Edited: DR - Dairion Gatot M.Ked SP - PD-KHOM

CURRICULUM VITAE
Edited :
Dr.Dairion Gatot M.Ked Sp.PD-KHOM
Hematology & Medical Onkology Division

Internal Departement of Medical Faculty
Universitas Sumatera Utara/H Adam Malik General Hospital
MEDAN-2022
CURRICULUM VITAE
Nama Lengkap : Dr. Dairion Gatot, M.Ked. SpPD.K-HOM
Pekerjaan : Ketua Divisi Hematologi Onkologi
FK-USU/RSUP H. Adam Malik Medan
Alamat Rumah : Jl.T. Amir Hamzah/Taman Binjai Indah
No F-4 Binjai – 20746
E-mail : drdairion@yahoo.com
Pendidikan Medis :
S1/Dokter Umum 1988 USU/Medan
Magister-Kedokteran 2016 USU/Medan
Sp-1 / Internis 2003 USU/Medan
Sp-2 / Konsultan HOM 2009 USU/Medan
Pendidikan – Workshop :
Hipnoterapi 2004 Imanta/AIA/IBH
Komunikasi Mendengar-Aktif 2011
Instruktur Hipnoterapi 2012 IBH
Profesional Hipnoterapi 2013 IBH
NLP 2015 Neo-NLP
Body Language 2016 IBLC
INTRODUCTION
PAIN
DEFINITION
Cancer pain does not have a specific definition
An unpleasant sensory and emotional experience

associated with actual or potential tissue injury or
described
Cancer in terms
pain was defined as painofinsuch
patientsdamage
caused by neoplastic disease itself
(International Association for the Study of Pain =
and / or diagnostic procedures or treatments (biopsy, chemotherapy,
radiotherapy, surgery)
IASP)
(Bonica, 1990; Jacox et al. 1994)
Epidemiology of Cancer Pain
Pancreas 80-100%
Bone 75-80%
Breast 50-100%
Lung 55-85%
Colon 50-95%
Lymphoma 20-70%
Leukemia 10-75
Public health problem
Barriers to Effective Cancer Pain Management
 It is curious , indeed tragic, that despite the availability of

straight forward, cost effective therapies, Cancer Pain remains
undertreated.
( R. Patt. The Patt center for Cancer)
 The factors contributing to undertreatment are complex, but

documented: 1-Knowledge Deficits
2-Beliefs
3-Attitude
By: 1-Health Care Providers
2-Health Care System
3-Patient-Family members
Classification
• Cancer pain etiology
• Cancer pain pathogenesis : Nociceptive,
Nonnociceptive(Neuropathic), Mixed
• Cancer pain temporal relationships : Acute,
Chronic
• Cancer pain localisation
– head, neck, thorax, abdomen, pelvis, limbs
• Cancer pain intensity
– mild, moderate, strong, severe, unbearable
Etiology
• Pain caused by the tumor directly (60-90%)
• Tumor infiltration of tissue (bone, viscera)
• Compression or infiltration of nerves, blood vessels, organ
obstruction
• Pain caused by diagnostic /
therapeutic procedures (5-20%)
• Biopsy, punction
• Chemotherapy
Etiology
• Radiotherapy
• Surgery
• Pain caused by the malignant disease indirectly
(10-25%)
• Infection (viral, fungal, bacterial)
• Inflammation , DVT, lymphoedema
• Pain caused by the concomitant existence of
conditions (3-10%)
• ( diabetic polineuropathy, headaches, OA )
PRINCIPLES OF CANCER PAIN
MANAGEMENT
ASSESMENT OF PAIN
Good history taking – Temporal pattern (acute,

-Pain is the fifth vital sign chronic, sub acute,
Site breakthrough pain, incident
Duration pain)
Onset Interference with daily living
Quality of pain Sleep
Aggravating factors Psychological status
Relieving factors Response to current and
12
previous therapy
Happy face – sad face scale
VISUAL ANALOG SCORE (VAS)

