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  • 1. SYAFRUDDIN GAUS DEPARTMENT OF ANESTHESIOLOGY, INTENSIVE CARE AND PAIN MANAGEMENT FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY
  • 2. Magnitude of Cancer Pain Etiology of Cancer Pain Pathophysiologic of Cancer Pain Clinical Characteristic of Cancer Pain Evaluation of Cancer Pain Management of Cancer Pain CPD Perioperative IDSAI, Medan Juli 2010
  • 3.  Bonica 1985  50 % of patient of all stage reported pain  > 70 % with advanced cancer  Faley 1985  50 % of patient with non metastatic cancer had significant pain  60-90 % of patient with advanced cancer reported debilitating pain  WHO 1986  70 % of patient with advanced cancer has pain  3,5 million people suffering from cancer pain with or without satisfactory treatment every day  Paice, 2006  20-75% have pain at first diagnosis  23- 100% report pain in advance stage CPD Perioperative IDSAI, Medan Juli 2010
  • 4. TOTAL PAIN SOMATIC SOURCE ANXIETY ANGERDEPRESSION Non-cancer pathology Cancer Symptoms of debility Side-effects of theraphy Loss of social position Loss of job prestige and income Loss of role in family Chronic fatigue and insomnia Sense of helpessness Disfigurement Bureaucratic bungling Friends who do not visit Delay in diagnosis Unavailable doctors Irritability Therapeutic failure Fear of hospital or nursing home Worry about family Fear of death Spiritual unrest Fear of pain Family finances Loss of dignity and bodily control Uncertainty about future WHO 1986 CPD Perioperative IDSAI, Medan Juli 2010
  • 5.  TUMOR-RELATED PAIN  TREATMENT-RELATED PAIN  DEBILITY-RELATED PAIN  NON-MALIGNANT CONCURRENT DISEASE CPD Perioperative IDSAI, Medan Juli 2010
  • 6.  Surgical procedures  Chemotherapy  Immediate acute pain : iv infusion pain  Painful sequelae : arthralgia, headache, mucositis  Radiotherapy  Soft tissue injury : mucositis, proctitis, peripheral neurophaty, ets CPD Perioperative IDSAI, Medan Juli 2010
  • 7.  NOCICEPTIVE PAIN  SOMATIC PAIN  VISCERAL PAIN  NEUROPHATIC PAIN  NERVE COMPRESSION  DEAFFERENTATION NERVE INJURY  SYMPATHETICALLY MEDIATED  PSYCHOGENIC PAIN CPD Perioperative IDSAI, Medan Juli 2010
  • 8. 1. Nociceptive pain  Somatic pain :  aching, stabbing, throbbing  Well localized  Visceral pain :  obstruction : gnawing, cramping  Organ capsule : aching, sharp, throbbing  Diffuse and difficult localize  May referred to somatic structure CPD Perioperative IDSAI, Medan Juli 2010
  • 9. 2. Neuropathic pain  Nerve compressions  Burning, prickling, electric like  Area innervated nerve  Malignancy compression  Deafferentation nerve injury  Same nerve compressions + shooting,stabbing  allodynia  Often loss afferent sensory function  Superficial burning pain CPD Perioperative IDSAI, Medan Juli 2010
  • 10.  Sympathetically mediated  Cutaneous vasodilatation, increased skin temperature, abnormal sweating, tropic cahanges and allodynia  Nondermatomal pattern pain  Diagnostic sympathetic block 3. Psychogenic pain - after pathology pain generating excluded - can contribute but pure psychogenic etiology is rare CPD Perioperative IDSAI, Medan Juli 2010
  • 11.  REFLECT  TUMOR SIZE  LOCATION  EXTENT TISSUE DESTRUCTION  MECHANISM OF PAIN  PAIN INTENSITY USED TO GUIDE ANALGESIC THERAPY CPD Perioperative IDSAI, Medan Juli 2010
  • 12.  MEDICAL HISTORY  PAIN HISTORY  PAIN ASSESSMENT :  LOCATION  CHARACTER  SEVERITY  ONSET  DURATION  TEMPORAL PATTERN  RELIEVING AND EXACERBATION FACTOR  ASSOCIATED SYMPTOMS  PREVIOUS ANALGESIC THERAPY  SPECIFIC CANCER TREATMENT CPD Perioperative IDSAI, Medan Juli 2010
  • 13.  ORIGINALLY INTRODUCED IN 1986  SIMPLE  THREE STEP  WIDELY AVAILABLE AND INEXPENSIVE ANALGESIC  GLOBALLY DISTRIBUTED AND CURRENTLY CONSIDERED AS STANDARD FOR MANAGEMENT CANCER PAIN CPD Perioperative IDSAI, Medan Juli 2010
  • 14. CPD Perioperative IDSAI, Medan Juli 2010
  • 15.  Mainstay of cancer pain  Multiple routes  Enteral  Parenteral ( iv, sc )  Spinal delivery  Transdermal  Transmucosal  Several formulation :  sustained release eg. MS Contin, Kadian, Avinza.  Rapid release : not available in Indonesia CPD Perioperative IDSAI, Medan Juli 2010
  • 16. Opioid Half live Equipotent IV dose ( mg/kg) Equipotent PO dose ( mg/kg ) Duration ( hr ) Morphine Fentanyl Pethidine Alfentanyl Sufentanyl Codeine Oxycodone 2-4 hrs 1 – 7 min 3 – 4 hrs 1.4 min 1.4 min 3 hrs 2 – 6 hrs 0.1 0.001 1 0.05 0.0001 1.2 N/A 0.3 – 0.5 0.001-0.005 transmucosal 1.5 – 2 N/A N/A 2 0.1 3-5 0.75 – 1 2 – 3 0.5 1 4 - 6 4 – 6 CPD Perioperative IDSAI, Medan Juli 2010
