Title: MANAGEMANT OF CANCER PAIN IN CHILDREN
1MANAGEMANT OF CANCER PAIN IN CHILDREN
2PHYSIOLOGY OF PAIN
- Pain is a protective mechanism for the body. It
causes the individual to remove the painful
stimuli, so prevent tissue damage. Nociceptors
are the receptors of pain. -
- Pain pathways
- The pain pathway includes the following
components - a. Peripheral receptors
- b. Neural pathways
- c. Spinal Cord mechanisms long tracts
- d. Brainstem, thalamus, cortex other areas.
- e. Descending pathways
3Pain transmission.
4- Pain Nerve Fibers
-
- Pain impulses are transmitted to the CNS
through 2 types of fibers, which are - A d fiber These are small myelinated nerve
fibers 2-5 µm. In diameter. They conduct at
velocity of 12-30 meter/second. A d fibers
synapse primarily in lamina I (lamina
marginalis). -
- C fibers These are unmyelinated nerve fibers
with a diameter of 0.4-1.2 µm. Their conduction
velocity is 0.6-2 meter /second. Slow pain is
claimed to be conducted via these fibers. The C
fibers synapse in lamina II and III substantial
gelationsa.
5Pain pathway
6 Developmental Stages in Pediatric Pain
Perception
7Types of Cancer Pain
- Nociceptive
- Soft tissues.
- Bone metastasis.
- Neuropathic.
- Visceral.
- Combined.
8Cancer Pain Syndromes
- Pain in the cancer patient results from
- 1- Direct tumor involvement
-
- 2- Pain associated with cancer therapy
-
- 3- Pain unrelated to the cancer or the cancer
therapy
91- Direct tumor involvement
- Direct tumor involvement of bone, hollow viscera,
or nerves is a common cause of pain in pediatric
cancer patients. - Pain caused by tumor occurs in 2546 of
patients, often as a result of leukemic
infiltration of bones or joints. - a- Somatic pain is typically well localized
Examples pain associated with primary or
metastatic bone disease. -
10- b- Visceral pain is poorly localized, often
described as "deep", "squeezing" and "pressure"
and may be associated with nausea, vomiting and
diaphoresis, particularly when acute. It may
result from the infiltration, compression,
distension or stretching of thoracic and
abdominal viscera by primary or metastatic
tumors. Example pain associated with tumors of
the liver primary or metastatic. - c- Neuropathic pain results from tumor
compression or infiltration of peripheral nerves
or the spinal cord. Chemical- or radiation-
induced injury also may result in this sort of
pain.
11- 2- Pain associated with cancer therapy
- It includes pain which occurred in the
course of, or as a result of, chemotherapy,
surgery, or radiation therapy. Procedural pain
occurs in approximately 40 of children. Last,
pain caused by treatment toxicities (e.g.,
mucositis) occurs in 4050 of children - 3- Pain unrelated to the cancer or the cancer
therapy.
12Mediators producing pain
- Malignant cells produce
- PGs.
- Cytokines Growth factors EGF, TGF, PDGF, and
Endothelin 1. - Macrophages (20-30) in malignant tumors
- TNFa.
- IL-1
13Importance of pain relief
- Elimination of stress response that has an
influence on - Sleep.
- Appetite and nutrition.
- Nitrogen balance.
- Cytokine cascade, towards immuno-suppression.
14Patient Assessment
- Assessment of patients pain.
- Assessment of patients psychological state.
- Assessment of patients social state.
- Assessment of patients family care giver state.
15Pain Assessment in Pediatric
- Pain assessment in children is difficult and this
has led to the proliferation of multiplicity of
pain assessment scales for neonates, infants and
children. Most of these scales try to assign a
numerical value to one of these dimensions
cognitive, physiological, sensory, behavioral,
and even facial expression. - Pain can be assessed by
- 1- Self-report (what children say).
- 2- biological markers (how their bodies react),
- 3- and behavioral methods (what children do).
161)Self-Report (e.g. face scale, graphic rating
scale.)
- Face scales
- Children are asked to indicate their pain by
pointing to one of the faces put in a scale.
Usually the child is trained by asking how he or
she would feel following some minor pain and then
a more severe pain. However, it is important to
be sure that the scale signifies pain and not
simple misery.
172)Biological Measures
- Heart rate Heart rate initially decreases and
than increases in response to short, sharp pain. - Arterial oxygen saturation Oxygen saturation
decreases during painful procedures. - Stress Hormones Surgery or trauma triggers the
release of stress hormones (corticosteroids,
catecholamine, glucagon and growth hormone) into
the blood with reduction in insulin levels. - Cortisol release widely studied in infants and
children, is not specific to pain and occurs in
many adverse situations.
183-Behavioral methods
- 1-Behavioral Pain Assessment Scales For Young
Children (FLACC Scale). - Five categories (F) Face (L) Legs (A)
Activity (C) Cry (C)Consolability - 2-The children's Hospital of Eastern Ontario pain
Scale (CHEOPS) - The scale assigns a point score to 6 categories
of behavior
19Social and Psychological Assessment
- This form of assessment is important to define a
successful plan for management. - The response of the patient is highly dependant
on his attitude to the situation (coping). - The family members who are going to carry, and
held responsibility for executing properly the
treatment plan, or caregivers.
