Palliative care monthly meeting Speaker: Dr Eric Liang 14 June 2011
 
 
 
 
<ul><li>Seminar A1 </li></ul><ul><li>“ Let me die….” </li></ul><ul><li>Our response to the dying patient </li></ul><ul><li...
<ul><li>Seminar D3 </li></ul><ul><li>Depression & anxiety in Palliative care </li></ul><ul><li>A “Normal” response to dyin...
<ul><li>Seminar E1 </li></ul><ul><li>Difficult pain (1) </li></ul><ul><li>Opioid rotation: not as hard as it looks </li></...
Seminar A1  “ Let me die…..”  <ul><li>What is the patient trying to tell us? </li></ul><ul><li>Express physical distress <...
<ul><li>How would you respond? </li></ul>
Examples of unhelpful responses <ul><li>“ You must be strong….” </li></ul><ul><li>“ You will be OK!.......” </li></ul><ul>...
Important issue: <ul><li>Recognise that this is a golden opportunity to explore </li></ul><ul><li>To show empathy and invi...
Example 1 <ul><li>Lady with ca breast  </li></ul><ul><li>Increasing L sided weakness secondary to brain met </li></ul><ul>...
<ul><li>Imp: extensive physical distress main concern / carers distress </li></ul><ul><li>Mx: </li></ul><ul><li>Commode ch...
Example 2 <ul><li>Man with ca stomach with peritoneal mets / RT tube feeding  </li></ul><ul><li>Divorced & remarried 6 mon...
<ul><li>Imp:  </li></ul><ul><li>Meaning of “Let me die “ is mainly psychological distress </li></ul><ul><li>Tired of the j...
Example 3 <ul><li>COAD & Ca lung patient / chemo stopped </li></ul><ul><li>Progressively getting weaker, walking needs ass...
<ul><li>Imp: </li></ul><ul><li>More existential issue </li></ul><ul><li>Patient is ready to go, but why need so much medic...
Palliative chemotherapy: benefit or burden? <ul><li>What is palliative chemotherapy? </li></ul><ul><li>Chemotherapy given ...
What are patient’s attitude towards chemo <ul><li>Chance to cure </li></ul><ul><li>Chance to prolong survival </li></ul><u...
<ul><li>General public: expect minimal but large benefit </li></ul><ul><li>Health care provider: in between the two above ...
<ul><li>Physicians view point: </li></ul><ul><li>Doctors appears willing to treatment with small benefits </li></ul><ul><l...
<ul><li>Benefits: </li></ul><ul><li>Symptom control / QoL </li></ul><ul><li>Tumour regression ( upto 20% of pt treated) </...
<ul><li>Burden </li></ul><ul><li>Costs (upto US $90,000 in 6 month) </li></ul><ul><li>Care giver burden ( psychological, e...
When to prescribe palliative chemo? <ul><li>Create a balance score of benefit vs harm </li></ul><ul><li>Note these factor ...
<ul><li>NOT to give pallative chemo as a substitute for antidepressant </li></ul>
Example 1 <ul><li>50/F with colorectal cancer </li></ul><ul><li>Responded to chemotherapy with minimal side effect  </li><...
Example 2 <ul><li>50/F ca colon with liver mets </li></ul><ul><li>Receiving 2nd line chemo & anti EGRF monoclonal antibody...
Example 3 <ul><li>30 yo man with advanced cancer wants to spend more time with his son </li></ul><ul><li>But progressive d...
Depression & anxiety in palliative care A “Normal” response to dying? <ul><li>Depression: </li></ul><ul><li>General popula...
<ul><li>Thanatophobia  </li></ul><ul><li>=Fear of death </li></ul><ul><li>Greek mythology / Thanato =God of death </li></u...
<ul><li>A spectum of possibility </li></ul><ul><li>Normal reaction </li></ul><ul><li>Grieve reaction </li></ul><ul><li>Ill...
<ul><li>Important to recognise: </li></ul><ul><li>Major depression is best predictor of MI, angioplasty, death 12 months a...
<ul><li>Important to treat/control anxiety as it will help to: </li></ul><ul><li>Enhance tolerance to other symptoms </li>...
Management of anxiety <ul><li>Reasuring stance help – knowledge & skill </li></ul><ul><li>Education helps </li></ul><ul><l...
medications <ul><li>Benzodiazepam </li></ul><ul><li>Anti-psychotic </li></ul><ul><li>Antihistamine </li></ul><ul><li>Anti ...
