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