Role of anaesthesiologist in management of cancer pain

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Role of anaesthesiologist in management of cancer pain

  1. 1. Role of Anaesthesiologist in Management of Cancer Pain Co – ordinator: Dr. Veena Gupta Speaker: Anand Maurya
  2. 2. What is Cancer?  Cancer is the uncontrolled growth of abnormal cells in the body, Cancerous cells are also called malignant cells.  Cancer grows out of normal cells in the body.  Normal cells multiply when the body needs them, and die when the body doesn't need them.  Cancer appears to occur when the growth of cells in the body is out of control and cells divide too quickly.  Cancer can develop in almost any organ or tissue, such as the lung, colon, breast, skin, bones, or nerve tissue.
  3. 3. Cancer Pain  Approximately 19 million people worldwide experience cancer pain every year.  Of these, 40–80% suffer from moderate to severe pain.  Their pain may be due to the  Cancerous lesion itself,  Metastatic disease,  Complications such as neural compression or infections,  Chemotherapy Treatment, or  Totally unrelated factors.  The pain manager must therefore have a good understanding of the nature of the cancer, its stage, the presence of metastatic disease, and treatments.
  4. 4. Components of Cancer Pain  Somatic Pain  Dull, sharp, localized  Tumor / Mass effect  Musculoskeletal involvement  Visceral Pain  Deep, squeezing, not well-localized  Infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera  Referred pain
  5. 5.  Neuropathic Pain  Shooting, sharp, burning, “pins & needles”  CA compressing or infiltrating nerves/nerve roots/blood supply to nerve  Nerve damage from treatments
  6. 6. Effects of Pain  Physiological  Increased catabolic demands: poor wound healing, weakness, muscle breakdown  Decreased limb movement: increased risk of DVT/PE  Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis.  Increased sodium and water retention  Decreased gastrointestinal mobility  Tachycardia and elevated blood pressure  Psychological  Negative emotions: anxiety, depression  Sleep deprivation  Existential suffering
  7. 7. What Does Pain Mean to Patients?  Poor prognosis or impending death  Particularly when pain worsens  Decreased autonomy  Impaired physical and social function  Decreased enjoyment and quality of life  Challenges to dignity  Threat of increased physical suffering
  8. 8. Patient Pain History  Onset / duration  Quality?  Site(s) of pain/radiation?  Severity of pain?  What aggravates or relieves pain?  Impact on sleep, mood, activity?  Effectiveness of medication?
  9. 9. Pharmacologic Management  Opioids  Tramadol  Morphine  Fentanyl  Codeine  Oxycodone  Hydrocodone  Methadone  Non-opioid therapy / Co-analgesics  NSAIDS  Acetaminophen  Topicals • Lidocaine, Capsaicin Practice Points: o Mild pain o “ceiling” effect o Start at lowest effective dose o Review pt’s underlying medical illnesses Practice Points: o If pain constant/chronic – use long-acting opioids with short- acting for breakthrough o Breakthrough dose - 10-20% of total daily dose o Assess pt’s clinical and financial situation before prescribing
  10. 10.  Adjuvants  Antidepressants • TCAs for neuropathic pain  Anticonvulsants  Corticosteroids  Neuroleptics  Alpha2 – agonists  Benzodiazepines  Antispasmodics  Muscle relaxants  NMDA-blockers  Systemic local anesthetics Practice Points: o Choose adjuvant carefully (risk:benefit) o Start low and titrate gradually o Avoid initiating several adjuvants concurrently
  11. 11. Non-Pharmacologic Management  Acupuncture  Yoga  Guided imagery  Cold/heat  Massage  Vibration  TENS units  Exercise programs  Hypnosis  Counseling
  12. 12. WHO Ladder
  13. 13. Role of Anaesthesia  Interventions  Palliative surgery  Kyphoplasty/Vertebroplasty  Sedation  Nerve Blocks  Epidural  Intrathecal pain pumps  Lidocaine infusion
  14. 14. Nerve Blocks for Pain Relief  A nerve block relieves pain by interrupting how pain signals are sent to your brain. It is done by injecting a substance, such as alcohol or phenol, into or around a nerve or into the spine.  Nerve blocks may be used for several purposes, such as:  To determine the source of pain.  To treat painful conditions.  To predict how pain will respond to long-term treatments.  For short-term pain relief after some surgeries and other procedures.  For anesthesia during some smaller procedures, such as finger surgery.  Nerve blocks are used to treat chronic pain when drugs or other treatments do not control pain or cause bad side effects.  A test block is usually performed with local anesthetic.
  15. 15. Types of Sympathetic Block  Diagnostic blocks are used to assess the sympathetic component of pain.  To define the sympathetic contribution to any particular pain syndrome, the diagnostic block must be a pure sympathetic block without any accompanying somatic block.  Use of diagnostic blocks is difficult and often inaccurate. Increasing skin temperature, decreasing pain, and anhydrosis in the distal extremity may indicate a successful sympathectomy.  Prognostic blocks can be used to try to test the effect on pain, blood flow, or sweating, but there may be a poor correlation between the prognostic block and the outcome of any subsequent surgical or neuroablative procedure.  Therapeutic blocks may be performed with local anaesthetics, neurolytic chemicals such as phenol or alcohol, neuroablative techniques such as radiofrequency lesioning, or with drugs such as guanethidine and bretylium in i.v. regional techniques.
  16. 16. Drugs and Techniques  Local anaesthetics are used for diagnostic, prognostic, and therapeutic blocks.  Lidocaine 1% is suitable for a diagnostic block, but bupivacaine 0.25–0.5% is often preferred for other blocks.  Neurolytic solutions are used for therapeutic blocks; the most common are phenol and alcohol.  Phenol destroys both motor and sensory nerve fibres by protein denaturation; at a concentration of 2–3% in saline, phenol seems to spare motor function.  As fibres can regenerate, these blocks are not permanent. Phenol is not as effective as alcohol in destroying the nerve cell body and its effect tends to be less profound and of shorter duration than alcohol.  Alcohol has a similar non-selective destructive action on nerves, but it produces a very high incidence of neuritis. Although 50–100% alcohol is used as a neurolytic, a local anaesthetic is commonly used as a diluent.

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