CANCER-PAIN-MANAGEMENT课件

Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,CANCER PAIN MANAGEMENT,Pain control should encompass“total pain”,Pain management specialists should not work in isolation,Education is fundamental to good pain management,Cancer pain management,A survey of physicians actively involved in cancer care,1/3 wait until prognosis 50%patients report 50%pain relief,30%minor adverse reactions,4%have to stop treatment,SSRIs less effective(50%reduction side effects),No difference in efficacy across different pain conditions,Adjuvant analgesics anticonvulsants,NNT=2.6 in trigeminal neuralgia,Evidence of efficacy in diabetic neuropathy,Evidence of efficacy in migraine prophylaxis,Relatively high risk for minor adverse effects,Difficult cancer pain may need specialist pain management,The WHO guidelines fail in 10-15%patients,This may be due to:-,opioid resistance,intolerable drug side effects,inability to deliver drugs effectively,e.g.GI problems,Simple nerve blocks,Complex,Nerve,Blocks,Spinal drug delivery,Much smaller drug doses are needed,2%patients with cancer pain,When simpler and more economic methods have failed,Indications failure of systemic treatment,intolerable drug side effects,Epidural or intrathecal,drug delivery,External&internal systems,Choice of patient for spinal drugs,Contraindications,Local or systemic infection,Non-correctable co-aggulopathy,Patient refusal,Indications,Segmental pain or spasticity,Not head pain,?Neuropathic pain,?Visceral pain,incident and cutaneous pain,Investigations,Cord compression?,Good CSF flow,Life expectancy,External or internal systems,Life expectancy 3 months?,Intrathecal or epidural drug delivery,?,Complications within 20 days after implant,Intrathecal 25%Epidural 8%,CSF leak was the main intrathecal complication,Complications after 20 days after implant,Intrathecal 5%Epidural 55%,Epidurals frequently obstruct or dislodge,Implantable or external system?,Pain problem,Patients condition,Experience of the team,Spinal drugs infection,Infection rates vary,1 per 168-1 per 2446 catheter days,20%cultures from cassettes,syringes and filters,colonised without clinical,Infection associated with prolonged,catheter placement time 100 min,Spinal drug delivery,Pain may change as patient approaches,the end of life,Small pump reservoir may mean,alternative method of analgesia needed,Clinical bottom line,Pain relief better with intrathecal than epidural systems,Treatment failures more common with external epidural catheters,compared with internal IT catheters,Treatment failures less common with internalised IT catheters,than with internalised epidural catheters,Higher rates of system removal with internalised epidural,catheters than with internalised IT catheters,Higher rates of catheter complications with epidural,than with IT catheters,Spinal drugs adverse effects,Dose escalation-Spinal opioid rotation,Sedation or itching with opioids,Hypotension with clonidine,Motor block with local anaesthetics,Subtle personality change,with ketamine,Hormonal and immune,suppression with opioids,Conclusions,A multi-disciplinary approach,Lessons now being applied to,Non-cancer pain,25,000 patients have been,treated world-wide,