Recommended
More Related Content
What's hot
What's hot (12)
Similar to Cancer pain พระนั่งเกล้า
Similar to Cancer pain พระนั่งเกล้า (20)
Cancer pain พระนั่งเกล้า
- 1. แนวทางเวชปฏิบัติ การดูแลรักษาผู้ป่ วยปวดจากมะเร็ง พญ.ฉันทนา หมอกเจริญพงศ์ กลุ่มงานเวชศาสตร์ประคับประคอง สถาบันมะเร็งแห่งชาติ กรมการแพทย์ กระทรวงสาธารณสุข
- 2. ความปวด ***** PAIN An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ประสบการณ์ที่ไม่สบายกาย ไม่สบายใจ ที่เกิดจากการ บาดเจ็บของเนื้อเยื่อหรือศักยภาพที่จะทาให้มีการบาดเจ็บ ของเนื้อเยื่อ หรือประหนึ่งว่ามีการบาดเจ็บ
- 3. Facts about cancer pain Frequency of occurrence varies with ; • stage of the disease • primary site of the tumor Frequency of occurrence varies with ; • stage of the disease • primary site of the tumor Moderate or severe pain occurs in 30 - 40% of the patients at the time of diagnosis and 60 - 100% with advanced cancer Moderate or severe pain occurs in 30 - 40% of the patients at the time of diagnosis and 60 - 100% with advanced cancer Most cancer patients have more than one pain Most cancer patients have more than one pain
- 5. Causes of Pain 1. Due to tumor involvement 78% • bone, nerve, soft tissue, viscera 2. Associated with treatment 19% • diagnosis and staging procedures • surgery • chemotherapy; mucositis, phlebitis, tissue necrosis, myalgia, arthralagia • radiotherapy; mucositis, neuropathy, myelopathy
- 6. 3. Due to general illness but not cancer (10%) • constipation • pressure • gastric distention • reflux esophagitis • bladder spasm (with catheterization) • musculoskeletal pain • thrombosis and embolism • mucositis • post herpetic neuralgia 4. Unrelated to cancer or its treatment(10%) Causes of Pain
- 7. ความปวดจากมะเร็งมีผลเสียทางด้านความเป็นอยู่ จิตใจ อารมณ์ สังคม ของผู้ป่ วยและผู้ใกล้ชิด
- 8. Assessment: Review of the systems 1. Systemic/constitutional – anorexia เบื่ออาหาร – weight loss น้าหนักลด – cachectic ผอมหนังหุ้มกระดูก – fatigue/weakness ความล้า / อ่อนแรง – insomnia นอนไม่หลับ 2. Neurologic – sedation ง่วงซึม – confusion มึนงง สับสน – hallucination ประสาทหลอน – headache ปวดศีรษะ – motor weakness กล้ามเนื้ออ่อนแรง – altered sensation การรับความรู้สึกเปลี่ยนแปลง – incontinence กลั้นไม่อยู่
- 9. Assessment: Review of the systems 3. Respiratory – dyspnea, cough, hiccough 4. Gastrointestinal – dysphagia - dehydration – nausea/vomiting - constipation/diarrhea 5. Psychological – irritability - depression – anxiety - dementia 6. Integument – decubitus – dry, sore mouth
- 10. Physical well-being Psychological well-being Social well-being Spiritual well-being Quality of life for cancer patients in pain
- 13. Pain Assessment • Location of all the pain • How the pain feels • Intensity of the pain • When, frequency, duration • What ease the pain, what worsen the pain • Medications taking • Side effects of pain medications • Quality of life issues • Pain diary!
