CANCER PAIN.ppt

7/26/2019 CANCER PAIN.ppt

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Departemen Anestesiologi dan Reanimasi

Fakultas Kedokteran USU

Medan

Dr. Hasanul Arifin SpAn

CANCER

PAINPAIN


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PAINPAIN

We must all die. But that I

can save him from days oftorture, that is what I feelas my great and ever new

privilege. Pain is a moreterrible lord of manindthan even death itself !.Albert Schweitzer (1875 1965)

On the Edge of the Prime!l "ore#t


6/52

P"#$A%#N of &AN" PAIN

Bonica '()*

5$ % of &!tient of !ll #t!ge re&orted &!in

' 7$ % with !d!nced c!ncer

+aley '()*

5$ % of &!tient with non met!#t!tic c!ncerh!d #ignic!nt &!in

6$9$ % of &!tient with !d!nced c!ncerre&orted debiliting &!in

W- '()

7$ % of &!tient with !d!nced c!ncer &!in

*+5 million &eo&le #,-ering from c!ncer

&!in with or witho,t #!ti#f!cttor. tre!tmenteer d!


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IN&I/#NIN&I/#N

moder!te or #eere &!in occ,r# in !bo,tonethird

( *$ /$ % ) of &!tient# !t the time ofdi!gno#i#

more th!n twothird# ( 6$ 1$$ % ) of&!tient#

with !d!nced or termin!l c!ncer

mo#t c!ncer &!tient# h!e more th!none &!in 0

8$ % of &!tient# h!d more th!n

Roger Woodruff, Palliative Medicine


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Patients witpain !mean"

#

$ %& 'one, pancreas, oesopagus

() * %& lung, stomac, epato'illiar+, prostate,'reast, cervi, ovar+

-) * (& oropar+n, colon, 'rain, kidne+.'ladder

/) * -& l+mpoma,leukemia, soft tissue

0ncidence of pain '+ primar+ site of cancer

Source 1 2onica 3 34 5e management of Pain4 Piladelpia, 6ea and Fe'iger, )77&

S i t e


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Physicaldimention

-"0ANI& PAIN

Sen#or.

di#crimin!tie2oti!tion!l

,n&le!#!nt #en#or.emotion!le4&erienced

!n ,n&le!#!nt #en#or. !nd

emotion!l e4&erience !##oci!tedwith !ct,!l or &otenti!l ti##,ed!m!ge or de#cribed in term of#,ch d!m!ge

In 0eneral PAIN is de1ned 2by IA3P'(4(5 as 6

PAIN

Psychologicaldimention


10/52

7# P#N-8#N-N of&AN" PAIN I3 $#"9

&-8P%#: and&-8P%I&A7#/ is thecumulative among 6

&-8P%#: and&-8P%I&A7#/ is thecumulative among 6-"0ANI& PAIN

P39&-%-0I&A%PAIN

3;++#"IN0

-"0ANI& PAIN

P39&-%-0I&A%PAIN

3;++#"IN0

7-7A% PAIN

BI-P39&-3-&I-&;%7;"-3PI"I7BI-P39&-3-&I-&;%7;"-3PI"I7


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Pain

3omatic or$isceral

Nociception

Neuropathic

8echanisms

Psychological

/isturbances

3u


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Total

Suffering

TOTAL SUFFERING

PainPain

Physical

Symptoms

Physical

SymptomsSpiritualSpiritual

ulturalultural

SocialSocial

PsychologicalPsychological

Pain

! p+sical s+mptoms

8 ps+cological pro'lems

8 social difficulties

8 cultural factors

8 spiritual concerns* 5otal Suffering


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PainPain

Physical3ymptom

s

Physical3ymptom

s

3piritual3piritual

&ultural&ultural Psychological

Psychological

3ocial3ocial

Unrelie"e# pain


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PainPain

Physical3ympto

ms

Physical3ympto

ms

3piritual

3piritual

&ultural

&ultural

Psychological

Psychological

3ocial3ocial

Unresolved or untreated pain


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$iagram of pain path%ays


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due to cancer

due to terap+

due to general illness

'ut no cancer

un related to cancer orterap+

3l!##ic!tion of &!in e4&eriencedb. &!tient# with c!ncer

nocicepti"e

9somatic

9"isceral

neuropathic

9central

9peripheral

9sympathetic

psychogenic

acute

cronic

7#8P-"A% PAT&OP&'SIOLOGIAL AETIOLOGIAL


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PA7-P93I-%-0I&A% -+PA7-P93I-%-0I&A% -+

PAINPAIN

NOIEPTI(ENOIEPTI(E:somaticsomatic:"isceral"isceral

NEUROPAT&I:central:peripheral:sympathetic

PS'&OGENIPS'&OGENI

or I$IOP&ATIor I$IOP&ATI


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&AN"PAIN3!n be diided into c!t!gorie#

'. -"0ANI& PAIN>. P39&-%-0I&A%

PAIN-"0ANI& PAIN

'. Nociceptive pain Som!tic &!in (#in+ m,#cle+ connectie ti##,e) i#cer!l &!in

(thor!cic !nd !bdomin!l i#cer!)

