Cancer Pain Management DR. PRADEEP JAIN Sr. Consultant Department of Anaesthesiology, Pain & Perioperative Medicine Sir Ganga Ram Hospital New Delhi - 110 060 Slide 2 Slide 3 Pain Management A Team Approach physician NURSING PHARMACY SOCIAL WORKER SPIRITUAL GUIDANCE CASE MANAGER DIETICIAN PHYSICAL REHAB Slide 4 Pain Management n Children with cancer do not need to suffer unrelieved pain n Effective pain management and palliative care are major priorities of the WHO cancer programme, together with primary prevention early detection & treatment of curable cancers n Analgesic therapies are essential in controlling pain and should be combined with appropriate psychosocial, physical & supportive approaches Slide 5 Pain in Cancer n 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 Slide 6 Why to Relieve Pain CHILDREN n Irritable, anxious & restless in response to pain n Develop mistrust & fear of hospitals, medical staff and treatment procedures n Experience night terrors, flashbacks, sleep disturbance and eating problem n Children with uncontrolled pain may feel victimized, depressed, isolated,lonely and their capacity to cope with cancer treatment may be impaired Slide 7 PATIENTS AND CLOSE RELATIVES n Distrustful towards the medical system n Experience depression & guilt about being unable to prevent the pain HEALTH CARE WORKERS n It numbs their compassion, creates guilt n Encourages denial that children are suffering Why to Relieve Pain Slide 8 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 Slide 9 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 Pain Assessment Slide 10 PRE VERBAL - Physiological changes - Behavioral response facial expression, body movement and type of cry PRE-SCHOOLERS n 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 n VAS and modified Mcgill Pain Questionnaire Slide 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 1995;5:53-61 Slide 12 Pain Assessment Scales The Wong Baker Scale 0 No Pain 10 Max. Pain VAS Slide 13 Approach to pain management n Flexibility is the key to managing cancer pain n Placebo should not be used in management of cancer pain n Drug treatment is the main stay in cancer pain management Effective (70 - 80%) Inexpensive Slide 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 Slide 15 Morphine Name derives from the Greek, Morpheus, the God of dreams, while opium is the Greek word for juice. n Oldest analgesic known to man n Land mark in the development of pain control n Dried exudate of the opium poppy papaver somini ferum. Slide 16 Guidelines for Analgesic Drug Therapy n By the ladder n By the clock n By the appropriate route n By the child Slide 17 By the ladder Slide 18 Morphine in Cancer Pain Management By the clock n at fixed interval of time n dose titrated against the patients pain - gradually increasing until the patient is comfortable n next dose before the effect of previous dose worn off n prn means pain relief negligible n making patients earn their analgesia is as unacceptable as making diabetic earn their insulin Slide 19 Morphine in Cancer Pain Management By Mouth n Treatment of choice n Tablets every 4 hourly n Slow release tablets MST - 12 hourly MXL - 24 hourly n A simple aqueous solution of the sulfate or hydrochloride salt every 4 hours Slide 20 Morphine in Cancer Pain Management By The Child n No standard doses. n No fixed upper dose limit (analgesic celing effect) n The right dose is the dose that relieves the pain n Range 5mg to >1000 mg Slide 21 Morphine n Drug of choice n Oral, S/C, I/V, rectally, epidural and Intrathecal n Oral dose 0.15 0.3mg/kg every 4 hour n Intermittent I/V 50-100 g /kg n Continuous I/V or S/C 15-30 g /kg/h n Controlled release oral preparation n < 6 months of age dose decrease to 1/3 Slide 22 Fentanyl n More potent then morphine n Hepato-renal compromise n < histamine release n Muscular rigidity n Only opioid with transdermal preparation n Oral Trans mucosal preparation n Sufentanyl nasal spray, Aerosol preparation Slide 23 Pediatric Cancer Pain Management Adjuvant drugs May be necessary for one of the three reasons: n To treat the adverse effects