20Cancer Pain management
- Although improved, it is considered up-till now
as an empirical treatment, hopes in the future to
have specific antagonists to each type of
mediator released. - Should be considered always as an adjuvant
treatment to anticancer therapy to improve the
outcome and prognosis. - Care is also paid for psychological, and
para-neoplastic syndromes.
21Aim of Management
- To prevent pain from coming rather than to relief
pain when it comes, this will - provide a better quality of life.
- Better monitor the clinical state of cancer
growth and dissemination. - decrease the total analgesic dose.
- prevent tolerance.
- improve patients immunity and suppress stress
response, and give a better response to
anti-cancer therapy.
22General roles for management
- Optimization of drug therapy
- Right analgesic.
- Right dose.
- Right schedule.
- Right co-analgesic.
- Individualization for each patient.
- Opioid Rotation if there is side effects.
- Anticipation of breakthrough pain.
- Prevention of side effect.
23- Management of cancer pain can be divided
according to causes into - 1. Management of Procedure related pain
- This includes topical local anesthetics,
intravenous sedation, transmucosal drug and
nitrous oxide. - 2. Management of Treatment related pain
- This is includes treatment of mucositis, post
operative pain, infection.
24- 3-Management of cancer related pain
- This includes a complex mechanism which
depend on severity of pain followed by choose
the appropriate drugs which depend on what is
called stepladder of WHO which divide pain into 3
categories - Step 1 Mild pain NSAIDs and Paracetamol are the
drugs of choice. - Step 2 Moderate pain where weak opioid with
NSAIDs are used as codeine or hydrocodone - Step 3 Severe pain strong opioid and
intervention therapy are used morphine,
hydromorphone, methadone, fentanyl, or
levorphanol.
25Step ladder WHO
26Oral Analgesics
- Easier.
- Desired.
- Remember that
- Concentrations unpredictable
- Constant serum level is important to keep the
patient not in pain. - Higher levels of metabolites
- Higher incidence of side effects.
- Burden on the kidney More ionized.
- The oral route cannot be used in patients
- Who are unable to swallow.
- Have a bowel obstruction or.
- Have persistent nausea and vomiting.
27Analgesics are given by
- Oclock, and not when needed.
- Full clinical dose.
- In sustained release formula.
- By step ladder system.
- With an adjuvant.
28Recommended dose for mild pain for pediatrics
29Opioids
- Problem of addiction
- Presence of pain protects against addiction.
- Side effects are mainly
- Tolerance.
- Constipation.
- Nausea / vomiting.
- Sedation / dizziness.
- Rash.
- Respiratory depression.
30Weak OpioidsSecond Step in WHO Ladder
- They can relief pain when we increase the dose
but with significantly higher incidence of side
effects. - Members are
- Codeine and dihydro-codeine.
- Tramadol.
- Dextro-propoxyphene.
31Strong Opioids
- Morphine available in.
- Immediate release( 4 hourly).
- Controlled release (12-hourly).
- Sustained release (24-hour dosing).
- Oxycodone.
- Fentanyl (available in a transdermal, and
transmucosal formulation). - Methadone.
- Hydromorphone.
- Oxymorphone (available in a rectal formulation).
- Meperidine is not used.
32Principles of Dosing
- Opioid naive patients should start on weak
opioids. - An immediate release formulae are only used for
dose titration, and break through pain. - Maintenance should be with sustained release
formulae. - Switching opioids is done with half or 2/3 of
equi-analgesic doses.
33Transdermal Route
- Transdermal drug systems deliver a drug to the
skin surface at a rate less than the maximum rate
of transport through the skin . - This enables to control the drug to remain within
the delivery system and not within the skin. - The stratum corium is difficult to penetrate.
- Stores a drug depot that prolong drug action.
34Transdermal Therapy System TTS
Drug Reservoir Alcohol is added
35Minimizing Side Effects
- Constipation
- Around the Oclock laxatives.
- Should be monitored as pain.
- Nausea and vomiting
- Secondary causes should be excluded.
- Anti-emetics.
- Sedation
- Psychostimulants.
- Opioid rotation may improve side effects
36Adjuvant Drugs
- Their presence is crucial in the success of
management. - They can promote sleep, relief anxiety,
potentiate pain relief, smooth side effects.
37Drugs for Bone Pain
- Nonsteroidal Anti-Inflammatory Drugs
- Corticosteroids
- Bisphosphonates
- Pamidronate, alendronate)
- Calcitonin
- Radiopharmaceuticals
- Strontium-89.
38Drugs Used for Bowel Obstruction
- Anticholinergics
- Scopolamine reduces peristalsis and secretions,
subjective reports of analgesic effects - Octreotidereduces peristalsis and secretions,
subjective reports of analgesic effects - Corticosteroidssubjective reports of analgesic
effects
39Conclusion
- Cancer Pain can greatly influence patients
prognosis and should be managed early, and
specifically. - Drug therapy is still the corner stone in cancer
pain management. - If properly scheduled, drug therapy can achieve
90 success.
40- No injectable forms are used for maintenance
except through a pump. - Sustained release formulae is the role.
- Oral formulations generally have more side
effects particularly with kidney affection. - Recently introduced fentanyl patch, and oxycodone
got their success from the less side effects they
produced.