- 15. Pain Assessment • Chronicity: Acute vs Chronic pain • Pain intensity • Pathophysiology: somatic vs. visceral nociceptive vs. neuropathic • Course of the disease: continuous, breakthrough, incident pain. • Pain syndrome: brain metastasis, bone pain
- 16. ChronicityChronicity Acute pain Chronic pain Onset well-defined ill-defined Cause acute injury or illness chronic progress Duration days/weeks predictable months/years unpredictable Physiologic al sympathetic over activity no sympathetic over activity
- 17. Acute pain Chronic pain Affective anxiety depression Cognitive meaningful meaningless Behavioral inactivity until recovery changes in life style changes in functional ability withdrawn Treatment cause temporary analgesics supportive regular analgesics
- 18. Categoral scales • Verbal rating scale (VRS) (verbal descriptor scale) • 2 – 7 words None Mild Moderate Severe • Pain relief None Slight Moderate Good Complete
- 19. Numerical rating scale (NRS) No pain 0 1 2 3 4 5 6 7 8 9 10 Worse pain imaginable Visual analog scale (VAS) No pain ____________________ Worse pain imaginable
- 20. Happy/sad faces.
- 21. Pain Assessment • Chronicity: Acute vs Chronic pain • Pain intensity • Pathophysiology: somatic vs. visceral nociceptive vs. neuropathic • Course of the disease: continuous, breakthrough, incident pain. • Pain syndrome: brain metastasis, bone pain
- 22. Pathophysiology • Nociceptive ( somatic and visceral ) – constant and well localized – aching, throbbing, gnawing – vague in distribution and quality, deep, dull, aching, dragging, squeezing, pressure-like • Neuropathic – may be constant, steady, and spontaneously maintained, intermittent, shock-like, shooting, lancinating, electrical, burning, tingling, numbing, pressing, squeezing, and itching – dysesthesia, hyperalgesia, allodynia, hyperesthesia, hyperpathia
- 23. Neuropathic Pain • Hardest mechanism to treat • Diagnose straightforward: nerve or dermatome distribution, no local tenderness but referred • Two types – Mixed: nociceptive/neuropathic due to tumor invasion or compression of nerve pathway; brachial, lumbosacral plexus, chest wall invasion, spinal cord compression – Pure (Deafferentation): no nociceptive element; PHN, post-thoracotomy syndrome, phantom pain
- 25. Bone Pain • Most common cause of pain in advanced cancer • Most common malignancies metastasize to bone: breast, prostate, lung, kidney, thyroid • Common problems: chronic bone pain, pathologic fracture, hypercalcemia • Treatment includes: NSAIDs, opioids, radiotherapy, Strontium-89, bisphosphonate, corticosteroids, calcitonin. • Early Orthopedic consultation and treatment is important
- 26. Pattern of pain Constant pain Breakthrough and incident pain Intermittent pain
- 28. Principle of Analgesic Use • Define the nature of pain • Maximize the current regimen • Understand the drug Pharmacology – Speed of onset and duration of action – Management of side effects – Beware of the drug interactions • Emphasize patient education
- 29. Cancer Pain Management • Pharmacologic treatment • Non- Pharmacologic treatment
- 30. WHO Analgesic Ladder (1992--) Non-opioid + Adjuvants Opioid for mild to moderate pain + Non-opioid + Adjuvants Opioid for Moderate to severe pain + Non-opioid + Adjuvants Pain Pain persist Pain persist Freedom from cancer pain
- 32. Essential concepts in the WHO approach to drug therapy • By the mouth • By the clock • By the ladder • For the individual • With attention to detail
- 33. Principles of analgesic used • Administer on strict schedule to prevent pain, not PRN • Give instructions for treatment of breakthrough pain • Following analgesic ladder • Review & assess
- 34. GENERAL RECOMMENDATIONS • Oral medications should be used as the first line approach. • Any proposed systemic regimen must be individualized. • There is no predetermined maximum dose of an opioid. • Dose titration may be required periodically.
- 35. Adverse drug effects from opioid therapy • Tolerance • Physical dependence • Addiction • Constipation • Sedation • Nausea-vomiting • Mental clouding • Myoclonus, pruritus, urinary retention • respiratory depression
- 36. Nausea • Moderate to severe 8.3 – 18.3% • Direct effect of opioids on CTZ • Decrease quality of life, limit food intake • Other underlying conditions; electrolyte imbalance, dehydration, brain metastasis, intestinal obstruction, ileus, chemotherapy, tumor of the GI, constipation, infection, blood poisoning, kidney problems, anxiety, etc.
