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Surfing in a Tsunami Living with Cancer Pain in Childhood – Susie Lord, Pain Grand Rounds Nov 2009 PowerPoint Presentation
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Surfing in a Tsunami Living with Cancer Pain in Childhood – Susie Lord, Pain Grand Rounds Nov 2009. Confidentiality. Outline. Themes The Case Discussion. Billy. Lived in the country Healthy boy until aged 10. Billy. At 10 yo presented with diplopia MRI  4 th ventricle lesion

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slide1

Surfing in a Tsunami

Living with Cancer Pain in Childhood – Susie Lord, Pain Grand Rounds Nov 2009

outline
Outline
  • Themes
  • The Case
  • Discussion
billy
Billy
  • Lived in the country
  • Healthy boy until aged 10
billy1
Billy
  • At 10 yo presented with diplopia
  • MRI  4th ventricle lesion
  • Surgical debulking
  • Medulloblastoma
medulloblastoma
Medulloblastoma
  • Primary malignant brain tumour
  • Invasive, rapidly growing
  • Spreads through CSF to brain and spine
  • Extra-neural metastases are rare
  • Symptoms: listlessness, vomiting, headache, stumbling gait, falls, nystagmus, diplopia, other CN palsies
cancer treatment
Cancer Treatment
  • Surgical resection
  • Radiotherapy brain and spine
  • Chemotherapy
  • 5 year survival approx 80%
  • Billy’s surveillance scans @ 1 yr  clear
onset of pain
Onset of Pain
  • 18 months after Dx  low back pain
onset of pain1
Onset of Pain
  • 18 months after Dx  low back pain
  • Rural assessment
    • Bone scan  hot spots in SIJs
  • JHCH assessment
    • Symptom relief  opioid analgesia
    • MRI  CT  PET scan
    • Biopsy  medulloblastoma
chemotherapy
Chemotherapy
  • After discussion with family
  • Paediatric Oncology Day Unit
  • Ronald McDonald House
admission
Admission
  • Increasing back and leg pain plus new jaw pain
  • Increased oral therapy
    • MS Contin 80  120 mg/day
    • Added Oxycodone IR 5-10 mg PRN
    • Added Dexamethasone 4 mg bd
  • Pain escalated over 4 days (7/10)  PCA  doubled dose
consultations
Consultations
  • Family (ies) re progress
  • Radiation Oncology
  • Pain Service
consult agenda
Consult Agenda
  • Assessment
  • ? Role of anti-neuropathic Rx
  • ? Role of neuraxial analgesia
  • ? Keen to go home < 1 week
biopsychosocial assessment
Biopsychosocial Assessment
  • Medical history to date
  • Pain history
  • Impact of pain and other experiences
  • Therapeutic resources to date
  • Family supports
  • School, friends, social supports
  • Spiritual needs / supports
  • Child’s, family’s understanding and goals
slide25

Big Family

A

F

M

SF

18

12

30kg

7

1

pain history
Pain History
  • Back pain
  • Leg pain
  • Jaw pain
pain history1
Pain History
  • Back pain

Bilateral lumbosacral spinal pain

Deep aching 3/10  incident pain 5/10

Yesterday shooting character 9-10/10

  • Leg pain
  • Jaw pain
pain history2
Pain History
  • Back pain

Bilateral lumbosacral spinal pain

Deep aching 3/10  incident pain 5/10

Yesterday shooting character 9-10/10

  • Leg pain

Left knee  day 4 right knee, lateral calf

Aching, hurting 2/10  aggravated by wt bearing

  • Jaw pain
pain history3
Pain History
  • Back pain

Bilateral lumbosacral spinal pain

Deep aching 3/10  incident pain 5/10

Yesterday shooting character 9-10/10

  • Leg pain

Left knee  day 4 right knee, lateral calf

Aching, hurting 2/10  aggravated by wt bearing

  • Jaw pain

Left > right mandible aching 2-3/10

Associated numbness in mental nerve territory

pain history4
Pain History
  • Back pain

Bilateral lumbosacral spinal pain

Deep aching 3/10  incident pain 5/10

Yesterday shooting character 9-10/10

  • Leg pain

Left knee  day 4 right knee, lateral calf

Aching, hurting 2/10  aggravated by wt bearing

  • Jaw pain

Left > right mandible aching 2-3/10

Associated numbness in mental nerve territory

billy s goals
Billy’s Goals
  • Pain relief
  • Think clearly
  • Be mobile
  • Go home
current analgesia
Current Analgesia
  • Paracetamol
  • Oral Morphine SR 160 mg/day
  • IV Morphine (PCA) 100 mg/day
d4 advice
D4 Advice
  • Increase PCA bolus dose 1.22mg
  • Review PCA usage and adjust Morphine SR dosing
  • Aim to convert PCA  oral IR
  • Start oral Gabapentin in anticipation
  • Consider Ketamine if more acute
neuraxial intro
Neuraxial Intro
  • Role when oral analgesia is inadequate and there are dose-limiting side-effects
  • For predominantly lower body pain
  • Local anaesthetic and other pain relievers
  • Epidural v intrathecal, temporary and portal
  • Community Mx might be possible if stable

