1 / 63

Cancer Pain in Children

Cancer Pain in Children. 13 th Annual Palliative Care Seminar Hector Rodriguez-Cortes, MD Pediatric Hematologist and Oncologist Pediatric Palliative Care and Hospice. Objectives:. Epidemiology of cancer pain Identify the three different pain categories

artemas-kristy
Download Presentation

Cancer Pain in Children

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cancer Pain in Children 13th Annual Palliative Care Seminar Hector Rodriguez-Cortes, MD Pediatric Hematologist and Oncologist Pediatric Palliative Care and Hospice

  2. Objectives: • Epidemiology of cancer pain • Identify the three different pain categories • Identify Treatment and Tumor-Related pain syndromes • Review the Two-step strategy of the WHO guideline

  3. Introduction • Cancer: • evokes immediate fear for patients and their families • potentially fatal disease • can be associated with pain • Symptoms: • may be interconnected • treatment of one symptom may exacerbate another

  4. FREQUENCY OF CANCER PAIN  • Multi-factorial: • type of malignancies • sites of involvement • presence or absence of metastases • Prevalence of moderate/severe pain • increasesduring the late phases of malignancy

  5. EPIDEMIOLOGY OF CANCER PAIN IN CHILDREN • Cancer pain: • tumor-related • treatment-related pattern: surgery, medications • Tumor-related pain: • predominates at diagnosis/ early treatment phase • May persisted for a median of 10 days after initiation of treatment. • Examples of tumor-related pain: • Brain tumors: • headache/ abnormal neurologic signs • Mets w spinal cord compression: back pain

  6. EPIDEMIOLOGY OF CANCER PAIN IN CHILDREN • Treatment-related pain: • mucositis • antineoplastic therapy • postoperative pain • procedure-related pain

  7. Breakthrough pain in Children with Cancer • Freidrichsdorf and Postier (2014) • Breakthrough Pain Questionnaire for Children • 57% of children experienced pain • Pain: major tumor tumor surgery >> tumor/ drug-related • Younger children (7-12 year of age) at higher risk than teenagers • PCA

  8. Reason for Breakthrough pain in Children with CancerFreidrichsdorf and Postier (2014) • disease progression • infection at the tumor site • development of tolerance • drug interactions • decreasing renal function • somatization and psychological distress.

  9. Pain Mechanisms

  10. PAIN MECHANISMS: • Experience of pain: • Subjective • can be modulated by developmental, familial, situational, emotional, and other factors. • lack of correlation between the extent of tissue injury and the intensity of pain or suffering.

  11. PAIN MECHANISMS: Terminology • Nociception: • sensationof tissue injury or inflammation • alerts an individual to potential or ongoing injury • prompts the avoidance or limitation of further injury • can be activated by: • chemical, thermal, or mechanical stimuli • lack of it can lead to a variety of medical complications • decubitus ulcers.

  12. Nociception

  13. Somatic pain: Pathophysiology • noxious stimuli • mechanical, thermal, or chemical • Pain signals are carried to the dorsal horn of the spinal cord by: • A-delta fibers: mechanical/thermal • C fibers: all three stimulus types • The signals ascend in the contralateral spinothalamic and spinoreticular tracts • thalamus

  14. Somatic pain

  15. TYPES OF PAIN • Pain can be divided into 3 categories: • Somatic • Visceral • Neuropathic • These categories are not mutually exclusivesince a patient's pain may have multiple etiologies.

  16. Somatic pain • Triggered by potential or real injury to tissues • cutaneous burn or an arthritic joint. • Pain • tender and localized. • constant and sometimes throbbing or aching. • it can be acute or chronic. • Bone metastasis is the most common cause of somatic pain

  17. Visceral pain  • Mechanism is not well characterized. • Pain: • Poorly localized • less constant • it can dull, colicky • Often referred to a distant cutaneous site. • diaphragmatic irritation: ipsilateral shoulder • passage of a renal stone • Associated: nausea and diaphoresis. • Noxious stimuli that can trigger visceral pain: • ischemia, inflammation, torsion, traction, distension, or impaction

  18. Visceral pain

  19. Neuropathic pain  • Causes: • Peripheral or central in etiology • infiltration of neural structures by tumor • fibrosis: radiation • injury: surgery • Described as: • prolonged, severe, burning, or squeezing • It can paroxystic • often associated with focal neurologic deficits • relatively resistance to opioids • Often associated with symptoms and signs of autonomic instability ( i.e.., tachycardia, sweating) • Example: herniated intervertebral disc, phantom limb pain, degenerative neuropathies such as Guillain-Barre syndrome.

  20. Neuropathic pain  • Clinical features: • Dysesthesias: • abnormal or unfamiliar unpleasant sensations • Allodynia: • an exaggerated response to otherwise non-noxious stimuli, such as light touch of the skin

  21. Neuropathic Pain

  22. Neuropathic pain 

  23. Pain Assessment

  24. Measuring Pain • Pain: • often under-recognized in cancer patients • should be assessed frequently and systematically • Principal barrier to effective pain management: • discrepancy between the patient's and physician's assessments of the pain • Anxiety and depression: • may exacerbate, rather than exaggerate, the pain.

