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Cancer Pain Management

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Cancer Pain Management DR. PRADEEP JAIN Sr. Consultant Department of Anaesthesiology, Pain & Perioperative Medicine Sir Ganga Ram Hospital New Delhi - 110 060 – PowerPoint PPT presentation

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Title: Cancer Pain Management


1
Cancer Pain Management
  • DR. PRADEEP JAIN
  • Sr. Consultant
  • Department of Anaesthesiology,
  • Pain Perioperative Medicine
  • Sir Ganga Ram Hospital
  • New Delhi - 110 060

2
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3
Pain Management A Team Approach
NURSING
PHARMACY
physician
SOCIAL WORKER
SPIRITUAL GUIDANCE
CASE MANAGER
PHYSICAL REHAB
DIETICIAN
4
Pain Management
  • Children with cancer do not need to suffer
    unrelieved pain
  • Effective pain management and palliative care are
    major priorities of the WHO cancer programme,
    together with primary prevention early detection
    treatment of curable cancers
  • Analgesic therapies are essential in controlling
    pain and should be combined with appropriate
    psychosocial, physical supportive approaches

5
Pain in Cancer
  • In the developed world, the major sources of pain
    in childrens are due to diagnostic and
    therapeutic procedures. In the developing world,
    most pain is disease related

6
Why to Relieve Pain
  • CHILDREN
  • Irritable, anxious restless in response to
    pain
  • Develop mistrust fear of hospitals, medical
    staff and treatment procedures
  • Experience night terrors, flashbacks, sleep
    disturbance and eating problem
  • Children with uncontrolled pain may feel
    victimized, depressed, isolated ,lonely and their
    capacity to cope with cancer treatment may be
    impaired

7
Why to Relieve Pain
  • PATIENTS AND CLOSE RELATIVES
  • Distrustful towards the medical system
  • Experience depression guilt about being unable
    to prevent the pain
  • HEALTH CARE WORKERS
  • It numbs their compassion, creates guilt
  • Encourages denial that children are suffering

8
Management Strategies
9
Pain Assessment
  • QUESTT
  • Q Question the child
  • U Use pain rating scales
  • E Evaluate childs behavior
  • S Secure parents involvement
  • T Take cause of pain into account
  • T Take earliest action

10
Pain Assessment
  • PRE VERBAL
  • - Physiological changes
  • - Behavioral response facial expression,
    body movement and type
  • of cry
  • PRE-SCHOOLERS
  • The various self-reporting scales are
  • The Oucher Scale
  • Happy-Sad Face Scale
  • Elands Colour Scale
  • Poker Chip Tool
  • Ladder Scale
  • Linear Analogue Scale
  • SCHOOL AGED CHILDRENS
  • VAS and modified Mcgill Pain Questionnaire

11
Neonatal Pain Assessment Scale
Krecheal SW, Bildner J CRIES a new neonatal
postoperative pain management score. Initial
testing of validity and reliability. Pediatric
Anesthesia 1995553-61
12
Pain Assessment Scales
The Wong Baker Scale
0 No Pain
10 Max. Pain
VAS
13
Approach to pain management
  • Flexibility is the key to managing cancer pain
  • Placebo should not be used in management of
    cancer pain
  • Drug treatment is the main stay in cancer pain
    management
  • Effective (70 - 80)
  • Inexpensive

14
Non Opioid Drugs
  • Mild to moderate pain
  • Adjunct to balanced pain management
  • Pharmacokinetics similar in infants aged over 6
    months to adults
  • Very little efficacy safety data for infants
    available
  • Paracetamol - tablet, syrup, suppositories dose
    10-15mg/kg orally 6 hr
  • Ibuprofen - tablet, syrup dose 10-20mg/kg
    orally 6 hr
  • Diclofenac - orally 1mg/kg 8-12 hr
  • Ketarolac - i/v 0.2-0.5 mg/kg

15
Morphine
  • Name derives from the Greek, Morpheus, the God of
    dreams, while opium is the Greek word for juice.
  • Oldest analgesic known to man
  • Land mark in the development of pain control
  • Dried exudate of the opium poppy papaver
    somini ferum.

16
Guidelines for Analgesic Drug Therapy
  • By the ladder
  • By the clock
  • By the appropriate route
  • By the child

17
By the ladder
18
Morphine in Cancer Pain ManagementBy the clock
  • at fixed interval of time
  • dose titrated against the patients pain -
    gradually increasing until the patient is
    comfortable
  • next dose before the effect of previous dose
    worn off
  • prn means pain relief negligible
  • making patients earn their analgesia is as
    unacceptable as making diabetic earn their insulin

19
Morphine in Cancer Pain ManagementBy Mouth
  • Treatment of choice
  • Tablets every 4 hourly
  • Slow release tablets
  • MST - 12 hourly
  • MXL - 24 hourly
  • A simple aqueous solution of the sulfate or
    hydrochloride salt every 4 hours

