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

Pain Management A Team Approach

physician

NURSING

PHARMACY

SOCIALWORKER

SPIRITUALGUIDANCE

CASEMANAGER

DIETICIAN

PHYSICALREHAB

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

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

Why to Relieve Pain

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

• 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

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

No Pain

10

Max. PainVAS

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, suppositoriesdose 10-15mg/kg orally 6 hr

• Ibuprofen - tablet, syrupdose 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 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

– 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. Applying: Don’t rub the cream

2. Covering: Allow a thick layer

3. Timing: Let it be undistributed

4. Removing: 60 min after application

1.

4.

2.

3.

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

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

Disposable Fixed Programme DevicesDisposable Fixed Programme Devices

• Light weight - Maximum portabilityLight weight - Maximum portability

• Non Electronic - No programmingNon Electronic - No programming

• Hydrostatic positive pressure Elastomeric Hydrostatic positive pressure Elastomeric

energyenergy

• 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 Hydrostatic positive pressure Elastomeric

energyenergy

• Flow restrictor - Flow rates are presetFlow restrictor - Flow rates are preset

• SimplicitySimplicity

• Minimal patient & nursing trainingMinimal 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

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

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….