seminar dan pelatihan -...
TRANSCRIPT
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YulistianiDepartemen Farmasi Klinik Fak. Farmasi UnairRumah Sakit Universitas Airlangga Surabaya
SEMINAR DAN PELATIHANEKSISTENSI APOTEKER
MEWUJUDKAN MASYARAKAT SEHATSurabaya, 4 Juni 2016
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Apoteker/FarmasisDalam Health Care Team
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Faktor yang mempengaruhikualitas Layanan Farmasi
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Nyeri (“pain”)
Suatu gejala yang diakibatkan olehbanyak penyebab, terdiri atasrangsangan sakit, interpretasi (persepsi) dan reaksi terhadap rangsangan tersebut
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EPIDEMIOLOGI
Jutaan orang – rasa sakit/nyeri
Di Amerika biaya karena nyeri -- > 60 juta US $
65 % pasien rawat inap di RS - terapi nyeri
50-80 % pasien pasca operasi – nyeri berat
70% pasien perawatan di rumah-nyeri kronik–
mengeluh mengalami nyeri walaupun telah mendapat
terapi, 25 % kondisi semakin buruk
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Klasifikasi Nyeri
AKUT KRONIS
• Respons fisiologik normal
- dapat diramalkan
terhadap rangsangan
kimia, panas, atau mekanik
~ pembedahan, trauma,
dan penyakit akut
• Biasanya waktunya
terbatas
• Pengatasan – hilangkan
penyebab
• Nyeri menetap dan penyebab
nyeri tidak selalu dapat
dihilangkan atau sulit diobati
• Nyeri kronik - kondisi medik
atau penyakit yang sulit/ tidak
dapat disembuhkan jangka
lama
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FAKTOR YANG MEMPENGARUHI NYERI
& PERSEPSI RASA NYERI
Nyeri danpersepsi nyeri
KankerLelah
Cemas
Emosi (kesedihan, marah)
Problema terapi
Kehilangan
Pengalaman nyerisebelumnya
Kesulitan hidup
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Patofisiologi Nyeri
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GAMBARAN NYERI DAN NYERI RUJUKAN
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Penilaian Nyeri
Numerical pain scale
0 1 2 3 4 5 6 7 8 9 10
No pain
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UPAYA PENANGANAN NYERI
OBAT
ANALGETIKA
SENTRAL
opioida/narkotika
PERIFER : NSAID
ANESTESI LOKAL
Procain, lidokain
ANALGETIKA AJUVAN/
TAMBAHAN
diazepam, amitriptilin,
fenitoin, dll
TANPA OBAT
Edukasi ~ perilaku
Terapi musik
Hipnosis
Rangsangan elektrik
dll
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WHO Ladder Step
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Klasifikasi nyeridan pemilihan analgesik (WHO)
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Pemilihan analgetika
Jenis nyeri Analgetika
Otot Ringan
Sedang
Berat
Parasetamol +/- NSAID
Parasetamol + NSAID + Narkotika lemah
Parasetamol + NSAID + Narkotika kuatOrgan dalam
Saraf Antidepresan + antikejang
(analgetika ajuvan)
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ANALGETIKA NONOPIOIDA / NONNARKOTIKA
• Asetaminofen/parasetamol
• Antalgin
• NSAID (OAINS=obat antiinflamasinonsteroid)
- Asetilsalisilat (asetosal)
- Nonasetilsalisilat (as.mefenamat, Na
diklofenak, piroxicam, ibuprofen, dll)
• Kortikosteroid : prednison, deksametason
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Asetaminofen (Parasetamol)
• Analgetika
• Antipiretika
• Efek secara selektif di sistem saraf pusat (ssp)
• Efek pada perifer rendah
• Tdk ada efek antiinflamasi
• Toksisitas liver (hepatotoksik) – dosis > 4 g/hari
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Ditarik dari peredaran
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Asetosal (Aspirin)
• Analgetika
• Antipiretika
• Antiinflamasi
• Hati-hati efek samping iritasi lambung
• Dosis ~ indikasi antiplatelet
analgetika-antiinflamasi
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Asetosal
Dosis lazim Efek
80 – 160 mg Antiplatelet
325 – 1000 mg Analgetika, antipiretika
325 mg – 6 grams antiinflamasi
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ANALGETIKA OPIOIDA-NARKOTIKA
Obat Dosis Lama kerja
Morfin 10 mg 3 - 4 jam
Codein 100 mg 3 – 4 jam
Pethidin 100 mg 1 – 2 jam
Fentanil 100 ug 15 – 30 mnt
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ANALGETIKA AJUVAN
• Antikonvulsan : karbamazepin, fenitoin
• Antidepresan : amitriptilin
• Anestesi lokal : lidokain HCl
• Antiemetika : metoklopramid
• Laksansia : laktulosa
• Neuroleptika/antipsikotik : haloperidol, flufenazin
• Anticemas : alprazolam, lorazepam
• Muscle relaxant: diazepam
• dll : capsaicin, glukosamin
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Kombinasi Opioida – Nonopioida
• Kodein + Asetosal
• Kodein + Asetaminofen
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Kombinasi nonopioida-ajuvan
Asetaminofen 500 mg + kafein 50 mg sakit kepala/gigi, nyeri otot