>. Non nociceptive pain :e,ro&!thic &!in (de!-erenti!tion

&!in) d!m!ge of &eri&her!l or


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8#&ANI38# of N-&IP7I$#

PAIN:ocice&tie &!in me!n# &!in withnocice&tion

:ocice&tie me!n# !ctiit. of !-erentne,ron# ind,ced b. ! no4io,# #tim,l,#

7"AN3/;&7I-N

7"AN38I33I-N

8-/;%A7I-N

P#"P7I-N


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PERCEPTION

Cortex

Thalamocortical

projections

Thalamus

Spinothalamic

tract Primary

Afferent

Nociceptor

Noxious

Stimulus

MODUATION

TRANSMISSION

TRANSDUCTION


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PERCEPTION

Cortex

Thalamocortical

pro)ections

Thalamus

Spinothalamic

tract Primary

Afferent

Nociceptor

Noxious

Stimulus

MODUATION

TRANSMISSION

TRANSDUCTION

Systemic

Opioi!s

Local

Anesthetic

Epi#ural

Su*arachnoi#

eliac Ple+us

Intra"enousIntrapleural

Intraperitoneal

Incisional

Local

Anesthetic

Epi#ural Opioi#

Su*arachnoi# Opioi#


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3-8A7I& PAIN

&haracteristic of pain6

#?ample 6

8echanisms 6

con#t!nt!ching+


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$I3"A%PAIN

&haracteristic ofpain6 con#t!nt

!ching or d,ll&oorl. loc!lized

,#,!ll. with n!,#e! !ndomitoften referred to c,tt!neo,##ite#

occ!tion!l colic. or cr!m&!cti!tion ofnocice&tor#&!ncre!tic c!ncerlier=l,ng met!#t!#i# with

#ho,lder

: 8echanism 6

: #?ample 6


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N#;"-PA7I& PAIN2/#A++#"#N7IA7I-N

PAIN5&haracteristic ofpain6

8echanisms 6

#?ample 6

burning painparo?ysmal shooting

or electrical shocliepainspontaneous dischargesof peripheral or centraln.s.loss of central inhibitionmetastasis brachial or

lumbosacralple?opathies

post herpetic neuralgia


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A#7I-%-0I&A% -+ PAINA#7I-%-0I&A% -+ PAIN

1; d,e to c!ncer

; d,e to ther!&.

*; d,e to gener!l illne## b,t

not c!ncer

/; ,nrel!ted to c!ncer or


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'. Pain associated with direct tumor

involvement /ue to invasion of bone>!#e of #,ll

Orbit!l #.ndromeP!r!#ell!r #in,# #.ndromeS&henoid #in,# #.ndrome3li,# #.ndrome?,g,l!r for!men #.ndrome

Occi&it!l cond.le #.ndrome

ertebr!l bod.Atl!nto!4i!l #.ndrome

37@1#.ndrome

1#.ndrome

S!cr!l #.ndrome

Bener!lized bone &!in2,lti&le met!#t!#e

Cntr!med,ll!r. neo&l!#m


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/ue to invasion of nerves

Peri&her!l nere #.ndrome

P!r!#&in!l m!##3he#t w!ll m!##

Detro&eritone!l m!##

P!inf,l &ol.n,ero&!th.

>r!chi!l+ l,mb!l+ #!cr!l&le4o&!thie#

e&tomeninge!l met!#t!#e

E&id,r!l #&in!l cord com&re##ion /ue to invasion of visceral

/ue to invasion of blood vessels

/ue to invasion of mucous

membranes

> Pain associated with cancer


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>. Pain associated with cancer

therapy 3urgery

Po#tthor!cotom. #.ndrome

Po#tm!#tectom. #.ndromePo#tr!dic!l nec di##ection #.ndrome

Po#t!m&,t!tion #.ndrome#

&hemotherapy

P!inf,l &ol.ne,ro&!th.A#e&tic necro#i# of bone

Steroid e,dorhe,m!ti#m

2,co#iti#

"adiation

D!di!tion bro#i# of br!chi!l or l,mbo#!cr!l

&le4,#

D!di!tion m.elo&h!t.

D!di!tionind,ced &eri&her!l nere t,mor#

2,co#iti#


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.Pain due to general illness

but not cancer

2.of!#ci!l &!in#

Po#ther&etic ne,r!lgi!

O#teo&oro#i#

ebiliting (dec,bit,#

,lcer)

etc


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/;Pain unrelated to cancer or th

!bo,t onefth of &!in re&orted b.&!tient#

with !d!nced c!ncer !re ,nrel!ted

to c!nceror ther!&.