<ul><li>Note on benzodiazepam: </li></ul><ul><li>fear of respiratory depression should not prevent the use </li></ul><ul><...
<ul><li>Other treatment: </li></ul><ul><li>Brief psychotherapy </li></ul><ul><li>Behavioural techniques </li></ul><ul><li>...
Demoralisation Impact on patients & caregivers <ul><li>The term demoralization emerged in 2000 </li></ul><ul><li>Psychosom...
Differentiation form depression <ul><li>Similar but different </li></ul><ul><li>Mood reactivity is usually preserved </li>...
<ul><li>Demoralisation scale </li></ul><ul><li>J Palliative Care 2004; 20:269-276 </li></ul>
Clinical association of demoralization syndrome <ul><li>Illness related: </li></ul><ul><li>Breaking of diagnosis </li></ul...
<ul><li>Treatment related </li></ul><ul><li>Limb amputation, mastectomy </li></ul><ul><li>Chemotherapy </li></ul><ul><li>T...
<ul><li>Countertransference & demoralization </li></ul><ul><li>Demoralization is contagious </li></ul><ul><li>Demoralized ...
<ul><li>encountering demoralization: </li></ul><ul><li>Treat physical symptoms </li></ul><ul><li>Address social, financial...
<ul><li>Difficult cancer pain </li></ul><ul><li>3 categories </li></ul><ul><li>Poorly responsive to morphine </li></ul><ul...
Treatment for difficult cancer pain <ul><li>Disease modifying agent </li></ul><ul><li>Identify psychosocial, emotional, sp...
<ul><li>Indication for opioid rotation </li></ul><ul><li>Dose limiting adverse effects </li></ul><ul><li>Difficult pain sy...
Stop & go method <ul><li>Rescue dose =1/6th of daily dose upto 3/day  </li></ul>12:1 morphine >300mg/day 8:1 morphine 90-3...
3 day Edmonton rotation schedule 2.5mg methadone 20mg morphine 20mg morphine 20mg morphine Breakthrough opioid 15mg /day 1...
<ul><li>Opioid rotation can be successful if…. </li></ul><ul><li>The basis for it is clear </li></ul><ul><li>It is part of...
Management of cancer pain <ul><li>WHO analgesic ladder </li></ul><ul><li>This manage to relief upto 80-90% of all cancer p...
Benefits of interventional techniques <ul><li>More targeted & effective </li></ul><ul><li>The dose of drugs much smaller t...
<ul><li>Choice of technique </li></ul><ul><li>Life expectancy </li></ul><ul><li>Mechanism & type of pain </li></ul><ul><li...
Peripheral nerve block <ul><li>Limited role </li></ul><ul><li>Case series on short term pain relief </li></ul><ul><li>Acut...
 
Epidural or intrathecal? <ul><li>Trend towards intrathecal </li></ul><ul><li>Lower dosages </li></ul><ul><li>Less frequent...
opioids <ul><li>Large studies shows improved quality of life, functional capacity & pain scores </li></ul><ul><li>Smith et...
morphine <ul><li>Hydrophilic nature </li></ul><ul><li>Spread to level distal to the site of injection </li></ul><ul><li>On...
Local anaesthetic <ul><li>Improves pain relief & patient satisfaction </li></ul><ul><li>Deer et al. Spine 2002; 2(4): 274-...
Neurolytic technique <ul><li>Interruption of nociceptive transmission from peripheral tissue to spinal cord </li></ul><ul>...
Intrathecal neurolysis <ul><li>Administration of alcohol or phenol into subarachnoid space </li></ul><ul><li>Aims to achie...
Coeliac plexus block <ul><li>Main indication for ca pancreas </li></ul><ul><li>Also for upper GI cancer </li></ul><ul><li>...
Complications <ul><li>Diarrhoea 30% & postural hypotension 60% </li></ul><ul><li>Short lived 48hrs </li></ul><ul><li>Neuro...
Other neurolytic blocks <ul><li>Superior hypogastric </li></ul><ul><li>Ganglion impar </li></ul><ul><li>intercostal </li><...
Summary <ul><li>Intervention should be appiled carefully, appropriately and at the right time </li></ul><ul><li>Improve qu...