  25. Pain measurement tools • Verbal numerical scale • rating pain from zero for "no pain," to 10 for "the worst imaginable pain" • easily implemented and recorded • 10 cm visual analog scale: • used, with or without intensity descriptors • do not reflect the complexity of the pain experience

  26. Pain measurement tools • Non-communicate pain: • intensity must be evaluated by other means. • nonverbal signs of pain • These include: • hypertension, tachycardia, and diaphoresis • Agitation or confusion • Apathy, inactivity, or irritability in patients with cognitive impairment

  27. Pain measurement tools

  28. Pain Management

  29. Principles for the pharmacological management of pain. • WHO: 1986 • dosing at regular intervals • using the appropriate route of administration • adapting treatment to the individual child • WHO: 2012 • using a two-step strategy

  30. Principles for the pharmacological management of pain. • WHO: 1986 • dosing at regular intervals • steady blood level: reducing peaks and troughs • using the appropriate route of administration • Least invasive route (often chosen by the child) • Transdermal patches: long onset time • adapting treatment to the individual child • Frequently assessment, reassessment and modification

  31. Principles for the pharmacological management of pain. • WHO: 1986 • WHO: 2012: two-step strategy • choice depends on the child’s level of pain. • Mild • Moderate to severe pain

  32. Three-step vs. Two-step approach • Difference: • three-step analgesic ladder: • use of codeine as a weak opioid • treatment of moderate pain • two-step approach: • low doses of strong opioid • Two-step: more effective strategy for persisting pain.

  33. The First Step: mild pain • Recommendations: • Paracetamoland ibuprofen • choice for first step (mild pain) • widely available in child-appropriate dosage forms • oral liquids • relatively inexpensive

  34. ANALGESIC MEDICATIONS: Non-opioids • Acetaminophen: • inhibits prostaglandin synthesis • lacks the sedative effects • minimal anti-inflammatory effect • no side effects such as gastritis and inhibition of platelet • Aspirinand NSAIDs in cancer patients: • risk for bleeding • Aspirin: • irreversible inhibition of platelet

  35. WHO PAIN 2012 guidelines

  36. The Second Step: Moderate to Severe pain Recommendations: • Morphine • drug of choice • other strong opioids • intolerable side-effects. • Administeropioidanalgesicsin the first step: • clinical judgement • carefulconsiderations of the disabilitycausedby pain

  37. Strong Opioids • Morphine: • first choice • metabolize in the liver • widely used • It can be administered: • oral, rectal, IV, SQ, epidural, intrathecal, or intraventricular • Starting dose for immediate-release oral morphine • 0.1 mg/kg q4 hours. • Very young infants should receive a reduced dose due delayed clearance

  38. Strong Opioids: • Hydromorphone: • oral, IV, SQ, epidural, and intrathecal • used if there are dose-limiting side effects from morphine. • 5-8 times as potent as morphine. • Fentanyl: • transdermal, oral transmucosal, and IV • 50-100 times more potent than morphine • very rapid onset: high lipid solubility • shorter duration of action after IV administration: • used in patients with dose-limiting side effects: pruritus

  39. Strong Opioids: • Meperidine • no advantages over morphine • major drawback: can cause dysphoria, excitation, and convulsions, particularly in patients with impaired renal clearance • Methadone • synthetic opioid that has a prolonged duration of action • its potency is similar to morphine. • convenient as a long-acting medication in patients who are unable to swallow slow-release morphine tablets

  40. WHO PAIN 2012 guidelines

  41. Tramadol • Centrally acting analgesic with opioid effects • Control of moderate to moderately severe pain • Food does not affect its rate of absorption • Dosing: • 17 years of age and over: • Starting dose: 25 mg/day q AM and titrated in 25 mg increments as separate doses every 3 days to reach 100 mg/day (25 mg q.i.d.). • may be increased by 50 mg as tolerated every 3 days to reach 200 mg/day (50 mg q.i.d.). • How supplied: 50 mg tab

  42. Codeine Excluded for pain relief from the two-steps Codeine • “weak” opioid • widely available • previously recommended to control moderate pain. • well-known safety but efficacy problems • genetic variability in biotransformation.

  43. Codeine: • prodrug • enzyme CYP2D6: • converted into its active metabolite morphine. • efficacy depends on the amount of active metabolite. • variable expressions of the enzymes • inter-individual and inter-ethnic differences • Fetus: absent or less than 1% • Children less < 5 year: 25% of the adult values

  44. Excluded medicine for pain relief:Codeine • Poor metabolizers: • vary in ethnic groups from 1% to 30% • ineffectiveness • Rapid metabolizer: • metabolize codeine quickly and extensively • risk of severe opioid toxicity, • high and uncontrolled conversion into morphine.

  45. SYNDROMES OF PEDIATRIC CANCER PAIN • Treatment-Related Syndromes • Tumor-Related Syndromes

  46. Treatment-Related Syndromes:Mucositis • Optimal management is not well established. • S/P BMT: • more intense and prolonged that chemotherapy-related. • Therapy: • topical therapies: sodium bicarbonate, hydrogen peroxide, nystatin, viscous lidocaine, dyclonine, • systemic therapies: opioids and systemic antifungal agents.

  47. Treatment-Related Syndromes:Graft-Versus-Host Disease • May be associated with severe abdominal pain. • GVHD is the next most common cause of pain after an allogeneic BMT • Pain due to GVHD frequently requires the administration of opioids

  48. Treatment-Related Syndromes:Phantom Limb Pain • Common among children after amputation of an extremity • Incidence/severity decrease with time after amputation • Prior treatment with chemo increased the risk after subsequent amputation. • Therapy: • tricyclic anti-depressants • opioids seen to be ineffective • early and frequent use of a limb prosthesis may reduce the duration and severity

More Related