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Cancer Pain Management

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Presentation on theme: "Cancer Pain Management"— Presentation transcript:

1 Cancer Pain Management
DR. PRADEEP JAIN Sr. Consultant Department of Anaesthesiology, Pain & Perioperative Medicine Sir Ganga Ram Hospital New Delhi


3 Pain Management A Team Approach

4 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

5 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

6 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

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

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

9 Pain Assessment QUESTT Q – Question the child
* 07/16/96 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 *

10 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

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

12 Pain Assessment Scales
* 07/16/96 Pain Assessment Scales The Wong Baker Scale The Wong Baker Scale The other scale used is OUCHER Scale which is available in versions for males and females and in multicultural forms. The child is asked to point to the picture that best shows how he or she feels. No Pain 10 Max. Pain VAS *

13 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 ( %) Inexpensive

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 mg/kg

15 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”.

16 Guidelines for Analgesic Drug Therapy
“By the ladder” “By the clock” “By the appropriate route” “By the child”

17 “By the ladder”

18 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

19 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

20 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

21 Morphine Drug of choice
Oral, S/C, I/V, rectally, epidural and Intrathecal Oral dose –0.3mg/kg every 4 hour Intermittent I/V g /kg Continuous I/V or S/C g /kg/h Controlled release oral preparation < 6 months of age dose decrease to 1/3

22 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

23 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:

24 Intrathecal Drug Delivery
Morphine most commonly used Epidural or Intrathecal administration Epidural percutaneous catheter Tunneled subcutaneous catheter

25 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

26 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

27 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

28 Oral Transmucosal Fentanyl
* 07/16/96 Oral Transmucosal Fentanyl Sedation 100,200,300 ug Dose:10-15ug/kg Onset 20 mins Nausea/vomiting common Fentanyl has been approved for transmucosal route. Oral fentanyl is available as fentanyl lollypop. Oral Fentanyl is useful as an analgesic when painful procedures are to be performed and there is no intravenous access. If IV access is available, the is no justification of using oral fentanyl. *

29 EMLA Application 1. 2. 3. 4. 1. Applying: Don’t rub the cream
* 07/16/96 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. This is the method of application. A thick layer of EMLA cream is applied on skin. On the top of it a transparent dressing is covered. The layer of EMLA should be thick enough to be visible through the dressing. The dressing is applies in such a way that, EMLA remains undistributed at that particular place. When you remove the dressing after 60 minutes, it should still be visible. The side effects include local allergy and sometime methemoglobinemia. 3. 4. *

30 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)

31 Programmable Electronic Devices
Interfaced with microprocessor Flexibility in programming Comprehensive display & memory of events Security features prevent tempering Event log Multiple application

32 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

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% ) ml/ Kg / hr Fentanyl g/ ml % Bupivicaine ml/ Kg / hr Morphine g/ Kg



36 Integral Part of Cancer Pain Treatment
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

37 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

38 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

39 Thank You….

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