<ul><li>Thank you  </li></ul>
 
 
 
 
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Palliative care monthly meeting

  1. 1. Palliative care monthly meeting Speaker: Dr Eric Liang 14 June 2011
  2. 6. <ul><li>Seminar A1 </li></ul><ul><li>“ Let me die….” </li></ul><ul><li>Our response to the dying patient </li></ul><ul><li>Dr JaanYang Kok </li></ul><ul><li>Seminar D2 </li></ul><ul><li>Palliative chemotherapy </li></ul><ul><li>Benefit or burden </li></ul><ul><li>A/Prof Simon Ong </li></ul>
  3. 7. <ul><li>Seminar D3 </li></ul><ul><li>Depression & anxiety in Palliative care </li></ul><ul><li>A “Normal” response to dying? </li></ul><ul><li>Dr Daniel Kwek </li></ul><ul><li>Seminar D4 </li></ul><ul><li>Demoralisation </li></ul><ul><li>The impact on patients & caregivers </li></ul>
  4. 8. <ul><li>Seminar E1 </li></ul><ul><li>Difficult pain (1) </li></ul><ul><li>Opioid rotation: not as hard as it looks </li></ul><ul><li>Dr Allyn Hum </li></ul><ul><li>Seminar E2 </li></ul><ul><li>Difficult pain (2) </li></ul><ul><li>Interventions in complex cancer pain </li></ul><ul><li>Dr Kian Hian Tan </li></ul>
  5. 9. Seminar A1 “ Let me die…..” <ul><li>What is the patient trying to tell us? </li></ul><ul><li>Express physical distress </li></ul><ul><li>Express psychological distress </li></ul><ul><li>Really wants to die </li></ul>
  6. 10. <ul><li>How would you respond? </li></ul>
  7. 11. Examples of unhelpful responses <ul><li>“ You must be strong….” </li></ul><ul><li>“ You will be OK!.......” </li></ul><ul><li>“ You will get better…….” </li></ul><ul><li>“ You must be positive, don’t say such words….” </li></ul><ul><li>“ Euthanesia is not legal…..” </li></ul><ul><li>“ I don’t have such a medication…..” </li></ul>
  8. 12. Important issue: <ul><li>Recognise that this is a golden opportunity to explore </li></ul><ul><li>To show empathy and invite the patient to talk </li></ul><ul><li>Practical 3 step approach </li></ul><ul><li>Assess physical distress & treat accordingly </li></ul><ul><li>Assess psychological distress & treat accordingly </li></ul><ul><li>Assess existential issue & assess for suicidal ideation </li></ul>
  9. 13. Example 1 <ul><li>Lady with ca breast </li></ul><ul><li>Increasing L sided weakness secondary to brain met </li></ul><ul><li>Was able to walk to toilet but not now </li></ul><ul><li>pain from hepatomegaly / poor appetite / impacted stool </li></ul><ul><li>Husband & maid supportive but difficult </li></ul><ul><li>Pt voiced out “let me die” </li></ul>
  10. 14. <ul><li>Imp: extensive physical distress main concern / carers distress </li></ul><ul><li>Mx: </li></ul><ul><li>Commode chair </li></ul><ul><li>Dexamethasone </li></ul><ul><li>Clear bowel </li></ul><ul><li>Adjust analgesic </li></ul><ul><li>Kept at home </li></ul><ul><li>Additional help from house nurse </li></ul>
  11. 15. Example 2 <ul><li>Man with ca stomach with peritoneal mets / RT tube feeding </li></ul><ul><li>Divorced & remarried 6 month before diagnosis </li></ul><ul><li>Tried all possible treatment </li></ul><ul><li>Pt felt sorry for his new wife </li></ul><ul><li>Wanted to live longer to accompany his wife </li></ul><ul><li>Many physical symptom </li></ul><ul><li>Voiced out “ Let me die….” </li></ul>
  12. 16. <ul><li>Imp: </li></ul><ul><li>Meaning of “Let me die “ is mainly psychological distress </li></ul><ul><li>Tired of the journey and want to die, but yet wants to live longer for the sake of his wife </li></ul><ul><li>Rx: </li></ul><ul><li>Aggressive mangement of pain & symptom </li></ul><ul><li>Support wife </li></ul><ul><li>Support pt staying home with wife as much as possible </li></ul>
  13. 17. Example 3 <ul><li>COAD & Ca lung patient / chemo stopped </li></ul><ul><li>Progressively getting weaker, walking needs assistance </li></ul><ul><li>Activities limited by dyspnoea </li></ul><ul><li>Frustrated with all the medication given </li></ul><ul><li>“ Nurses force me to take medication” </li></ul><ul><li>refused all medication & voiced out “Let me die” </li></ul>
