Download 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
PHARMACY
physician
Pain Management
A Team Approach
SPIRITUAL
GUIDANCE
SOCIAL
WORKER
CASE
MANAGER
PHYSICAL
REHAB
DIETICIAN
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
• 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:
–The Oucher Scale
–Happy-Sad Face Scale
–Eland’s Colour Scale
–Poker Chip Tool
–Ladder Scale
–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
10
No
Pain
Max.
Pain
VAS
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
•
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
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”.
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

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
0.15 –0.3mg/kg every 4 hour
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
– 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 N2O

GA
Oral Transmucosal Fentanyl

Sedation

100,200,300 ug

Dose:10-15ug/kg

Onset 20 mins

Nausea/vomiting common
EMLA Application
1.




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
2.
3.
4.
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)
Programmable
Electronic Devices
• Interfaced with microprocessor
• Flexibility in programming
• Comprehensive display & memory of events
• Security features prevent tempering
• Event log
• Multiple application
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
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
Influence thought

Behavioural
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
SGRH
Thank You….