dr. nur surya - aps in makassar

ACUTE PAIN SERVICES IN MAKASSAR

Nur Surya Wirawan

Department of Anesthesiology, Intensive Care and Pain Management Faculty of Medicine, Hasanuddin University

The Chance for Anaesthesiology“The Departments of Anaesthesiology now have a golden opportunity to expand their services into a field where we easily can get many satisfied customers, something very different from the operating room or the intensive care unit, where our patients are asleep or too sick to appreciate our efforts.”

(Breivik. Pain Digest 1993;3:27)

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIANOMOR 519/MENKES/PER/III/2011

TENTANGPEDOMAN PENYELENGGARAAN PELAYANAN ANESTESIOLOGI DAN

TERAPI INTENSIF DI RUMAH SAKIT

Menanggulangi masalah nyeri akut di rumah sakit (nyeri akibat pembedahan, trauma, maupun nyeri persalinan).

BRIAN READY; ESTABLISHED THE FIRST ACUTE PAIN SERVICE IN 1988 IN SEATTLE, US

HISTORY OF APSBefore introduction of APS (1988); traditional postoperative pain was managed by surgeon (surgeon-based)

Intramuscularly (IM), usually opioid

Prescribed by the surgeon Administered by the nurses Given prn (as required)

SOME REASONS CITED FOR POOR ANALGESIA Common idea that pain is merely a symptom and not

harmful in itself. Mistaken impression that analgesia makes inaccurate

diagnosis. Fear of potential addiction to opioids and respiratory

depression Lack of appreciation of variability in analgesic response

to opioids. Misinterpretation of doctor’s orders by nursing staff. Patient’s difficulties in communicating their need for

analgesia.

Australian National Health and Medical Center. Acute pain management: scientific evidence (1999)

OUR EXPERIENCE INWAHIDIN HOSPITAL HASANUDDIN UNIVERSITYACUTE PAIN SERVICE

PELAYANAN NYERI AKUT (APS)

Tujuan APS RSWS

Memberikan Analgesia pasca bedah Aplikasi dan pengembangan teknik

analgesia yang baru Pelatihan bagi dokter dan perawat dalam

penanganan nyeri Sebagai lahan penelitian dan

pengembangan keilmuan

There are Two Kinds of Organization Structure of APS 1. Anesthesiology-Based

APSIntroduced by B. Ready in US, 1988

2. Nurse-Based APSIntroduced by N. Rawal in Sweden,

1991

ACUTE PAIN SERVICE FKUH-RSWS MAKASSAR

Provide management analgesia postoperative Mainly, EPIDURAL ANALGESIA Regular assessment and record Resident based APS Anesthesiologist Supervised Panduan Pelayanan Nyeri Pasca Bedah FKUH-

RSWS

APS MODALITIES IN WAHIDIN1. Combination of NSAID + opioid

For patients without epidural catheter Intermittent NSAID IV Continuous opioid IV (drip / syringe pump)

2. Combination of LA+ opioid For patients with epidural catheter Intermittent OR with syringe pump

PCA

Continuous epidural

Bupivacaine 0,0625% -0,1 % + Fentanyl 25µg

4 - 8 ml / jam

Intermittent epidural Dosis Interval (ml) (jam)

Bupivacaine 0,125% + Fentanyl 2µg/ml

6-10 6

EPIDURAL MODALITIES

RECORDING IN WARD AND HCU

F, 32 yr. Haemorrhoidectomy , 5 days after SC, with cont epidural analgesia

Male, 70 y.o. Fracture Femur, with continuous epidural analgesia

Male, 52 y.o. Post laparatomy, with Patient Controlled Epidural Analgesia Anesthesiologist-supervised APS

DIAGRAM KASUS SESUAI PEMBEDAHANN=2823,2004-2009

Digesti

fObg

yn

Ortope

di

Urolog

i

Thora

xtum

or

Plasti

k 0.00

10.00

20.00

30.00

40.0030.77 29.53

13.40

22.08

2.48 0.74 0.99

%

%

ACUTE PAIN SERVICE FKUH-RSWS MAKASSAR( 2010 – 2011)

Bagian  n %Digestif 234 28,8Obgyn 202 24,8

Ortopedi 185 22,7Urologi 140 17,2

Dll ( Thorax, Oncology, plastik dan pediatrik 51 6,2

Total 812 100

TABEL KASUS APS SESUAI PEMBEDAHAN TAHUN 2010, N=812

DIAGRAM KASUS APS SESUAI PEMBEDAHAN TAHUN 2010, N=812

Orthop

aedi

ObsGyn

Oncolog

y

Digestive

Urolog

y

Thora

x-vasc

ularPla

stic

Pediat

rics

0

20

40

60

80

100

120

140

160

IntermittentContinuous

ACUTE PAIN SERVICE FKUH-RSWS MAKASSAR( 2010 – 2011)

Bagian  n %Digestif 291 28,9Obgyn 270 26,8

Ortopedi 236 23,5Urologi 156 15,5

Dll ( Thorax, Oncology, plastik dan pediatrik 51 5,0

Total 1004 100

TABEL KASUS APS SESUAI PEMBEDAHAN TAHUN 2011, N=1004

ACUTE PAIN SERVICE FKUH-RSWS MAKASSAR( 2010 – 2011)

DIAGRAM KASUS APS SESUAI PEMBEDAHAN

TAHUN 2011, N=1004

VAS SCORE IN FIRST DAY (2011)

Before (8 hrs)

After (8 hrs)

Before (16 hrs)

After (16 hrs)

Before (24 hrs)

After (24 hrs)

0

10

20

30

40

50

60

70

80

90

65

78

70

80 80

88

1310 12 12 10

7

05

105 5 5

85

0 0 0 0

6

03 3 5

00 0 0 0 0 0

62 0 0 0 00 0

50 0 02 0 0 0 0 00 0 0 0 0 0

VAS 1 VAS 2 VAS 3 VAS 4 VAS 5 VAS 6 VAS 7 VAS 8 VAS 9 VAS 10

%

VAS SCORE IN SECOND DAY

0

10

20

30

40

50

60

70

80

90

100

86

98

88

98 96100

50

12

2 40

4 2 0 0 0 00 0 0 0 0 05

0 0 0 0 00 0 0 0 0 00 0 0 0 0 00 0 0 0 0 00 0 0 0 0 00 0 0 0 0 0

VAS 1 VAS 2 VAS 3 VAS 4 VAS 5 VAS 6 VAS 7 VAS 8 VAS 9 VAS 10

SATISFACTION RATE

2%8%

65%

23%2%

Satisfaction Rate

UnsatisfiedLess SatisfiedSatisfiedVery SatisfiedGreatful

NURSE TRAINING FOR PAIN MANAGEMENT

“ make pain visible “

CHANGING TO NURSE BASED APS

CONCLUSION The key to successful and safe postoperative

pain management is not so much the use of new, sophisticated and expensive techniques, but organizational structure, good protocol and excellent training of the staff is the key point

S. Schug

GUIDELINES AND PROTOCOL Side effect and the management Troubleshooting for inadequate analgesia

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