The WHO Analgesic Ladder
Severe Pain
Moderate Pain
Mild Pain
Step Ladder WHO Modified
Step 1: NSAID
• Mechanism: Special
Cyclooxygenaseinhibitor
(COX-1 and COX-2) Consideration
PG degradation. • High risk patients
• Decrease pain by reducing • Monitoring
pain receptor sensitivity, • Misoprostol
reduce the inflammatory • Interindividual
process and edema Variability
• Usage • Cox-1 sparing NSAID
• COX-2/COX-1 ratio • Ketorolac-
• Ceiling phenomenon Bromfenac
Step 2 and 3: Opioids
• Indication: Weak Opioid

• Mechanism • Intermediate Potency
• Almost in combination
• Weak vs Strong !
With other
Potent vs less meds(NSAID..etc)
Potent • Weakness due to the
ceiling dose of NSAID or
other
• When it is used (sole) in
equianalgesic doses,
control severe pain
Common Weak Opioids
Percodan Oxycodone 5mg ASA 325mg
Percocet Oxycodone 5mg Acetaminophen

325mg
Lorcet Hydrocodone Acetaminophen
10mg 650mg
Tylenol#3 Codeine 30mg Acetaminophen3
#4 Codeine 60mg 00mg
DHC plus Dihydrocodeine Acetam.356mg

16mg Caffeine 30mg
Common Strong Opioids
Generic Trade Route Equi.doses Duration.avg
Morphine** MSIR Parenteral 10mg 3-4 hr

(MS) Oral 30mg
MS.(S.R) MS Contin Oral 30mg 8-12 hr
Hyro- Dilaudid Parenteral 1.5mg 3-4 hr

Morphone Oral 7.5mg
Methadone* Dolophine Parenteral 20mg 4-8 hr
Oral 10mg 4-8 hr
Levorphanol Levo- Parenteral 2mg 4-8 hr
Dromoran Oral 2mg
Oxycodon SR Oxycontin Oral 30mg 12 hr
Management of Opioid Side Effect
1. Constipation
GI peristalsis , Secretion aggravated by , fluid intake ,
physical activity and poor diet
-Prevention
-Treatment
2. Nausea & Vomiting
Stimulation of chemoreceptor 
Prochlorperazine/Haloperidol
Delayed gastric emptying  Metchlopramide
Increased vestibular sensitivity  Dimenhydrinate
If persist, modify the dose, opioid rotation, change the route

Continue……..
Sedation-Confusion Other Route: Why?

1-Prevention • Rectal :
2-Modify the doses Oxycodon-
Hydromorphone
3-If persist • Transdermal :
revaluate Fentanyl
4-Opioid Rotation Patches.25,50,100ug/hr
5-Change the route • Subcutaneous

• Intravenous
Petunjuk Praktis
ABC dst
A. Asking the patient and family.
B. Believe ,what the patient said.
C. Choose the right treatment.
D. Delivery, the medicine, etc.
E. Empower patient, ( enables)
Pengobatan
Pengobatan nyeri kanker multidisiplin.
Pengobatan terbagi 2 .
1.Pengobatan non farmakologik.
Pengobatan bukan dengan obat, seperti ,
operasi, radiasi, fisioterapi, dsb.
2.Pengobatan farmakologik.
Pengobatan memakai obat.
Sekitar 90% , nyeri kanker dapat diatasi dengan
obat obatan.
Pedoman
• Cara Konversi morfin iv menjadi oral.
• -Perbandingan 1 : 2,5/ 3.
• contoh :Mo iv 30 mg/24 jam,
• oral seharusnya 90 mg/24 jam.
• dikurangi 30% untuk cegah gangguan
toleransi parsial . 60 mg/ 24 jam.
• ( 6 x 10 mg immediate tablet)
• bila terkontrol, ganti 2 x 30 mg MST.
Pedoman
• Setiap pemberian codein, dan morfin
• Harus + laksansia.
• Anti muntah dipertimbangkan.
• Anti dote morfin: Naloxone.
• Psikoterapi selalu menyertai.
• Morfin ,oral, tepat waktu dan long acting..
Tangga nyeri WHO
(Step Ladder MODIFIED)
Merupakan pedoman yang banyak dipakai
untuk mengatasi nyeri kanker.
Pedoman ini memudahkan penatalaksanaan
nyeri kanker.
Alat bantu yang cocok adalah VAS.
Pemakaian obat nyeri akan jelas dan
efisien.
Step Ladder WHO Modified
Pengobatan nyeri
1. Nyeri ringan
2. Nyeri sedang .
3. Nyeri berat.
Nyeri ringan
Untuk nyeri kanker pada pasien kelompok
ini maka obat yang diberkan antara lain
Untuk pasien dengan nilai VAS 0 - 4.
Acetaminofen 300 – 600 mg max 6 kali
sehari .
NSAID ( Non Steroid Anti Inflamation
Drugs ) , Ibuprofen ,ketofrofen, mefenamic
acid dan sebagainya.
Hati hati gastritis .
Pengobatan nyeri
1. Nyeri ringan
2. Nyeri sedang .
3. Nyeri berat.
Nyeri sedang
• Obat kelompok golongan pertama dapat
diberikan dan ditambahkan dengan ,
opioid ringan seperti , codein , tramadol
dan obat ajuvant / penunjang lainnya.
• Penilaian dilakukan pada kelompok ini