!rthriti#

i#ch!emic he!rt di#e!#e

&eri&her!l !#c,l!r di#e!#e


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+A&7-"3 IN+%;#N&IN0+A&7-"3 IN+%;#N&IN0

PAINPAINC cultural bacgroundcultural bacground

C previous painprevious pain

e?periencee?perience

C meaning of the painmeaning of the pain

C situational factorssituational factors

C medicali@ationmedicali@ation


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@he c!ncer it#elf c!,#e#&!in

thro,gh0 E4ten#ion into #oftti##,e#

i#cer!l inolement >one inolement

:ere com&re##ion

:ere inF,r.


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Total

Suffering

TOTAL SUFFERING

PainPain

Physical

Symptoms

Physical

SymptomsSpiritualSpiritual

ulturalultural

SocialSocial

PsychologicalPsychological

Pain

8 p+sical s+mptoms8 ps+cological pro'lems

8 social difficulties

8 cultural factors

8 spiritual concerns* 5otal Suffering

7he distinction between &linical Pain and 7otal


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&linica

lPain

&linica

lPain

Physical

Pain

Physical

Pain

Physical3ympto

ms

Physical3ympto

ms3piritual3piritual

&ultural&ultural Psychological

Psychological

3ocial3ocial

7otal

3u


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P&'SIAL PAIN

Pain related to cancer

Pain related to treatment

Pain unrelated to cancer

LINIAL PAIN

Wat te patient sa+s it is

Wat as to 'e treated

5e concept of ;linical Pain

Pain

Other physical symptoms

Psychological pro*lems

Social #ifficulties

ultural factors

Spiritual concerns

8 or *

8 or *

8 or *

8 or *

8 or *

8 or *


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P93I&A%P93I&A%

PAINPAIN

&%INI&A%&%INI&A%

PAINPAIN

Progre##ie &!in

2,lti&le or incre!#ing

n,mber of &!in#

Signic!nt limit!tion

of !ctiit.

oor &rior m!n!gement

3ontrolled &!in

St!ble &!in

:o limit!tion of !ctiit

Bood &rior m!n!geme

9


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P93I&A% PAINP93I&A% PAIN

&%INI&A% PAIN&%INI&A% PAIN

Cn#omni!+

e4h!,#tion+ f!tig,e

#econd!r. to &!in

Per#i#tent co,gh or

omiting

Other di#tre##ing

#.m&tom#

:o in#omni!+

e4h!,#tion+ f!tig,e

:o co,ghing+omiting

:o other di#tre##ing

#.m&tom#

9


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P93I&A% PAINP93I&A% PAIN

&%INI&A% PAIN&%INI&A% PAIN

CAb!ndonment

C>oredom

C2ent!l i#ol!tion

C"in!nci!l &roblem#

CProblem# with

inter&er#on!l rel!tion

#hi

Soci!l

diGc,ltie# 0 none

or re#oled

9


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In#asi#e Proce!ures for Cancer Pain

2etween ( and 7 of all cancer pain can 'e

controlled wit oral medication, 'ut for tose

patients wit unrelieved pain invasive procedures

ave an important role4 Appropriate use of invasivemeasures in te )&9


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Neurolytic A$ents

Ethanol (alcohol).

>tanol as 'een used etensivel+ for

neurol+tic procedures in concentrations

from


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Phenol.

Studies '+ Mandl in )7/&( reported tat -# penol applied

to cervical ganglia in animals produced local necrosis in ?@

ours, complete degeneration '+ @/ da+s, and regenerationin (/ da+s4 5us, sensor+ recover+ after penol is faster

tan after alcool4 Penol, like alcool, as 'een

administered for su'aracnoid, periperal nerve, and

ganglion neurol+sis4


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Neurosur$ical Proce!ures

Wit te development of te multidisciplinar+

approac to pain management and an ever*

growing range of availa'le parmacologic agents,

few patients reuire surgical intervention tointerrupt central or periperal nociceptive

patwa+s4

5e most commonl+ performed surgical

procedure for cancer pain relief is anterolateral

cordotom+, wic a'lates te spinotalamic tract


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1; P!in i# common &roblem !nd ! m!For#.m&tom of c!ncer &!tient;

; P!in i# one !t mo#t fe!red !#&ect !nd c!nc!,#e to #,icide

*; 3!ncer &!in c!n be org!nic or .chologic!l&!in

/; Org!nic &!in m!. be #om!tic+ i#cer!l or

ne,ro&!thic &!in or combined;

5; @ot!l &!in i# !>COPSH3IOSO3CO3J@JDOSPCDC@JA&roblem;


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7AND 9-; +-"7AND 9-; +-"


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CANCER PAIN.ppt