10th Malaysian Hospice Congress

Palliative Care Meeting the Increasing Needs

WHEN STANDARD REGIME FAILS, WHAT TO DO?

Ungku Kamariah bte Ungku Ahmad Pain Specialist and Anaesthesiologist Hospital Sultan Ismail Johor Bahru
1st 3rd June 2012 Persada Johor International Convention Center Johor Bahru

Although few people die of Pain, many die in Pain and even more live in Pain

Declaration on Chronic Pain IASP Global Day on Pain 2004

The Epidemiology of Pain: Cancer Pain

Prevalence data: - 25 million living with ca in the world wide Prevalence of pain: - increased with progression of disease Intensity, type and location of pain: - varies with 1 site, extension, progression and type of Rx employed

Cont.
pain occurs in 30% of all cancer patients, regardless of the stage of the disease. not all cancer patients feel pain, and pain is rarely a sign of early cancer. 30% - 40% of patients suffers with pain while on active Rx 90% of patients with advanced cancer experience severe pain Pain usually increases as cancer progresses..

As many as 50% of patients may be under treated for cancer pain

Cont.

Survey combining epidemiology & ethnographic data on 2266 ca pt in USA who was referred to an anaesthetic base pain clinic services were evaluated:
98%

suffers pain Scores severe to worst was 70% despite 92% was on treatment using analgesia /co-analgesia

(Hill CS. JAMA, 1995) (APF 1999) (Bonica JJ. In: The Management of Pain. 2nd ed. Philadelphia: Lea & Febiger; 1990

Cancer Pain Management

90% patients relief WHO oral guidelines.
5-7% patients - relief parenteral route.

2-3% - interventional spinal therapy.

Mercadante: Pain: 1999:79:1-13.

Canadian Family Physician June 2010 vol. 56 no. 6

Cancer pain syndromes less responsive to conservative management

Opioid-insensitive pain Incident pain associated with long bone fractures/metastaces Visceral nociception Opioid-intolerance

W.H.O. Guidelines for Cancer Pain

Neuroablative techniques Intraspinal opioids / local anaesthetics

Regional catheters S/C or IV opioids / adjuvants / ketamine

Oral opioids / adjuvants.

Psychological therapies Acupuncture; TENS Simple analgesics; NSAIDs.

Anti-neoplastic drugs; XRT

Subcutaneous(S/C) or IV opioids/ adjuvants/ ketamine

Parenteral opioid

PCA (Patient control analgesia):

Morphine : 1-2 mg per bolus Fentanyl: 10-20mcg per bolus

S/C ( subcutaneous):

Morphine :5-10mg 4hrly

S/C or IV opioids/ adjuvants/ ketamine

Local Anaesthetic + NMDA inhibitor infusion: Lignocaine + ketamine IV infusion

Ketamine 2-4mg/hr+ lignocaine 1-2gm over 24hr Solution: ketamine 2mg/ml + lignocaine 40mg/ml

Invasive Analgesic Technique

Anaesthetic Neurosurgical

Anaesthetic technique
Neuro-axial analgesia - epidural - intrathecal Regional analgesia (via LA catheter /infusion) - specific nerve eg. Femoral, brachial etc. - intrapleural cath Neurolytic techniques

cont.Selection

criteria:

Unilateral / bilateral block Duration of analgesic benefit Immediate & long term risk Duration of survival Availability of local expertise Anticipitated hospitalisation time

Selection criteria:

No other option -opioid insensitive pain / intolerance -viceral nonciceptive pain -incident pain

Neuro-axial Analgesia

Epidural intrathecal

Neuroaxial Analgesia: Intrathecal or Epidural ?

Complications: 1 - 20 days
20 + days

IT 20%
5%

EPIDURAL 8%
55%

Crul. Regional Anaesthesia, 1991:16:209

Subcutaneous injection port

Neuroaxial drug selection

Long acting LA as primary agent eg. bupivicaine Opioid : morphine hydromorphone 3rd line agent occasionally needed midazolam (controversial) clonidine

AXILLARY BLOCK

catheter is infused with 0.125-0.25% bupivacaine at 5-10ml/hr. Or attach to a PCA

Neurolytic techniques

Defination:
To

lysis the nerve Drug used : acohol 50% or phenol Success rate for pain relief 80-90% Duration of pain relief : 1-1 year Deafferentation

Area for neurolysis:

Intercostal neurolysis* Paravertebral neurolysis Coeliac plexus neurolysis* Hypogastric neurolysis Superior hypogastric neurolysis* Ganglion impar neurolysis*

Waldman;Atlas Interventional PainManagement :Saunders1998

Waldmann;AtlasIntervetion in PainManagement, WBSaunders2002

Waldman:Atlas Interventional Pain management;WB Saunders 1998

Complications
A. Common : Diarrhoea and postural hypotension short-lived Neurological injury or paralysis rare (1:700) but devastating Trauma/spasm/chemical irritation to Artery of Adamcowitz implicated, not technique Discuss with referring medical team and patient prior to proceeding

B. Uncommon Complication

Paresthesia of lumbar somatic nerves Deficit of above nerve Intra thecal injection Intrapsoas injection Intravascular Vascular thrombosis Retroperitoneal hematoma Pneumothorax

Lower chest pain Failure of ejaculation Sensation of warmth or fullness in lower extremity Urinary abnormalities Chylothorax Renal injury Abscess Peritonitis

Alternative neurolytic uses

Nociception limited to a specific nerve root or peripheral nerve may be amenable to neurolysis

Clinical circumstances determine whether loss of motor and/or sensory function has acceptable risk:benefit

Cont.
Recent examples include: Intrathecal hypobaric alcohol to T9-10 dermatome CT-guided L2 nerve root neurolysis Superficial peroneal nerve neurolysis for ischaemic forefoot

last

References:

Cancer Pain by Richard B. Patt Neurolytic blockade pain management by Micheal Cousin & Phillip O Brindenbaugh Neurolytic in cancer patient by Timothy Sample