1 who pain relief


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  • The coeliac plexus is formed from the convergence of the greater, lesser and least splanchnic nerves, the preganglionic parasympathetic fibres, and the visceral sensory afferents from the stomach to the left half of the colon. These convergences form two semilunar 'ganglia' (right and left) and a mesh-like structure, which lies anterior to the aorta, at the level of the coeliac artery. Normal anatomical variations in site occur, with the coeliac ganglia situated anywhere from the middle of the second lumbar vertebra to the level of the T12-L1 disc. The posterior approach is often used, with the needles placed bilaterally at the lower border of the twelfth rib and the use of radiological imaging to guide the needles (fluoroscopy, ultrasound or CT scanning may equally be used; reported complications are similar). Radio-opaque dye should be used to identify inadvertent intravascular injection, which can occur even when an aspiration for blood has been negative. For neurolytic coeliac plexus block NCPB , both alcohol and phenol have been used, but alcohol is preferably used because: 1. More spasm of lumbar segmental arteries with phenol than with alcohol. 2. Large volumes of chemical required with the risk of systemic phenol toxicity. 3. Concentrations higher than 50% alcohol are no more effective. Pure alcohol also causes skin damage on accidental contact.
  • 1 who pain relief

    1. 1. Palliative care For cancer patients Team approach
    2. 2. Sympathy is not enough
    3. 3. What can we do ?
    4. 5. Better quality of life
    5. 6. Cancer pain management Dr. Ahmed Helmy Abouel Soud Board member of WSPC Professor of Pain Relief, N.C.I., Cairo University, Egypt
    6. 7. Cancer pain <ul><li>70 % of advanced cases </li></ul><ul><li>Any site & any type </li></ul>
    7. 8. Tools <ul><li>Drugs </li></ul><ul><li>Interventions </li></ul>
    8. 9. Pharmacotherapy <ul><li>WHO ladder system </li></ul><ul><li>By the clock </li></ul><ul><li>Oral or transdermal rout </li></ul><ul><li>Full dose </li></ul>
    9. 10. WHO ladder system <ul><li>Non opioid ± adjuvants </li></ul><ul><li>Weak opioids + I </li></ul><ul><li>Strong opioids + I </li></ul>
    10. 11. Sustained release opioids <ul><li>Oral weak opioids e.g. tramundine, D.H.C. </li></ul><ul><li>Oral strong opioids e.g. MST, oxycontin and MXL </li></ul><ul><li>Transdermal e.g. Fentanyl patch (Durogesic) </li></ul>
    11. 12. Newer Fentanyl (Durogesic) patch <ul><li>Simpler, thinner </li></ul><ul><li>Better adhesion </li></ul><ul><li>Fentanyl in dissolved state with no ethanol as permeation enhancer </li></ul><ul><li>Can be divided </li></ul><ul><li>Guarantee stable blood fentanyl level for 72 h </li></ul>
    12. 13. Side effects
    13. 14. Pain interventions minimally invasive procedures <ul><li>Delivery of opioids to the C.N.S . </li></ul><ul><li>Destruction of pain pathway </li></ul>
    14. 15. Delivery of opioids to the C.N.S. <ul><li>Frequent delivery by special device </li></ul><ul><li>Generalized pain, initial good response to the systemic drug with appearance of tolerance or side effects, adequate test response </li></ul><ul><li>Better response with lower dose and lesser side effects </li></ul>
    15. 16. Pain pathway destruction <ul><li>Advanced cancer </li></ul><ul><li>Localized severe pain </li></ul><ul><li>Accessible target </li></ul>
    16. 17. Ideal procedure <ul><li>Life long </li></ul><ul><li>High success rate with selective destruction </li></ul><ul><li>Complete or satisfactory pain relief </li></ul><ul><li>Percutaneous by R.F. or neurolytics </li></ul><ul><li>Under local anesthesia </li></ul><ul><li>No or minimal morbidity </li></ul>
    17. 18. Common targets <ul><li>Celiac plexus </li></ul><ul><li>Superior hypogastric plexus </li></ul><ul><li>Ganglion impar </li></ul><ul><li>Posterior root </li></ul><ul><li>Spinothalamic tract </li></ul><ul><li>Trigeminal tract & nucleus </li></ul>
    18. 19. Neurolytic procedures <ul><li>Celiac plexus </li></ul><ul><li>Superior hypogastric plexus </li></ul><ul><li>Ganglion impar </li></ul><ul><li>Posterior root </li></ul>
    19. 20. Celiac plexus destruction <ul><li>Upper abdominal visceral pain </li></ul><ul><li>Pancreas, hepatobiliary, stomach, intestine </li></ul><ul><li>85% success </li></ul>
    20. 21. Celiac Plexus
    21. 22. Superior hypogastric plexus destruction <ul><li>Pelvic visceral pain </li></ul><ul><li>Bladder, prostate, cervix, uterus, ovary, colon& rectum </li></ul><ul><li>75% success </li></ul>
    22. 23. Ganglion impar <ul><li>Junction of the two paravertebral sympathetic chains </li></ul><ul><li>Sacroccygeal junction </li></ul><ul><li>SMP at the perineal region </li></ul><ul><li>Ca rectum, anal canal, vagina& vulva </li></ul><ul><li>50-60% success </li></ul>
    23. 24. Posterior (sensory) root <ul><li>Localized somatic </li></ul><ul><li>Rib metastases, ca rectum & anal canal </li></ul><ul><li>70% success </li></ul><ul><li>Sensory loss </li></ul>
    24. 25. Percutaneous RF procedures <ul><li>Cordotomy </li></ul><ul><li>Tractotomy-nucleotomy </li></ul><ul><li>Spinothalamic tract </li></ul><ul><li>Trigeminal tract & nucleus </li></ul>
    25. 26. Spinothalamic tract <ul><li>Crossed fibers </li></ul><ul><li>Anterolateral quadrant </li></ul><ul><li>Pain & temperature </li></ul><ul><li>Somatotopic organization </li></ul><ul><li>Important relations </li></ul>
    26. 27. Cordotomy <ul><li>Unilateral cancer pain below the clavicle </li></ul><ul><li>Lung, pleura, pelvic bones & muscles, upper & lower limb </li></ul><ul><li>95% success </li></ul><ul><li>Loss of pinprick & temp </li></ul>
    27. 28. Descending trigeminal tract & subnucleus caudalis <ul><li>Posterolateral part </li></ul><ul><li>Joined by VII, IX and X </li></ul><ul><li>Somatotopic organization </li></ul><ul><li>Important relations </li></ul><ul><li>Pain & temperature </li></ul>
    28. 29. Trigeminal Tractotomy-Nucleotomy <ul><li>Percutaneous </li></ul><ul><li>under L.A. & sedation </li></ul><ul><li>C-T guided </li></ul><ul><li>R.F. </li></ul><ul><li>Occiput / C1 level </li></ul><ul><li>75 % success </li></ul>
    29. 30. Can we offer this ?