20
Morphine in Cancer Pain ManagementBy The Child
  • No standard doses.
  • No fixed upper dose limit (analgesic celing
    effect)
  • The right dose is the dose that relieves the
    pain
  • Range 5mg to gt1000 mg

21
Morphine
  • Drug of choice
  • Oral, S/C, I/V, rectally, epidural and
    Intrathecal
  • Oral dose 0.15 0.3mg/kg every 4 hour
  • Intermittent I/V 50-100 ?g /kg
  • Continuous I/V or S/C 15-30 ?g /kg/h
  • Controlled release oral preparation
  • lt 6 months of age dose decrease to 1/3

22
Fentanyl
  • More potent then morphine
  • Hepato-renal compromise
  • lt histamine release
  • Muscular rigidity
  • Only opioid with transdermal preparation
  • Oral Trans mucosal preparation
  • Sufentanyl nasal spray, Aerosol preparation

23
Pediatric Cancer Pain ManagementAdjuvant drugs
  • May be necessary for one of the three reasons
  • To treat the adverse effects of analgesic
  • To enhance pain relief
  • To treat concomitant psychological disturbances

24
Intrathecal Drug Delivery
  • Morphine most commonly used
  • Epidural or Intrathecal administration
  • Epidural percutaneous catheter
  • Tunneled subcutaneous catheter

25
Procedure Related Pain General Principles
  • Prophylaxis should involve both pharmacological
    and non pharmacological approaches
  • The specific approaches used should be tailored
    to the individual
  • Children must be adequately prepared for all
    invasive and diagnostic procedures
  • To be done in specially designated treatment
    rooms

26
Algorithms for Pain Management During Procedures
  • PAINLESS PROCEDURE (CT, MRI)
  • Individualized preparation
  • chloral hydrate 1 hour before procedure
  • Pentobarbital
  • MILD PAINFUL PROCEDURE (I/V CANNULATION)
  • Parental presence
  • Local anaesthetics
  • Topical anaesthetics
  • Buffered lidocaine
  • Behavioural techniques e.g. bubble-blowing,
    distraction

27
Algorithms for Pain Management During Procedures
  • MODERATELY PAINFUL PROCEDURE (L.P.)
  • Benzodiazepines
  • SEVERE PAINFUL PROCEDURES (B.M ASPIRATION,
    BIOPSY)
  • No venous access oral midazolam with morphine,
    I/M Ketamine
  • Venous access midazolam with fantanyl,
    morphine,Ketamine, propofol and N2O
  • GA

28
Oral Transmucosal Fentanyl
  • Sedation
  • 100,200,300 ug
  • Dose10-15ug/kg
  • Onset 20 mins
  • Nausea/vomiting common

29
EMLA Application
  • 1. Applying
  • Dont rub the cream
  • 2. Covering
  • Allow a thick layer
  • 3. Timing
  • Let it be undistributed
  • 4. Removing
  • 60 min after application

3.
30
Nitrous Oxide Analgesia
  • Provide good analgesia, sedation and amnesia
    without resulting in loss of consciousness known
    as relative analgesia
  • Bone marrow aspiration, lumbar, puncture, venous
    cannulation and wound dressings
  • Administration
  • Demand system(entonox )
  • Constant flowdevices(quantiflex apparatus/
    anaesthesia machine)

31
Programmable Electronic Devices
  • Interfaced with microprocessor
  • Flexibility in programming
  • Comprehensive display memory of events
  • Security features prevent tempering
  • Event log
  • Multiple application

32
Disposable Fixed Programme Devices
  • Light weight - Maximum portability
  • Non Electronic - No programming
  • Hydrostatic positive pressure Elastomeric energy
  • Flow restrictor - Flow rates are preset
  • Simplicity
  • Minimal patient nursing training

33
PEDIATRIC PO PAIN RELIEF
  • PCA
  • Morphine loding dose 50 ?g/ Kg
  • Infusion rate 15 ?g/ Kg/
    hr
  • PCEA
  • Bupivicaine Bolus 0.5 ml/ Kg ( 0.25 )
    Infusion rate - ( 0.125 ) 0.1 -
    0.5 ml/ Kg / hr
  • Fentanyl 2 ?g/ ml 0.125 Bupivicaine -
    0.1 - 0.5 ml/ Kg / hr
  • Morphine 20 - 50 ?g/ Kg

34
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36
Non Drug Pain Therapy
  • Supportive Support and empower the child and
    family
  • Cognitive Influence thought
  • Behavioural Changes behaviour
  • Physical Affects sensory system

Integral Part of Cancer Pain Treatment
37
Cancer Pain
  • Freedom from pain should be seen as a right of
    every cancer patient and access to pain therapy
    as a measure of respect of this right

38
Conclusion
  • Nothing would have a greater impact on the
    quality of life of children with cancer than the
    dissemination and implementation of the current
    principles of palliative care, including pain
    relief symptom control

39
Thank You.
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