  • 17.  Least lipid soluble  Metabolites M6G and M3G ( longer half lifes )  M6G more potent than morphine  M3G ( no analgesic effect ) role in tolerance  Slow release ( controlled release or sustained release ) use for chronic and cancer pain  Slow onset, prolonged duration  fast titration its impossible CPD Perioperative IDSAI, Medan Juli 2010
  • 18.  Highly lipid soluble synthetic opioid  Rapid onset and short duration  Metabolite inactive (safe for renal impairment)  Suitable for transdermal administration CPD Perioperative IDSAI, Medan Juli 2010
  • 19.  Synthetized as a potential substitute for atropine  ( atropine like effect )  Weak affinity for NMDA receptor  Pethidine superior in renal and biliary colic but evidenced show that all opioids are equally effective  Metabolite is norphetidine ( normeperidine ) with long half-life ( 15-20 hrs )  analgesia ( µ receptors ) but neurotoxicity ( CNS excitation : anxiety, mood changes, tremors, twitching, myoclonic , convulsion ) CPD Perioperative IDSAI, Medan Juli 2010
  • 20.  Treatment  Discontinue pethidine  Substitue to alternative opioid  Symptomatic treatment  DO NOT administer naloxone  Suggest  Dose limit : 1000 mg in first 24 hrs and 600-700 mg/day thereafter, Reduced in elderly  Should be avoided in renal impairment CPD Perioperative IDSAI, Medan Juli 2010
  • 21.  Centrally acting synthetic analgesia  µ receptors activity ( by main metabolite M1 ( O-desmethyl-tramadol ))  Inhibit reuptake NE and serotonine (5HT ) in nerve terminal  Advantages of equianalgesic dose opioid  Less sedation  Less repiratory depression  Less constipation  Nausea and vomiting similar  Not a controlled drug CPD Perioperative IDSAI, Medan Juli 2010
  • 22.  Epilepsy was relatively contra indication  Seizure have been reported but probably similar with other opioid  Accumulation M1 in renal failure can cause respiratory depression  Total daily dose : 600 mg CPD Perioperative IDSAI, Medan Juli 2010
  • 23.  Naturally alkaloid like morphine  Metabolized in liver by CYP 2D6  converted to morphine (2-10%)  analgesic effect of Codeine ( ineffective prodrug of morphine )  Usually for mild to moderate pain  Combine with non-opioid agents like acetominophen or aspirin  increased analgesic efficacy but also decreased opioid relate adverse effect CPD Perioperative IDSAI, Medan Juli 2010
  • 24. Oral dose ( mg ) Opioid Parenteral iv/sc/im ( mg ) 400 Meperidine 100 100 Tramadol 100 200 Codeine 130 30 Morphine 10 - Fentanyl 0.15 – 0.20 - Sufentanyl 0.02 Morphine 50 mg PO in 24 hrs = fentanyl patch 25 mcg/hr CPD Perioperative IDSAI, Medan Juli 2010
  • 25.  Analgesic antipyretic  Used in all steps in Stepladder WHO  Recommend dose 4000 mg/d  Dose adjustment in hepatic dysfunction CPD Perioperative IDSAI, Medan Juli 2010
  • 26.  Analgesic, antipyretic and anti-inflammatory  Nonselective agents and selective COX-2 inhibitors  Effective component in multimodal therapy  Carefully selected patients due to adverse effect  COX-2 inhibitors proveide protection adverse effect but concern in Cardiovascular effect CPD Perioperative IDSAI, Medan Juli 2010
  • 27.  Antidepressant  Inhibition NE and serotonin reuptake  For neurophatic pain  Delays onset day to week  Mood elevating and sleep enhancing effect  Adverse effect on cardiac , glaucoma n prostatic  Amitriptyline, Nortryptiline and Despiramine  Anticonvulsant  For neurophatic pain eg. Chemotherapy  Na channel blocker : Carbamazepine and clonazepam  Gabapentin : Ca Channel and can act as NMDA antagonist . 900 – 3600 mg/d CPD Perioperative IDSAI, Medan Juli 2010
  • 28.  Corticosteroids  Inhibit prostaglandin synthesis and reduce edema  For neuropathic pain syndrome  Bone pain , malignant intestinal obstruction  Dexamethasone 12 – 24 mg once daily  NMDA antagonist  Bind EAA glutamat  For severe neuropathic pain  Routine use limited due to cognitive changes CPD Perioperative IDSAI, Medan Juli 2010
  • 29.  Local anesthetic  Inhibiting ions across neural membrane  Relieving neuropathic pain  Orally, topically, intravenously, subcutaneously, spinally  For Intractable neuropathic pain : Lidocaine intravenous 1 – 2 mg/kg ( max 500 mg ) over 1 hour then 1 -2 mg/kg/h continuous infusion CPD Perioperative IDSAI, Medan Juli 2010
  • 30.  Nerve block  Sympathetic nerve block  Myofacial trigger point  Neurolytic block : celiac plexus block  Epidural or intratechal drugs CPD Perioperative IDSAI, Medan Juli 2010
  • 31.  Physical therapy  TENS  Accupuncture  Counterirritation  Psychological approach  Depression and anxiety most often  Cognitive intervention : relaxation CPD Perioperative IDSAI, Medan Juli 2010
  • 32. CPD Perioperative IDSAI, Medan Juli 2010