- 37. Nausea • Usually subside within few days • Treatment; – Metoclopramide ( block in GI tract and CTZ) – Butyrophenones (haloperidol, droperidol) (at CTZ) – Phenothiazine (CTZ, GI, vestibular) – Antihistamine (dramamine,hydroxyzine) (H1 blockade and VC) – Hyoscine, scopolamine (VC and GI) – Ondansetron (5HT3 in GI and CTZ) – Benzodiazepine (lorazepam) GABA agonist
- 38. Constipation • The most troublesome, almost everyone is involved, will not develop tolerance
- 39. Treatment of Constipation • Stimulant laxatives • Senokot 1 tab hs – 4 tab tid orally • Dulcolax 1 tab hs – 3 tab tid orally • Bulk-forming laxatives • Metamucil 1 tsp in 8 oz water OD – tid • Bran • Saline or osmotic cathartics • MOM 15 – 40 ml OD – bid • Magnesium citrate solution 240 ml OD
- 40. CNS effects • Aggravating factors; – High doses opioid – Psychoactive drugs – Renal failure • Slow down of cognitive function, sedation, hallucination and delirium, fluctuation of consciousness, change in sleep-wake cycle, agitation, myoclonus. • Improve spontaneously
- 41. CNS effects • Role of M-3-G • Management; – Opioid rotation – Dose reduction – Circadian modulation – Hydration – Psychostimulants – Other drugs; haloperidol, midazolam, baclofen, clonazepam,clonidine
- 42. Adjuvants • Antidepressants : tricyclic antidepressant (amitriptyline), SSRI (Fluoxitine) • Anticonvulsants : Carbamazepine (tegretol), Hydantion (dilantin), Gabapentin (Neurontin) • Sedatives, hypnotics, tranquilizers • Steriod • Muscle relaxants
- 43. ADJUVANTS DRUGS - Anticonvulsants - Antidepressants - Local anesthetics - Corticosteroids - Antihistaminics - Muscle relaxants - Psychostimulants - Drug action on bone INDICATIONS - neuropathic pain - neuropathic pain - neuropathic pain - multiple - coanalgesic, antiemetic - muscle spasm - opioid sedation - bone pain
- 44. Antidepressants • Used in neuropathic pain ; several studies in Diabetic neuropathy, Post-herpetic neuralgia, phantom limb pain, migraine headache • Reduce insomnia and anxiety • 1-2 weeks lag time for clinical effects • Start 10-20 mg hs • Escalated 4-5 day intervals to doses 100- 150 mg • Abrupt escalation not recommended
- 45. TCA Uses Limited by Side Effects • Anticholinergic : dry mouth, visual changes, constipation, tachycardia, urinary retention, reduced gastric motility, worsen narrow angle glaucoma • Antihistamine : sedation • Alpha adrenergic blockade : orthoststic hypotension • Sodium channel blockade : prolonged QT and QRS
- 46. สรุปแนวทางการระงับปวดผู้ป่ วยโรคมะเร็ง • มะเร็งเป็นโรคที่มีผลร้ายต่อชีวิต มะเร็งระยะท้ายทา ให้ผู้ป่ วยจานวนมากมีความปวด • ความปวดที่พบในผู้ป่ วยมะเร็งมีหลายสาเหตุรักษา ตามความเหมาะสมของแต่ละสาเหตุ • การประเมินความปวดมีทั้งทางกายและทางใจ • ปริมาณความปวดดูได้จาก VAS ฯ
- 47. สรุปแนวทางการระงับปวดผู้ป่ วยโรคมะเร็ง • การระงับปวดใช้ยาเป็นหลัก • ให้ยาระงับปวดตามความรุนแรง ตามเวลาอย่าง ต่อเนื่อง เสริมเมื่อต้องการเพิ่ม และประเมิน ผลการรักษาบ่อยๆ • ยังมีการระงับปวดโดยไม่ใช้ยาอีกหลายวิธี • ดูแลคุณภาพชีวิตของผู้ป่ วย
- 48. Thank you