Neuraxial Techniques in Palliative Care

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Neuraxial Techniques in Palliative Care Karen H
Simpson Consultant in Pain Medicine Leeds
Teaching Hospital Trust
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• Cancer Pain Management
• Pain management part of a broader therapeutic
  endeavor
• Palliative care is the active, total care of the
  patient with
• active, progressive, life-threatening disease
• Both involve a variety of health care
  professionals
• Continuing management includes
• control of pain and symptoms
• maintenance of function
• psychosocial and spiritual support
• comprehensive end of life care

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• Cancer pain
• Pain common in cancer
• WHO estimate 4 million people worldwide have
  cancer pain
• Many patients have more than one site of pain
• gt50 of patients in hospitals and hospices have
  pain
• Advanced cancer more likely to be painful
• Breakthrough and incident pain common
• Adequate pain relief achieved by 75 patients
  using
• simple techniques e.g. WHO analgesic ladder

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• Why Pain Control Can Be a Problem
• Survey of physicians actively involved in cancer
  care
• 1/3 wait until the prognosis lt6 months before
  giving
• maximal analgesia (Von Roenn et al. 1993)
•  
• Study of 81 doctors only 5 could convert a
  parenteral
• dose of morphine to an equivalent of MST and
  were
• unfamiliar palliative radiation (Mortimer and
  Bartlett 1997)
•  
• Study of 318 nurses knowledge about pain
  assessment
• and management showed lack of understanding
  about
• opioids (Hamilton and Edgar 1992)

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Basic Pain Management Principles  Meticulous
assessment of pain and appropriate
investigation Decrease pain improve quality of
life Do no further harm Allow patient and carers
choices Use resources as effectively as possible
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• Basic Pain Management in Cancer
• Modify the disease process if the cause cannot
  be removed
• Remove exacerbating factors
• Explore meaning of pain for the patient and
  carers
• Modify social/physical environment
• Treat associated mood disorders
• Regular oral analgesics and co-analgesics
• Nerve block or neuromodulation
• Neurosurgery

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• Nerve Blockade or Neuromodulation
•  
• May help about 10 patients
• If pain persists despite optimal oral analgesia
•  
• If effective oral analgesia gives intolerable
  side effects
•  
• Rapid, effective analgesia is required with
  limited time
• available for titration of oral analgesics or
  co-analgesics
•  
• Conditions that readily respond to nerve blocks
• e.g. joint pain, ischaemic pain

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• Neuraxial blocks
•  
• Local anaesthetic/steroid
• Somatic and/or sympathetic blocks
• Neurolytic blocks
• Spinal drug delivery
• Neuro-destructive surgical procedures
•  
• Ideally combined approach aimed at several
• different levels within nervous system provides
• optimum relief with least adverse effects

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Simple Nerve Blocks
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Complex Nerve Blocks
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Autonomic Nerve Blocks
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• Spinal Drug Delivery
•  
• Much smaller drug doses needed
• 1-2 patients with cancer pain
• If simpler and more economic methods fail
•  
• Indications
• failure of systemic treatment
• intolerable drug side effects

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• Choice of Patient for Spinal Drugs
•  
• Contraindications
• Local or systemic infection
• Head pain
• Non-correctable co-aggulopathy
• Patient refusal
• Lack of resources
• Lack of aftercare and community support
•  
• Indications
• Segmental pain or spasticity
• Positive response to test doses

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• Investigations
• Cord compression
• Good CSF flow
• Infection screen
• Coagulation
• Life expectancy
• Aftercare

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Epidural or Intrathecal Drug Delivery
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• Intrathecal or Epidural Delivery?
• Intrathecal drugs need not pass dura
• IT used in lower doses and volumes
• (10-20 epidural dose)
• Large volumes epidurally - spinal cord
  compression
• Change in epidural fat influences drug delivery
• Epidural catheters blocked by fibrosis
• Infection not more likely with intrathecal

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External or Internal Systems
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• Implantable or External System?
• Pain problem
• Patients condition and expected survival
• Experience of the team
• Support available

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Spinal Drugs   Opioids Clonidine Ketamine Octreoti
de Midazolam Neostigmine Baclofen Local
anaesthetics Ziconotide
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• Conclusions
• Patients should be referred early for
  consideration
• of interventions
• The pain must be carefully assessed and
  investigated
• Careful explanation to ensure the full
  understanding
• and consent of the patient is essential
• Patients and carers must be given adequate time
  to
• think about interventions and ask questions

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• Conclusions
• Those involved in patients care after block
  must
• understand the nature of the procedure
• what block can and cannot achieve
• how to look after the patient
• what the likely effects and side effects
• Nerve blocks must not cause functional defects
• Neuro-destructive procedures must be selective
  of sensory
• or autonomic nerves leaving motor paths and
  sphincters intact
• Neuraxial techniques should not be a treatment
  given in isolation
• but must form part of an overall strategy for
  analgesia

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• Conclusions
• Nerve blocks often forgotten or left as a last
  resort
• Patient may become too ill to tolerate technique
  
• or come to hospital for more complex procedures
• Need careful selection of patients and timing of
  interventions
• Early discussion between colleagues essential

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• Conclusions
• Anaesthetists should make themselves easily
  available
• for consultation about patients with difficult
  cancer pain
• Pain services should offer prompt treatment
• The choice of techniques offered depends on the
  skills
• and resources of the local pain management
  service