  14. 18. <ul><li>Imp: </li></ul><ul><li>More existential issue </li></ul><ul><li>Patient is ready to go, but why need so much medication </li></ul><ul><li>Mx: </li></ul><ul><li>Review medication </li></ul><ul><li>Stop meds except those absolutely necessary </li></ul><ul><li>Stop medication may not hasten death but too much medication will certainly hasten patient’s suffering </li></ul>
  15. 19. Palliative chemotherapy: benefit or burden? <ul><li>What is palliative chemotherapy? </li></ul><ul><li>Chemotherapy given aiming for symptomatic improvement to enhance comforte of patient & to improve QoL </li></ul><ul><li>Not aiming for prolonging survival </li></ul>
  16. 20. What are patient’s attitude towards chemo <ul><li>Chance to cure </li></ul><ul><li>Chance to prolong survival </li></ul><ul><li>Only to relief symptom </li></ul><ul><li>Patient may wants to have intensive treatment for small benefit </li></ul><ul><li>(may not be understood by someone who is well) </li></ul>
  17. 21. <ul><li>General public: expect minimal but large benefit </li></ul><ul><li>Health care provider: in between the two above </li></ul>
  18. 22. <ul><li>Physicians view point: </li></ul><ul><li>Doctors appears willing to treatment with small benefits </li></ul><ul><li>Due likely to: </li></ul><ul><li>Uncertainty in prognostication </li></ul><ul><li>Not to decrease patient’s hope </li></ul><ul><li>18% & 8% of patient received chemotherapy 4 & 2 weeks before death respectively </li></ul><ul><li>Mostly decided by physicians </li></ul>
  19. 23. <ul><li>Benefits: </li></ul><ul><li>Symptom control / QoL </li></ul><ul><li>Tumour regression ( upto 20% of pt treated) </li></ul><ul><li>Longer survival (eg target therapy provide 20-25 month of survival) </li></ul>
  20. 24. <ul><li>Burden </li></ul><ul><li>Costs (upto US $90,000 in 6 month) </li></ul><ul><li>Care giver burden ( psychological, economical, occupational burden ) </li></ul><ul><li>Drug Toxicity (20-40% mild / upto 10% severe / death 1-3%) </li></ul>
  21. 25. When to prescribe palliative chemo? <ul><li>Create a balance score of benefit vs harm </li></ul><ul><li>Note these factor may not be equal in importance </li></ul><ul><li>Override by patient’s desire </li></ul><ul><li>Given when there is meaningful potential benefit without unbearable toxicity and taken patients wish into account </li></ul>
  22. 26. <ul><li>NOT to give pallative chemo as a substitute for antidepressant </li></ul>
  23. 27. Example 1 <ul><li>50/F with colorectal cancer </li></ul><ul><li>Responded to chemotherapy with minimal side effect </li></ul><ul><li>Survived for 3 years </li></ul><ul><li>Palliative chemo has added enjoyable & meaningful years to her life </li></ul>
  24. 28. Example 2 <ul><li>50/F ca colon with liver mets </li></ul><ul><li>Receiving 2nd line chemo & anti EGRF monoclonal antibody </li></ul><ul><li>Family is crushed by the financial burden </li></ul><ul><li>Although patient’s chemo is able to provide tumour regression & prolong survival </li></ul><ul><li>But the overwhelming economic & psychological burden is far exceeding the benefit </li></ul>
  25. 29. Example 3 <ul><li>30 yo man with advanced cancer wants to spend more time with his son </li></ul><ul><li>But progressive disease despite chemo x2 </li></ul><ul><li>Patient still contemplated for further chemo for longer survival to accompany his son </li></ul>
  26. 30. Depression & anxiety in palliative care A “Normal” response to dying? <ul><li>Depression: </li></ul><ul><li>General population 6-10% </li></ul><ul><li>Oncology 45-58% </li></ul><ul><li>Palliative care 24% </li></ul><ul><li>Death </li></ul><ul><li>Unknown, irreversibility, loneiness, separation, loss of life </li></ul><ul><li>Also: confined, pain, SOB, loss of consciousness </li></ul>
