PAIN MANAGEMENT PATHWAY
Dedi Susila, dr. SpAn. KMN
Pain and Regional Anasthesia division,
SMF / Lab Anastesi & Reanimasi FK UNAIR-RSUD Dr Soetomo
What is the Pain ???
Pain is an Unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in term of such damage
Merskey, International Association for Study of Pain, 1979
WHO 1986
Symptoms of debility
Non-cancer pathology
Side-effects of therapy
Cancer
ORGANIC PAIN
Loss of social position
Bureaucratic procedure
Loss of job prestige and income
Loss of role in family
Friends do not visit
TOTAL
DEPRESSION
Chronic fatigue and insomnia
PAIN
ANGER
Unavailable doctors
Sense of helpesness
Disfigurement
Fear of hospital or nursing home
Worry about family
Fear of death
Spiritual unrest
Delay in diagnosis
Irritability
ANXIETY
Therapeutic failure
Fear of pain
Family finances
Loss of dignity and bodily control
Uncertainty about future
Wanne morris et all, Essential Pain Management 1 st edition 2011
SSC
Cortex and
Thalamus
PAIN PATHWAY
FLC
VPL
MT
Hypothalamus
and Pituitary
Sympathetic
Outflow
PAG
HypothalamicPituitary Outflow
Midbrain
LC
Descending
Pathaways
Ascending
Pathaways
Brainstem
NRM
Peripheral
Nociceptor
C-Fiber Sensory
Afferent
NSTT
PSTT
Spinal Cord
Delta Sensory
Afferent
Sympathetic
Efferent
A-Alpha Motor
Efferent
Classification of Pain
Based on Duration: Acute and
Chronic.
Based on Clinical Context:
Postsurgical
Malignancy related
Neuropathic
Degenerative .
Based on Organ
Headache
Pelvic pain
Lowback pain
Based on Pathophysiology :
- Nociceptive pain
- Inflammatory pain
- Pathological pain
Neuropathic pain
Dysfunctional pain
From neurobiological perspective pain
can be divided into 3 types
PAIN
Nociceptive
Pain
Inflammatory
Pain
Pathological
Pain
Neurophatic Pain
Dysfunctional Pain
Woolf CJ. What is this thing called pain? J Clin Invest 2010; 120(11): 3742-3744
Nociceptive Pain
Pain due to potential tissue damage .
Due to noxious stimulus, to protect further
damage.
E.g. touching something too hot, cold or sharp
Adaptive and protective pain.
Also called physiological pain withdrawal
reflex.
WITHDRAWAL REFLEX
Inflammatory Pain
Associated with actual tissue damage and
infiltration of immune cells.
To promote repairing by pain hypersensitivity
until healing occurs.
Adaptive and protective pain
Pain is one of the cardinal features of
inflammatory.
Inflammatory Pain
Pain may occur without
noxious stimuli
Clinical Signs:
Calor (heat)
Dolor (pain)
Rubor (redness)
Tumor (swelling)
Functio laesa (loss of function)
Bimolecular changes
in inflammation
THE BEGINNING OF INFLAMMATION PAIN
Inflammation Pain
HYPERALGESIA
ALLODYNIA
Sensitization
Inflammation pain
10
Normal
Pain
Response
(Nociceptive pain)
Hyperalgesia
Pain Intensity
8
6
Injury
Allodynia
4
2
0
Stimulus Intensity
normally painless stimuli
Gottschalk A et al. Am Fam Physician. 2001;63:1979-84.
PATHOLOGICAL PAIN
MALADAPTIVE PAIN, can be;
Neurophatic pain
Dysfunctional pain
Is a disease of nervous system suffering,
reduce quality of live.
C Pathological pain
Spontaneous pain
Pain hypersensitivity
Peripheral
Nerve damage
Neuropathic pain
Neural lesion
Positive and negative
symptoms
Injury
Stroke
Abnormal
Central processing
Spontaneous pain
Pain hypersensitivity
Normal peripheral
Tissue and nerves
Dysfunctional Pain
No neural lesion
No inflammation
Positive symptoms
Abnormal
Central processing
Maladaptive, low-threshold pain
Disease state of nervous system
Nociceptive
pain
Pain
Comparation of nociceptive,
inflammatory and pathological pain
Inflammatory
pain
No stimulus
Modified by AHT
Response
duration
Pain
No stimulus
Neuropathic
pain
Response
duration
Pain
No stimulus
Response
duration
Used Multimodal Pain Management to Cover
All Point of Target
Pain Neurobiology is a complex of Dynamic
Interrelated systems
Unimodal Analgesia cannot be sufficient to
provide optimal pain management
Additive & Synergistic effects of Multiple
modes should improve outcome
Non-pharmacological analgesic
techniques :
Immobilisation of injured limbs or body parts
Ice and elevation
Explanation of cause of pain and likely
outcomes to allay anxienty
Keeping the patient in as calm an
environments as possible
Psychological techniques such as distraction
Emergency Care Acute Pain Management Manual, Australian Government
National Healt and Medical Research Council, 2011
Target Point of Analgesic Agents
Ketamin
Paracetamol
Gabapentin
Perception
Opioids
Gabapentinoids
Clonidine
Modulation
Transduction
Dexamethasone
Ketorolac
Corticosteroids
NSAID
COXIB
Local Anesthetic
Transduction
DRG
Transmission
Modulation
Local anesthetics
Cryotherapy
COXIBs
Nociceptive Pain
Is responsive to NSAIDs, coxibs,
Noxious Peripheral
Stimuli
paracetamol
and opiates
Pain-Autonomic Response
Heat
- Withdrawal Reflex
Cold
Intense
Mechanical
Force
Nociceptor Sensory
Neuron
Brain
Chemical
Irritants
Spinal Cord
Woolf. Ann Intern Med. 2004;140:441-451.
Inflammatory Pain
Is responsive to NSAIDs,coxibs,
Inflammation
paracetamol, and
opiates Pain
Spontaneous
Macrophage
Pain Hypersensitivity
-Allodynia
-Hyperalgesia
Mast Cell
Neutrophil
Granulocyte
Nociceptor Sensory
Neuron
Brain
Tissue
Damage
Spinal Cord
Woolf. Ann Intern Med. 2004;140:441-451.
Neurogenic Pain Neuropathic Pain
Spontaneous Pain
Pain Hypersensitivity
May respond to
local anaesthetic
anticonvulsants, antidepressants
new drug Gabapentinoid Gabapentin
Peripheral Nerve
Brain
- Pregabalin
Damage
Less responsive to opioids
Stroke
No response to NSAIDs,
coxibs,
or
Spinal Cord
Injury
paracetamol.
Woolf. Ann Intern Med. 2004;140:441-451.
Choice of Analgesic Technique
(Analgesic Ladder of WFSA)
Pain
Intensity
Opiate
And
NSAID
and
Paracetamol
Oral route available give orally
Oral route unavailable
Rectal paracetamol & NSAID Opiate:
High Tech: PCA
Low tech: IM algorithm Epidural
infusion analgesia
NSAID
and
Paracetamol
Pain
decreases as
time passes
Paracetamol
WHO Analgesic LADDER