Metampiron 250 mg + diazepam 2 mg sakit kepala, neuralgia, sakit pinggang, ketegangan
Metampiron 250 mg + lidokain HCl 15 mg sakit kepala, nyeri saraf, sakit pinggang
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CONTOH PERESEPAN
/ Carbamazepin 200 mg
1-3dd1
Dokter SpS
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NSAID +Asetaminofen
Efek analgetika lebih besar daripada
bentuk tunggal
Menghindari efek samping pada
penggunaan narkotika tunggal
Termasuk obat bebas Over-the-
counter (OTC)
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Analgetika ajuvan
Jenis Indikasi
Benzodiazepin (alprazolam,
lorazepam)
anticemas, relaksasi otot
Antihistamin (CTM,
cetirizin, dll)
nyeri~mual, muntah
-TCA (amitriptilin,
imipramin, doxepin)
-Antikonvulsan (fenitoin,
karbamazepin, klonazepam)
-Neuroleptika (flufenazin,
haloperidol)
nyeri neurogenik
nyeri phantom
neuralgia trigeminal
pasca trauma
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Adjuvant analgesics – nyeri neuropati
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Nyeri saraf
Jenis nyeri Analgetika
Luka Amitriptilin (TCA), mexiletin
Neuralgia trigeminal Karbamazepin, lamotrigin, baklofen
Nyeri muka atipikal Amitriptilin
Neuralgia pasca herpes TCA, tramadol, gabapentin, morfin
Pasca amputasi Gabapentin, morfin
Pasca stroke Amitriptilin, lamotrigin
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CONTOH PERESEPAN
/ Proris Syr fl.I
3dd1
Pro: An. D (1,5 th)
Dokter SpPD
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CONTOH PERESEPAN
/ Danazol No. V
1dd1
Pro: Ny. SM (35 th)
Dokter SpOG
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DANAZOL
Derivat testost. (19-nortestosteron) ~
efek progestin
Tx. Endometriosis
Mekanisme kerja :
level hipotalamik ~ LH, FSH
produksi estrogen
pertumbuhan jaringan endometrium
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CONTOH PERESEPAN
/ Parasetamol 1/3
/ Ibuprofen 1/3
/ GG 1/3
/ CTM 1/4
mf pulv dtd No. XII
3dd1
Pro: By. M (7 bl)
Dokter Umum
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CONTOH PERESEPAN
/ Glibenklamid 5 mg No. XX
1-1-0
/ Metformin No. XX
0-1-1
/ Captopril 25 mg No. XX
2dd1
/ Antalgin No. XXX
3dd1
/ Vit. B1 No. XXX
3dd1
Pro: Tn. N (61 th)
Dokter SpPD
Indikasi
antalgin?
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CONTOH PERESEPAN
/ Antalgin1/3
/ Ibuprofen 1/3
/ Vit.B1 1/3
mf pulv dtd No. XII
3dd1
Pro: By. M (7 bl)
Dokter Umum
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CONTOH PERESEPAN
/ Glibenklamid 5 mg No. XX
1-1-0
/ Metformin tb No. XX
0-1-1
/ Captopril 25 mg No. XX
2dd1
/ Amitriptilin tb No. XXX
3dd1
/ Vit. B1 tb No. XXX
3dd1
Pro: Tn. N (61 th)
Dokter SpPD
Indikasi
amitriptilin?
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CONTOH PERESEPAN
/ Diklofenak Na 25 mg No. XV
3dd1
/ Allopurinol 100 mg No. V
1dd1
Pro: Ny. P (56 th)
Dokter SpPD
Bidang Rheumatologi
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CONTOH PERESEPAN
/ Meloxicam 15 mg No. X
1dd1
/ Meloxicam supp 15 mg No. V
1dd1
/ Ranitidin 150 mg No. XX
2dd1
Pro: Tn. N (61 th)
Dokter SpPD
Divisi Rheumatologi
Konseling?
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STUDI KASUS
/ Tramadol 50 mg No. XC
3dd1
/ Multivitamin No. XXX
1dd1
Pro: Ny. P (56 th)
Dokter SpB
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Tramadol
Mekanisme analgetika – sentral
Lebih efektif dari kombinasi kodein + parasetamol
ADR- mual, konstipasi, mulut kering
dizziness, sakit kepala, sedasi,
kejang (overdosis), diaforesis
+ alkohol sedasi & hipnotik
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Peran Apoteker dalam Manajemen Nyeri
Nyeri – penyebabnya multifaktorialNyeri akutmonitoring bbrp kali/hariNyeri kronikmonitoring hari-minggu
Terapi nyeri : terapi non obat & terapi obat(analgesik & ajuvan analgesik)
Terapi obat : R/ dan swamedikasi Pemilihan analgesik bergantung pada :
Jenis & lama nyeriRiwayat nyeri sebelumnyaRiwayat analgesik sebelumnyaADR/ESO
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Peran Apoteker dalam Manajemen Nyeri
Evaluasi frekuensi nyeri jenis obat, rutepemberian, dosis, kombinasi obat
Opioida e.s konstipasi intake cairan + makanan berserat + laksatif ?
Antidepresan (benzodiazepin) + opioidadepresi ssp
Waspada : misuse, abuse, overuse
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PRINSIP EDUKASI
Menilai karakteristik nyeri :
keluhan (sumber nyeri)
riwayat analgetika
Memilih analgetika paling efektif dengan ESO minimal
Regimentasi - aturan pakai nyeri akut - kronik
Menilai efek samping Narkotika-konstipasi
Asetosal/NSAID-iritasi lambung
Pendekatan obat - non obat
Makanan mengandung triptofan (keju) pemicu nyeri
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