  27. 31. <ul><li>Thanatophobia </li></ul><ul><li>=Fear of death </li></ul><ul><li>Greek mythology / Thanato =God of death </li></ul><ul><li>Is a well recognized entity in human psyche </li></ul><ul><li>Phobia becomes abnormal when: </li></ul><ul><li>The fear go beyond the normal intensity, duration, perversiveness & quality </li></ul><ul><li>Interfere with patient’s functioning in life </li></ul>
  28. 32. <ul><li>A spectum of possibility </li></ul><ul><li>Normal reaction </li></ul><ul><li>Grieve reaction </li></ul><ul><li>Illness related symptom </li></ul><ul><li>Adjustment disorder </li></ul><ul><li>Due to medication </li></ul><ul><li>Psychiatric disorder </li></ul><ul><li>Organic brain syndrome </li></ul>
  29. 33. <ul><li>Important to recognise: </li></ul><ul><li>Major depression is best predictor of MI, angioplasty, death 12 months after cardiac catheterization </li></ul><ul><li>In GAD, there is increased risk of VT </li></ul><ul><li>Depression increases mortality after stroke </li></ul>
  30. 34. <ul><li>Important to treat/control anxiety as it will help to: </li></ul><ul><li>Enhance tolerance to other symptoms </li></ul><ul><li>Affect compliance </li></ul><ul><li>Influence staff & family reaction </li></ul><ul><li>Note: </li></ul><ul><li>Also related to procedures & tests </li></ul><ul><li>Often physical & somatic symptoms may overshadow anxiety symptom </li></ul>
  31. 35. Management of anxiety <ul><li>Reasuring stance help – knowledge & skill </li></ul><ul><li>Education helps </li></ul><ul><li>Psychological methods </li></ul><ul><li>Pharmacological treatments </li></ul><ul><li>Note: </li></ul><ul><li>Assumption that high anxiety is inevitable is not helpful </li></ul><ul><li>Use somatic symptoms as cues to inquire about the patient’s psychological states which commonly is fear, worry or apprehension </li></ul><ul><li>Take patient’s subject level of distress </li></ul>
  32. 36. medications <ul><li>Benzodiazepam </li></ul><ul><li>Anti-psychotic </li></ul><ul><li>Antihistamine </li></ul><ul><li>Anti depressant </li></ul><ul><li>Opioid </li></ul>
  33. 37. <ul><li>Note on benzodiazepam: </li></ul><ul><li>fear of respiratory depression should not prevent the use </li></ul><ul><li>Use short acting </li></ul><ul><li>Start with small dose </li></ul><ul><li>Increase the dose slowly </li></ul><ul><li>Switch to long acting ones if appropriate </li></ul><ul><li>Alternatively can use low dose antipsychotic </li></ul>
  34. 38. <ul><li>Other treatment: </li></ul><ul><li>Brief psychotherapy </li></ul><ul><li>Behavioural techniques </li></ul><ul><li>Patient with high spirituality or intrinsic religiosity is less likely to have psychological disturbance </li></ul><ul><li>Ability to derive the meaning of life & maintain peace internally </li></ul>
  35. 39. Demoralisation Impact on patients & caregivers <ul><li>The term demoralization emerged in 2000 </li></ul><ul><li>Psychosomatics: 2000;41: 418-425 </li></ul><ul><li>Recent definition: </li></ul><ul><li>Loss of meaning, purpose, with helplessness, hopelessness </li></ul><ul><li>Inability to cope, social isolation </li></ul><ul><li>Suicidal ideation may develop from hopelessness & meaninglessness </li></ul><ul><li>Absurd to reduce the patient’s entire psychopathology , psychosocial & biological contribution to illness in one diagnostic label </li></ul>
  36. 40. Differentiation form depression <ul><li>Similar but different </li></ul><ul><li>Mood reactivity is usually preserved </li></ul><ul><li>(able to respond to happy news) </li></ul><ul><li>Treatment of physical symptoms, resolution of psychological / spiritual or social issues restore hope & spirit rapidly </li></ul><ul><li>Fail to show robust improvement with antidepressant medication </li></ul>