of analgesic: n To enhance pain relief n To treat concomitant psychological disturbances: Slide 24 Intrathecal Drug Delivery n Morphine most commonly used n Epidural or Intrathecal administration n Epidural percutaneous catheter n Tunneled subcutaneous catheter Slide 25 Procedure Related Pain General Principles n Prophylaxis should involve both pharmacological and non pharmacological approaches n The specific approaches used should be tailored to the individual n Children must be adequately prepared for all invasive and diagnostic procedures n To be done in specially designated treatment rooms Slide 26 Algorithms for Pain Management During Procedures PAINLESS PROCEDURE (CT, MRI) n Individualized preparation n chloral hydrate 1 hour before procedure n Pentobarbital MILD PAINFUL PROCEDURE (I/V CANNULATION) n Parental presence n Local anaesthetics Topical anaesthetics Buffered lidocaine n Behavioural techniques e.g. bubble-blowing, distraction Slide 27 Algorithms for Pain Management During Procedures MODERATELY PAINFUL PROCEDURE (L.P.) n Benzodiazepines SEVERE PAINFUL PROCEDURES (B.M ASPIRATION, BIOPSY) n No venous access oral midazolam with morphine, I/M Ketamine n Venous access midazolam with fantanyl, morphine,Ketamine, propofol and N 2 O n GA Slide 28 Oral Transmucosal Fentanyl n Sedation n 100,200,300 ug n Dose:10-15ug/kg n Onset 20 mins n Nausea/vomiting common Slide 29 EMLA Application n 1. Applying: Dont rub the cream n 2. Covering: Allow a thick layer n 3. Timing: Let it be undistributed n 4. Removing: 60 min after application 1. 4. 2. 3. Slide 30 Nitrous Oxide Analgesia n Provide good analgesia, sedation and amnesia without resulting in loss of consciousness known as relative analgesia n Bone marrow aspiration, lumbar, puncture, venous cannulation and wound dressings n Administration Demand system (entonox ) Constant flowdevices (quantiflex apparatus/ anaesthesia machine) Slide 31 Programmable Electronic Devices Interfaced with microprocessorInterfaced with microprocessor Flexibility in programmingFlexibility in programming Comprehensive display & memory of eventsComprehensive display & memory of events Security features prevent temperingSecurity features prevent tempering Event logEvent log Multiple applicationMultiple application Interfaced with microprocessorInterfaced with microprocessor Flexibility in programmingFlexibility in programming Comprehensive display & memory of eventsComprehensive display & memory of events Security features prevent temperingSecurity features prevent tempering Event logEvent log Multiple applicationMultiple application Slide 32 Disposable Fixed Programme Devices Light weight - Maximum portabilityLight weight - Maximum portability Non Electronic - No programmingNon Electronic - No programming Hydrostatic positive pressure Elastomeric energyHydrostatic positive pressure Elastomeric energy Flow restrictor - Flow rates are presetFlow restrictor - Flow rates are preset SimplicitySimplicity Minimal patient & nursing trainingMinimal patient & nursing training Light weight - Maximum portabilityLight weight - Maximum portability Non Electronic - No programmingNon Electronic - No programming Hydrostatic positive pressure Elastomeric energyHydrostatic positive pressure Elastomeric energy Flow restrictor - Flow rates are presetFlow restrictor - Flow rates are preset SimplicitySimplicity Minimal patient & nursing trainingMinimal patient & nursing training Slide 33 PEDIATRIC PO PAIN RELIEF PCA n Morphine loding dose 50 g/ Kg Infusion rate 15 g/ Kg/ hr PCEA n Bupivicaine Bolus 0.5 ml/ Kg ( 0.25% ) Infusion rate - ( 0.125% ) 0.1 - 0.5 ml/ Kg / hr n Fentanyl 2 g/ ml + 0.125% Bupivicaine - 0.1 - 0.5 ml/ Kg / hr n Morphine 20 - 50 g/ Kg Slide 34 Slide 35 Slide 36 Non Drug Pain Therapy n SupportiveSupport and empower the child and family n Cognitive Influence thought n Behavioural Changes behaviour n Physical Affects sensory system Integral Part of Cancer Pain Treatment Slide 37 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 Cancer Pain Slide 38 Conclusion n 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 Slide 39 Thank You.