management service
Treatment of postoperative pain requires good multi-
disciplinary and multi-professional co-operation.
Staff training
Physiology and pathophysiology of pain
Pharmacology of analgesics
Locally available treatment methods
Monitoring routines with regard to treatment of pain
Local document for treatment and assessment of pain

Audit and quality control

Before establishing an acute pain service for the first time, it is
important to audit the effectiveness of the current pain
management systems in your hospital.
 Negative effects of pain
Long term negative effects of acute pain:
Severe acute pain is a risk factor for the
development of chronic pain
There is a risk of behavioural changes in
children for a prolonged period (up to 1 year)
after surgical pain
 Physiology of pain
Two major mechanisms in the physiology
of pain:
Nociceptive (sensory): Inflammatory pain
due to chemical, mechanical and thermal
stimuli at the nociceptors (nerves that respond
to painful stimuli).
Neuropathic: Pain due to neural damage in
peripheral nerves or within the central
nervous system.
 The mechanism of peripheral pain
sensitisation
Normally, C- fibres (slow-conducting fibres
that transmit dull aching pain) are silent in
the absence of stimulation, but following
acute tissue injury in the presence of
ongoing pathophysiology, these nociceptors
become sensitised and release a complex
mix of pain and inflammatory mediators
leading to pain sensations
 The mechanism of central
sensitisation
Sustained or repetitive C-nociceptor activity
produces alterations in the response of the
CNS to inputs from the periphery. When
identical noxious stimuli are repeatedly
applied to the skin at a certain rate, there is
a progressive build-up in the response of
spinal cord dorsal horn neurons (known as
wind up).