 Further discussion if/when indicated

neuraxial intro1
Neuraxial Intro
  • Systemic treatment being optimised
  • Radiotherapy might reduce pain
  • Info just a foundation for future discussions if needed down the track
d5 acute exacerbation
D5 Acute Exacerbation
  • Incident pain on transfer into a chair
  • Same location – bilateral low lumbar
  • No distal radiation
  • Deep hurting, constant
  • Pain score 3/10 9/10
  • IV Morphine usage 12mg in prev hour  responsive but sleepy, RR 10/min
d5 advice
D5 Advice
  • Continue PCA
  • Supplemental O2 if SpO2 < 94%
  • Commence Ketamine Infusion (0.25mg/kg/hour)
  • Consider opioid rotation
d6 10 progress
D6-10 Progress
  • Background pain better controlled
  • Playing, colouring, talking and watching TV with family
  • Incident pain
    • Transfers, ambulating
    • Bilateral back and right hip
  • PCA usage variable (0 most hours, to 15-18 mg/hr especially when toileting)
d6 10 advice
D6-10 Advice
  • Stepwise adjustments
    • MS Contin 200 mg/day
    • IV Morphine 3 mg bolus 110170 mg/day
    • Ketamine continuing 7 mg/hr
    • Gabapentin increasing to 300 mg tds
d6 10 advice1
D6-10 Advice
  • Stepwise adjustments
    • MS Contin 200 mg/day
    • IV Morphine 3 mg bolus 110170 mg/day
    • Ketamine continuing 7 mg/hr
    • Gabapentin increasing to 300 mg tds
  • Planning for pre/post radiotherapy analgesia
    • Titration, rotation, additional antineuropathic Rxs, intrathecal
d11 12 exacerbation
D11-12 Exacerbation
  • Transfer to Mater for Radiotherapy planning session – on/off 5 beds
  • Severe exacerbation back/hip pain
  • No improvement over 24 hours
  • IV Morphine PCA 300 mg/day 25 mg/hour
d13 reassessment
D13 Reassessment
  • Evident that pain will prevent daily TF to Mater for radiotherapy next week
  • Added Methadone 5 mg bd PO with view to gradual cross-over rotation
  • Rotation to Hydromorphone PCA with 600  800 mcg bolus
  • Ketamine increased to 10 mg/hr
  • Plan / consent for semi-urgent IT
intrathecal analgesia
Intrathecal Analgesia
  • Benefits
    • Systematic Review – Walker et al. Anesth Analg 2002
    • Improved analgesic efficacy with fewer adverse effects
    • LA + opioid combinations improve control of incident pain
    • Clonidine + opioid combinations improve neuropathic pain
intrathecal analgesia1
Intrathecal Analgesia
  • Benefits
    • Systematic Review – Walker et al. Anesth Analg 2002
    • Improved analgesic efficacy with fewer adverse effects
    • LA + opioid combinations improve control of incident pain
    • Clonidine + opioid combinations improve neuropathic pain
  • Risks and consequences (unquantifiable)
    • Patient – Anticoagulation / tumour / immunocompromise
    • Procedure – GA / nerve damage / haem / infectn / CSF leak
    • Functional – catheter obstruction / migration
    • Drug – local or systemic toxicity / adverse effects
slide49

Retrospective over 8 years  11 children

  • PNET, rhabdomyosarcoma, osteogenic sarcoma, solid tumours
consent
Consent

Big Family

A

F

M

SF

18

12

30kg

7

1

d14 intrathecal started
D14 Intrathecal Started
  • Opioid – 50% of systemic dose  IT morphine (x 0.01)  3 mg/day
  • Clonidine – 1mcg/kg/day  30 mcg/day
  • Bupivacaine – 0.04-0.4mg/kg/hr  halve this due to goals  15 mg/day
w3 intrathecal titration
W3 Intrathecal Titration
  • Daily IT titration (20%)
  • Systemic Rx reductions
  • Radiotherapy transfers
  • Incident pain management
  • Pain meaning  distress
w4 community transition planning
W4 Community Transition Planning
  • Attempted to simplify analgesia delivery – challenging
  • Pumps to allow flexible dosing
  • Liaison with Level 3 and 2 services
  • Family meetings / SW
  • Contingencies
w5 7 pain challenges
W5-7 Pain Challenges
  • Tumour load  pain escalation and new pains  DVT & anticoag  marrow failure
  • Significant opioid tolerance
  • Opioid-induced hyperalgesia
  • Relative / variable success
w5 7 real challenges
W5-7 Real Challenges
  • Being able to think and move
  • Being unable to go home
  • Existential suffering – Billy
  • Existential suffering – family
child centred play
Child-Centred Play
  • The child initiates and directs all aspects of play
    • Activity
    • Equipment
    • Symbolism
    • Roles
principles
Principles
  • Tracking
  • Reflection
  • Acknowledging feelings
  • Returning responsibility
slide67

Analgesia…

Window of Opportunity

w4 community transition planning1
W4 Community Transition Planning
  • Attempted to simplify analgesia delivery – challenging
  • Pumps to allow flexible dosing
  • Liaison with Level 3 and 2 services
  • Family meetings / SW
  • Contingencies
w5 7 pain challenges1
W5-7 Pain Challenges
  • Tumour load  pain escalation and new pains  DVT & anticoag  marrow failure
  • Significant opioid tolerance
  • Opioid-induced hyperalgesia
  • Relative / variable success
w5 7 real challenges1
W5-7 Real Challenges
  • Being able to think and move
  • Being unable to go home
  • Existential suffering – Billy
  • Existential suffering – family