1. Role of Anaesthesiologist in
Management of Cancer
Pain
Co – ordinator: Dr. Veena Gupta
Speaker: Anand Maurya

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. 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. 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.  Neuropathic Pain
 Shooting, sharp, burning, “pins & needles”
 CA compressing or infiltrating nerves/nerve roots/blood supply to
nerve
 Nerve damage from treatments

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. 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. 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. 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.  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. Non-Pharmacologic Management
 Acupuncture
 Yoga
 Guided imagery
 Cold/heat
 Massage
 Vibration
 TENS units
 Exercise programs
 Hypnosis
 Counseling

12. WHO Ladder

13. Role of Anaesthesia
 Interventions
 Palliative surgery
 Kyphoplasty/Vertebroplasty
 Sedation
 Nerve Blocks
 Epidural
 Intrathecal pain pumps
 Lidocaine infusion

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. 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. 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.