  37. 41. <ul><li>Demoralisation scale </li></ul><ul><li>J Palliative Care 2004; 20:269-276 </li></ul>
  38. 42. Clinical association of demoralization syndrome <ul><li>Illness related: </li></ul><ul><li>Breaking of diagnosis </li></ul><ul><li>At news of disease of progression </li></ul><ul><li>High burden of physical symptom </li></ul><ul><li>Body disfigurement, paraplegia </li></ul>
  39. 43. <ul><li>Treatment related </li></ul><ul><li>Limb amputation, mastectomy </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Threatens dignity eg becoming incontinent / dependent </li></ul><ul><li>Patient factor: </li></ul><ul><li>Younger age more affected </li></ul><ul><li>Past Hx of mental illness </li></ul><ul><li>Axis II / maladaptive coping style </li></ul><ul><li>Poor relationships </li></ul>
  40. 44. <ul><li>Countertransference & demoralization </li></ul><ul><li>Demoralization is contagious </li></ul><ul><li>Demoralized patient can lead to demoralized care-giver </li></ul><ul><li>(and vice versa) </li></ul><ul><li>Demoralized patient can also lead to demoralized medical & allied health team members </li></ul>
  41. 45. <ul><li>encountering demoralization: </li></ul><ul><li>Treat physical symptoms </li></ul><ul><li>Address social, financial concern </li></ul><ul><li>Focus interviewing as a bridge to brief psychotherapy </li></ul><ul><li>Concept of presence </li></ul><ul><li>Facilitating repair of relationship </li></ul><ul><li>Acknowledge suffering “ this is a hard illness to have..” </li></ul><ul><li>Restoring value & dignity </li></ul>
  42. 46. <ul><li>Difficult cancer pain </li></ul><ul><li>3 categories </li></ul><ul><li>Poorly responsive to morphine </li></ul><ul><li>Episodic breakthrough despite background analgesia </li></ul><ul><li>Dose limiting adverse effect </li></ul>
  43. 47. Treatment for difficult cancer pain <ul><li>Disease modifying agent </li></ul><ul><li>Identify psychosocial, emotional, spiritual suffering </li></ul><ul><li>Change route of administration of opioid </li></ul><ul><li>Opioid rotation </li></ul><ul><li>Use of adjuvants </li></ul><ul><li>Invasive analgesic techniques </li></ul>
  44. 48. <ul><li>Indication for opioid rotation </li></ul><ul><li>Dose limiting adverse effects </li></ul><ul><li>Difficult pain syndrome </li></ul><ul><li>Poorly controlled pain </li></ul>
  45. 49. Stop & go method <ul><li>Rescue dose =1/6th of daily dose upto 3/day </li></ul>12:1 morphine >300mg/day 8:1 morphine 90-300mg/day 4:1 morphine <90mg/day stop Day 1 Methadone dose morphine
  46. 50. 3 day Edmonton rotation schedule 2.5mg methadone 20mg morphine 20mg morphine 20mg morphine Breakthrough opioid 15mg /day 15mg Target dose 10mg 2/3 target dose 5mg 1/3 target dose methadone Cease morphine 66mg decrease 1/3 135mg decrease 1/3 morphine Day 4 Day 3 Day 2 Day 1 opioid
  47. 51. <ul><li>Opioid rotation can be successful if…. </li></ul><ul><li>The basis for it is clear </li></ul><ul><li>It is part of the assessment & therapeutic strategy of the patient </li></ul><ul><li>Equianalgesic ratios are used </li></ul><ul><li>Incomplete cross tolerance is account for </li></ul><ul><li>Continued assessment of the patient </li></ul>
  48. 52. Management of cancer pain <ul><li>WHO analgesic ladder </li></ul><ul><li>This manage to relief upto 80-90% of all cancer pain </li></ul><ul><li>Levy Oncology 1999;13: 9-14 </li></ul><ul><li>Surgical interventions on appropriate nerves may provide pain relief if drugs are not wholly effective </li></ul><ul><li>(Quoted from WHO) </li></ul>
  49. 53. Benefits of interventional techniques <ul><li>More targeted & effective </li></ul><ul><li>The dose of drugs much smaller than if given iv or po </li></ul><ul><li>Intrathecal : intravenous =1: 100 </li></ul><ul><li>Epidural or intrathecal analgesic usually produce fewer unwanted effects eg drowsiness </li></ul>
