Palliative care

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Palliative care

• For cancer patients
• Team approach

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Sympathy is not enough
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What can we do ?
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(No Transcript)
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Better quality of life
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Cancer pain management

• Dr. Ahmed Helmy Abouel Soud
• Board member of WSPC
• Professor of Pain Relief, N.C.I., Cairo
  University, Egypt

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Cancer pain

• 70 of advanced cases
• Any site any type

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Tools

• Drugs
• Interventions

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Pharmacotherapy

• WHO ladder system
• By the clock
• Oral or transdermal rout
• Full dose

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WHO ladder system

• Non opioid adjuvants
• Weak opioids I
• Strong opioids I

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Sustained release opioids

• Oral weak opioids e.g. tramundine, D.H.C.
• Oral strong opioids e.g. MST, oxycontin and MXL

• Transdermal e.g. Fentanyl patch (Durogesic)

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Newer Fentanyl (Durogesic) patch

• Simpler, thinner
• Better adhesion
• Fentanyl in dissolved state with no ethanol as
  permeation enhancer

• Can be divided
• Guarantee stable blood fentanyl level for 72 h

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Side effects
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Pain interventionsminimally invasive procedures

• Delivery of opioids to the C.N.S.

• Destruction of pain pathway

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Delivery of opioids to the C.N.S.

• Frequent delivery by special device
• Generalized pain, initial good response to the
  systemic drug with appearance of tolerance or
  side effects, adequate test response
• Better response with lower dose and lesser side
  effects

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Pain pathway destruction

• Advanced cancer
• Localized severe pain
• Accessible target

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Ideal procedure

• Life long
• High success rate with selective destruction
• Complete or satisfactory pain relief
• Percutaneous by R.F. or neurolytics
• Under local anesthesia
• No or minimal morbidity

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Common targets

• Celiac plexus
• Superior hypogastric plexus
• Ganglion impar
• Posterior root
• Spinothalamic tract
• Trigeminal tract nucleus

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Neurolytic procedures

• Celiac plexus
• Superior hypogastric plexus
• Ganglion impar
• Posterior root

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Celiac plexus destruction

• Upper abdominal visceral pain
• Pancreas, hepatobiliary, stomach, intestine
• 85 success

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Celiac Plexus
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Superior hypogastric plexus destruction

• Pelvic visceral pain
• Bladder, prostate, cervix, uterus, ovary, colon
  rectum
• 75 success

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Ganglion impar

• Junction of the two paravertebral sympathetic
  chains
• Sacroccygeal junction
• SMP at the perineal region
• Ca rectum, anal canal, vagina vulva
• 50-60 success

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Posterior (sensory) root

• Localized somatic
• Rib metastases, ca rectum anal canal
• 70 success
• Sensory loss

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Percutaneous RF procedures

• Cordotomy
• Tractotomy-nucleotomy

• Spinothalamic tract
• Trigeminal tract nucleus

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Spinothalamic tract

• Crossed fibers
• Anterolateral quadrant
• Pain temperature
• Somatotopic organization
• Important relations

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Cordotomy

• Unilateral cancer pain below the clavicle
• Lung, pleura, pelvic bones muscles, upper
  lower limb
• 95 success
• Loss of pinprick temp

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Descending trigeminal tract subnucleus caudalis

• Posterolateral part
• Joined by VII, IX and X
• Somatotopic organization
• Important relations
• Pain temperature

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Trigeminal Tractotomy-Nucleotomy

• Percutaneous
• under L.A. sedation
• C-T guided
• R.F.
• Occiput / C1 level
• 75 success

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Can we offer this ?