Transcript Flexibility is the key to managing cancer pain
Cancer Pain Management
DR. PRADEEP JAIN Sr. Consultant Department of Anaesthesiology, Pain & Perioperative Medicine Sir Ganga Ram Hospital New Delhi - 110 060
Global Crusade Against Pain
Chronic Pain is a Disease State
Global Crusade Against Pain Chronic Pain is a Disease State
NURSING physician SPIRITUAL GUIDANCE CASE MANAGER Pain Management
A Team Approach
DIETICIAN PHARMACY SOCIAL WORKER PHYSICAL REHAB
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
Pain in Cancer
In the developed world, the major sources of pain in children’s are due to diagnostic and therapeutic procedures. In the developing world, most pain is disease related
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
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
Management Strategies
Assess the child Conduct physical examination Determine primary cause of pain Evaluates secondary causes (environmental and internal ) Develop treatment plan Analgesic drugs and non analgesic therapies Implement Plan Assess regularly and revise plan as necessary
Pain Assessment
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QUESTT Q – Question the child U – Use pain rating scales E – Evaluate child’s behavior S – Secure parent’s involvement T – Take cause of pain into account T – Take earliest action
Pain Assessment PRE VERBAL - Physiological changes - Behavioral response –facial expression, body movement and type of cry PRE-SCHOOLERS
The various self-reporting scales are:
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The Oucher Scale
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Happy-Sad Face Scale
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Eland’s Colour Scale
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Poker Chip Tool
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Ladder Scale
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Linear Analogue Scale SCHOOL AGED CHILDRENS
VAS and modified Mcgill Pain Questionnaire
Neonatal Pain Assessment Scale
Krecheal SW, Bildner J CRIES: a new neonatal postoperative pain management score. Initial testing of validity and reliability. Pediatric Anesthesia 1995;5:53-61
Pain Assessment Scales The Wong Baker Scale
0 No Pain
VAS
10 Max. Pain
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
Non Opioid Drugs
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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 Ketarolac orally 1mg/kg 8-12 hr i/v 0.2-0.5 mg/kg
Morphine
Name derives from the Greek,
Morpheus
juice.
,
the God of dreams, while opium is the Greek word for Oldest analgesic known to man Land mark in the development of pain control Dried exudate of the opium poppy ‘’ papaver somini ferum”.
Guidelines for Analgesic Drug Therapy
“By the ladder”
“By the clock”
“By the appropriate route”
“By the child”
“By the ladder”
Morphine in Cancer Pain Management
“By 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
Morphine in Cancer Pain Management
“By 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
Morphine in Cancer Pain Management
“By 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 >1000 mg
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
< 6 months of age dose decrease to 1/3
Fentanyl
More potent then morphine
Hepato-renal compromise
< histamine release
Muscular rigidity
Only opioid with transdermal preparation
Oral Trans mucosal preparation
Sufentanyl nasal spray, Aerosol preparation
Pediatric Cancer Pain Management
Adjuvant 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:
Intrathecal Drug Delivery
Morphine most commonly used
Epidural or Intrathecal administration
Epidural percutaneous catheter
Tunneled subcutaneous catheter
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
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
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Topical anaesthetics Buffered lidocaine Behavioural techniques e.g. bubble-blowing, distraction
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 N 2 O
GA
Oral Transmucosal Fentanyl
Sedation
100,200,300 ug
Dose:10-15ug/kg
Onset 20 mins
Nausea/vomiting common
EMLA Application
1. Applying: Don’t rub the cream 2. Covering: Allow a thick layer 3. Timing: Let it be undistributed 4. Removing: 60 min after application
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Nitrous Oxide Analgesia
Provide good analgesia, sedation and amnesia without resulting in loss of consciousness known as relative analgesia
B
one marrow aspiration, lumbar, puncture, venous cannulation and wound dressings Administration
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Demand system (entonox )
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Constant flowdevices (quantiflex apparatus/ anaesthesia machine)
Programmable Electronic Devices
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Interfaced with microprocessor
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Flexibility in programming
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Comprehensive display & memory of events
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Security features prevent tempering
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Event log
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Multiple application
Disposable Fixed Programme Devices
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Light weight - Maximum portability
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Non Electronic - No programming
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Hydrostatic positive pressure Elastomeric energy
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Flow restrictor - Flow rates are preset
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Simplicity
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Minimal patient & nursing training
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
Non Drug Pain Therapy
Supportive Support and empower the child and family
Cognitive Behavioural Influence thought Changes behaviour
Physical Affects sensory system
Integral Part of Cancer Pain Treatment
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
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
Thank You….
SGRH