  50. 54. <ul><li>Choice of technique </li></ul><ul><li>Life expectancy </li></ul><ul><li>Mechanism & type of pain </li></ul><ul><li>Site of pain </li></ul><ul><li>Patients preference </li></ul><ul><li>Support available </li></ul>
  51. 55. Peripheral nerve block <ul><li>Limited role </li></ul><ul><li>Case series on short term pain relief </li></ul><ul><li>Acute pain relief especially during the perioperative period </li></ul><ul><li>Catheter infusions but limited time catheter can be left in-situ </li></ul>
  52. 57. Epidural or intrathecal? <ul><li>Trend towards intrathecal </li></ul><ul><li>Lower dosages </li></ul><ul><li>Less frequent pump refills </li></ul><ul><li>Less incidence of cath occlusion or fibrosis </li></ul>
  53. 58. opioids <ul><li>Large studies shows improved quality of life, functional capacity & pain scores </li></ul><ul><li>Smith et al J Clinical Oncology 2002;20:4040-49 </li></ul><ul><li>Asso with lower incidence of side effect as compared with oral or parental routes </li></ul><ul><li>Most freq S/E: </li></ul><ul><li>Constipation </li></ul><ul><li>Urinary retention </li></ul><ul><li>Sweating </li></ul><ul><li>Nausea /vomiting </li></ul><ul><li>Respiratory depression 4-7% </li></ul>
  54. 59. morphine <ul><li>Hydrophilic nature </li></ul><ul><li>Spread to level distal to the site of injection </li></ul><ul><li>Only FDA approved opioid </li></ul><ul><li>Other (not FDA approved)opioid: </li></ul><ul><li>Fentanyl </li></ul><ul><li>hydromorphone </li></ul>
  55. 60. Local anaesthetic <ul><li>Improves pain relief & patient satisfaction </li></ul><ul><li>Deer et al. Spine 2002; 2(4): 274-8 </li></ul><ul><li>Provide pain relief in patient who failed IT opioid therapy </li></ul><ul><li>Synergistic effect </li></ul><ul><li>Less opioid tolerance </li></ul><ul><li>Most common: bupivacaine </li></ul>
  56. 61. Neurolytic technique <ul><li>Interruption of nociceptive transmission from peripheral tissue to spinal cord </li></ul><ul><li>Persistent localised pain with limited life expectancy </li></ul><ul><li>Less uterised if alternative intervention available </li></ul><ul><li>Use as one-off intervention or limited resources or infrastructure available for catheter systems </li></ul><ul><li>Mainly alcohol or phenol </li></ul>
  57. 62. Intrathecal neurolysis <ul><li>Administration of alcohol or phenol into subarachnoid space </li></ul><ul><li>Aims to achieve pure sensory segmental block </li></ul><ul><li>Suitable for terminal ca with limited life expectancy with somatic pain </li></ul><ul><li>Associated with potential devastating complications </li></ul>
  58. 63. Coeliac plexus block <ul><li>Main indication for ca pancreas </li></ul><ul><li>Also for upper GI cancer </li></ul><ul><li>Pain referred to back or upper abdomen </li></ul><ul><li>Strong evidence of efficacy upto 90% </li></ul><ul><li>Eisenberg et al. Anaesth Anal 1995;80:290-5 </li></ul>
  59. 64. Complications <ul><li>Diarrhoea 30% & postural hypotension 60% </li></ul><ul><li>Short lived 48hrs </li></ul><ul><li>Neurological injury or paralysis rare (1:700) but devastating </li></ul><ul><li>Trauma /spasm / chemical irritation to Artery of Adamcowtiz implicated </li></ul>
  60. 65. Other neurolytic blocks <ul><li>Superior hypogastric </li></ul><ul><li>Ganglion impar </li></ul><ul><li>intercostal </li></ul>
  61. 66. Summary <ul><li>Intervention should be appiled carefully, appropriately and at the right time </li></ul><ul><li>Improve quality of life </li></ul><ul><li>Reduction in medication usage </li></ul><ul><li>Good evidence for coeliac block & intrathecal analgesia </li></ul><ul><li>Aftercare crucial </li></ul>
  62. 67. <ul><li>Thank you </li></ul>

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