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Transcript of Anesthesia and Chronic pain management, Cape Breton Regional Hospital I have no disclosures and do...
Anesthesia and Chronic pain management, Cape Breton Regional Hospital
I have no disclosures and do not receive any sponsorships from any of the companies that might be mentioned
Background – evolution in cancer care – earlier diagnosis, more effective treatment with increased survival.
WHO ladder approach-limitations in certain circumstances.
Multidisciplinary/multimodal approach – decision making.
The role of the ‘interventional procedure’.
Assessment is the key ? Tumor related ? Therapy side effects ? Chronic pain in cancer patients Psychosocial assessment Physical exam Directed studies
Realistic expectations Rarely eliminate “all pain” Spectrum of ‘success’:1. Improve QOL2. Reduce medication including side effects3. Avoid complications4. Obtain thoughtful, realistic informed
consent (including family)
Radiation: Conventional/Stereotactic Biphosphonates: MOA-supresses osteoclast
mediated bone resorption, eg IV zoledronic acid Radiopharmaceuticals: samarium, strontium Danosumab: (RANKL-Ab) – osteoclast maturation
inhibitor Hormonal therapies: prostate/breast Orthopedic treatments: Bracing/Surgery/PMMA
injection
60-80% well addressed by oncologists
Poorly controlled group – who to call?1. Depends on the problem2. Depends on local
expertise/availability3. Depends on patient preferences4. But call someone!!
Traditional/Etiologic: Nociceptive vs. Neuropathic
New Challenge: ‘Acute’ vs. ‘Chronic Cancer Pain’ Pain Throughout the cancer cycle:1. Pain at diagnosis2. Painful diagnostic procedures and/or resective
surgery3. Pain due to chemo/radiation4. Painful progression/metastasis
WHO 30 years on – time for critical reappraisal ? Treatments available in 1982 Lack or efficacy Not evidence based Long-term opioid efficacy and side effects
problematic Mechanism based, individualized approaches
important Last resort WHO options offer better pain
control/fewer side effects Pain problematic throughout cancer cycle –
prevent chronic pain by addressing acute pain better
Treat pain early to prevent morbidity Use adjuvants/procedures/physical
medicine techniques early to avoid morbidity and transition to chronic pain
Adopt chronic pain treatment strategies early in the cycle
‘Consider’ intervention the fourth step in the WHO ladder approach
No rules exist for the timing of interventional procedures – it is your call
“Incidental” Nature Peaks/Valleys hard to capture Bracing challenging Surgical options may be limited r/t
overall debility “Snowball effect” of debility to
morbidity to mortality
Multidisciplinary care Primary care, pain specialist, physical medicine,
surgeon, psychologist, palliative care physician, physical therapist, occupational therapist, social work, chaplin
Multimodal Care Adjuvant medications Procedures/injections/RF/implantables, etc. Opioids Topicals Holistic approaches
When:1. Refractory to usual management2. Unacceptable side effects from
analgesics e.g. opiate induced hyperalgesia and myoclonus
Which:1. Neuraxial infusions2. Other pain procedures: Nerve blocks,
neurolytics, radiofrequency, vertebral augmentation, etc …
Neuraxial Treatment indicated in:1. Intolerable side effects of existing
oral/intravenous management2. Inadequate analgesia on oral intravenous
management Options:
Tunneled/temporary epidural or plexus infusions
Refractory Cancer PainLife expectancy ≤ 3 months1. Need for local anesthetics (e.g. chest wall mass)
anticipated2. Need for high dose LA
Epidural catheter (tunneled e.g. Du Pens)Diffuse pain, epidural space obliterated, need for IT PCA/
unavailability of programmable pump
Intrathecal catheter (tunneled e.g. Du Pens)
Life expectancy ≥ 3 monthsSomatic / visceral pain
Single Shot IT trialNeuropathic Pain Equivocal results
IT Catheter Trial≥ 50% pain relief ≤ 50% pain reliefImplant pump Further medical
management
Retrospective review (baseline vs. 3 months)60 months, N=160138 available at 3 months
Numerical pain scores reduced:7.09 ± 1.8 to 3.7 ± 2.4 (p<0.001)
Oral opioid intake declined 577 mg/d to 206 mg/d MOED (p<0.001)
Drowsiness/mental clouding decreased:- 5.4 to 2.9/10 and 4.5 to 2.5/10
Zhuang M et al, IARS 80th Congress March 2006, San Francisco, CA
N = 300 Serious infections approx 10; 5 pump
explants (< 2%) Paralysis 1 (<< 1%) Revision rate/catheter, etc: 5 – 10%
Meta-Analysis Superficial infection 2.3% Deep infection 1.4% Every 71st patient will have an infection after 54
days of therapy Bleeding 0.9% Neurological injury 0.4%
Aprili D et al, Anesthesiology 2009
1. Likely to help2. Focal pain3. No contraindications
Neurolytic blocks (alcohol, phenol or glycerol)where motor/sensory separation exists. Consider local block first
RF ablation (nerves/tumor)? Role of pulsed RF Vertebral augmentation Plexus blocks Simple injections
Cancer patients can have coexisting VCF’s Trend is towards ignoring these fractures This is possibly benign neglect Quick and relatively affordable procedure
with excellent results and pain relief NEJM article condemning vertebroplasty had
poor design and statistics. It compared vertebroplasty to poorly (non-ISIS standard) performed medial branch blocks
Role of vertebroplasty vs. kyphoplasty vs. the significant discrepancy in procedural cost vs. benefit
Indicated for intractable pain after failure of less invasive procedures in patients with a short life expectancy
May provide profound pain relief for pelvic malignancies at the cost of bladder and bowel control
Never the first treatment of choice Experience very limited in the current
environment A valuable tool however, should not be
discounted
Severe intractable pain Intolerable side effects of analgesic therapy Intrathecal catheter not an option Advanced/terminal malignancy Pain well localized – unilateral, localized
trunk or involving only a few dermatomes Primary somatic pain mechanism Absence of intraspinal tumor spread Pain relieved with prognostic local block Realistic expectations by patient and family Patient clearly understands possible side
effects
Quality of analgesia might be less than after local anesthetic
Duration of effect not permanent Requires downward titration of opiates Lack of procedural skill in physician pool Potential for long term complications Neuropathic pain and dysesthesias Analgesic failure – incomplete block,
wrong neural target New pain at distal site
Celiac plexus block – relieves pain from intra abdominal viscera excluding left colon and pelvic content
Superior hypogastric plexus block – manages visceral component of pelvic pain
Ganglion Impar block – manages persistant burning associated with pelvic pain
Intercostal blocks – manages chest wall malignancy
Gasserian block – manages trigeminal tumor infiltration pain
Meticulous selection significantly increases success
Inferior to intrathecal pumps, cost of the latter often prohibitive – visible versus invisible cost
Both alcohol and phenol are cheap Possible future resurgence of these
techniques due to increasingly hostile financial environment
Do not allow perfect to be the enemy of good