antara 1 dan 2 hari.
Obat
Nyeri sedang .
Selain obat nyeri ringan dapat
ditambahkan , opioid ringan seperti .
1. codein , dosis maks 6 x 30 mg / hari.
efek samping , obstipasi , dari awal s
sudah harus minum obat oencahar.
2. Tramadol, dosis maks 600 mg /hari ,
relatif lebih mahal,
Pengobatan nyeri
1. Nyeri ringan
2. Nyeri sedang .
3. Nyeri berat.
Nyeri berat.
Harus dievaluasi dan nyeri yang diderita
pasien harus dikenal .
Dalam 24 jam sebaiknya sudah terkontrol.
Sebaiknya dimulai dengan infus kemudian
dilanjutkan morfin kerja lambat , Morfin
kerja cepat dan selanjutnya morfin kerja
lambat dan .
Pedoman Pengobatan
WHO memberikan rekomendasi .
1. Melalui mulut ( Oral ).
2. Tepat waktu ( Round the clock ).
3. Sesuai tangga nyeri / Step Ladder.
4. Perorangan / Individual.
5. Penuh perhatian ( Attention to detail )
Obat nyeri berat
Obat nyeri berat adalah opioid kuat, dan
dapat ditambahkan obat yang lain.
1. Morfin injeksi .
2. Morfin tablet ,kerja cepat.
3. Morfin tablet , kerja lama.
4. Fentanyl Transdermal patch,
tempel pada kulit.
Morfin injeksi
• Untuk pemakaian awal nyeri berat , atau
kesulitan menelan .
• Untuk mencari dosis tepat.
• Pemberian iv. Sc.
• Mudah untuk pengaturan dosis.
• Harus dirawat.
Morfin tablet kerja cepat
Morfin tablet , kerja 4 – 6 jam.
Bisa di gerus dan dibagi.
Sering diberikan , merepotkan.
Mudah mengatur cara pemberian .
Jarang sekali efek toksik.
Biasanya pemberian transisi setelah morfin
infus .
Morfin tablet kerja lambat
Tablet kemasan tertentu; MST ( 10 , 15, 30
mg )
Masa keja 8 – 12 jam.
Tidak efektif digerus dan dibagi.
Praktis hanya 2 kali sehari ( bisa 3 x ).
Pengaturan dosis, disesuaikan dsengan
kemasan : misal 2 x 35 mg .
BERKERJASAMA
SAMA-SAMABERKERJA
BERSATU KITA MAJU

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CURRICULUM VITAE

Hematology & Medical Onkology Division

An unpleasant sensory and emotional experience

 It is curious , indeed tragic, that despite the availability of

 The factors contributing to undertreatment are complex, but

Good history taking – Temporal pattern (acute,

VISUAL ANALOG SCORE (VAS)

• Indication: Weak Opioid

Percocet Oxycodone 5mg Acetaminophen

DHC plus Dihydrocodeine Acetam.356mg

Morphine** MSIR Parenteral 10mg 3-4 hr

Hyro- Dilaudid Parenteral 1.5mg 3-4 hr

If persist, modify the dose, opioid rotation, change the route

Sedation-Confusion Other Route: Why?

5-Change the route • Subcutaneous

• Penilaian dilakukan pada kelompok ini

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