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Surfing in a Tsunami Living with Cancer Pain in Childhood – Susie Lord, Pain Grand Rounds Nov 2009

Surfing in a Tsunami Living with Cancer Pain in Childhood – Susie Lord, Pain Grand Rounds Nov 2009. Confidentiality. Outline. Themes The Case Discussion. Billy. Lived in the country Healthy boy until aged 10. Billy. At 10 yo presented with diplopia MRI  4 th ventricle lesion

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Surfing in a Tsunami Living with Cancer Pain in Childhood – Susie Lord, Pain Grand Rounds Nov 2009

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  1. Surfing in a Tsunami Living with Cancer Pain in Childhood – Susie Lord, Pain Grand Rounds Nov 2009

  2. Confidentiality

  3. Outline • Themes • The Case • Discussion

  4. Billy • Lived in the country • Healthy boy until aged 10

  5. Billy • At 10 yo presented with diplopia • MRI  4th ventricle lesion • Surgical debulking • Medulloblastoma

  6. Medulloblastoma • Primary malignant brain tumour • Invasive, rapidly growing • Spreads through CSF to brain and spine • Extra-neural metastases are rare • Symptoms: listlessness, vomiting, headache, stumbling gait, falls, nystagmus, diplopia, other CN palsies

  7. Cancer Treatment • Surgical resection • Radiotherapy brain and spine • Chemotherapy • 5 year survival approx 80% • Billy’s surveillance scans @ 1 yr  clear

  8. Onset of Pain • 18 months after Dx  low back pain

  9. Onset of Pain • 18 months after Dx  low back pain • Rural assessment • Bone scan  hot spots in SIJs • JHCH assessment • Symptom relief  opioid analgesia • MRI  CT  PET scan • Biopsy  medulloblastoma

  10. Chemotherapy • After discussion with family • Paediatric Oncology Day Unit • Ronald McDonald House

  11. Admission • Increasing back and leg pain plus new jaw pain • Increased oral therapy • MS Contin 80  120 mg/day • Added Oxycodone IR 5-10 mg PRN • Added Dexamethasone 4 mg bd • Pain escalated over 4 days (7/10)  PCA  doubled dose

  12. Consultations • Family (ies) re progress • Radiation Oncology • Pain Service

  13. Consult Agenda • Assessment • ? Role of anti-neuropathic Rx • ? Role of neuraxial analgesia • ? Keen to go home < 1 week

  14. Biopsychosocial Assessment • Medical history to date • Pain history • Impact of pain and other experiences • Therapeutic resources to date • Family supports • School, friends, social supports • Spiritual needs / supports • Child’s, family’s understanding and goals

  15. Big Family A F M SF 18 12 30kg 7 1

  16. Pain History • Back pain • Leg pain • Jaw pain

  17. Pain History • Back pain Bilateral lumbosacral spinal pain Deep aching 3/10  incident pain 5/10 Yesterday shooting character 9-10/10 • Leg pain • Jaw pain

  18. Pain History • Back pain Bilateral lumbosacral spinal pain Deep aching 3/10  incident pain 5/10 Yesterday shooting character 9-10/10 • Leg pain Left knee  day 4 right knee, lateral calf Aching, hurting 2/10  aggravated by wt bearing • Jaw pain

  19. Pain History • Back pain Bilateral lumbosacral spinal pain Deep aching 3/10  incident pain 5/10 Yesterday shooting character 9-10/10 • Leg pain Left knee  day 4 right knee, lateral calf Aching, hurting 2/10  aggravated by wt bearing • Jaw pain Left > right mandible aching 2-3/10 Associated numbness in mental nerve territory

  20. Pain History • Back pain Bilateral lumbosacral spinal pain Deep aching 3/10  incident pain 5/10 Yesterday shooting character 9-10/10 • Leg pain Left knee  day 4 right knee, lateral calf Aching, hurting 2/10  aggravated by wt bearing • Jaw pain Left > right mandible aching 2-3/10 Associated numbness in mental nerve territory

  21. Billy’s Goals • Pain relief • Think clearly • Be mobile • Go home

  22. Current Analgesia • Paracetamol • Oral Morphine SR 160 mg/day • IV Morphine (PCA) 100 mg/day

  23. D4 Advice • Increase PCA bolus dose 1.22mg • Review PCA usage and adjust Morphine SR dosing • Aim to convert PCA  oral IR • Start oral Gabapentin in anticipation • Consider Ketamine if more acute

  24. Neuraxial Intro • Role when oral analgesia is inadequate and there are dose-limiting side-effects • For predominantly lower body pain • Local anaesthetic and other pain relievers • Epidural v intrathecal, temporary and portal • Community Mx might be possible if stable  Further discussion if/when indicated

  25. Intrathecal

  26. Neuraxial Intro • Systemic treatment being optimised • Radiotherapy might reduce pain • Info just a foundation for future discussions if needed down the track

  27. D5 Acute Exacerbation • Incident pain on transfer into a chair • Same location – bilateral low lumbar • No distal radiation • Deep hurting, constant • Pain score 3/10 9/10 • IV Morphine usage 12mg in prev hour  responsive but sleepy, RR 10/min

  28. D5 Advice • Continue PCA • Supplemental O2 if SpO2 < 94% • Commence Ketamine Infusion (0.25mg/kg/hour) • Consider opioid rotation

  29. D6-10 Progress • Background pain better controlled • Playing, colouring, talking and watching TV with family • Incident pain • Transfers, ambulating • Bilateral back and right hip • PCA usage variable (0 most hours, to 15-18 mg/hr especially when toileting)

  30. D6-10 Advice • Stepwise adjustments • MS Contin 200 mg/day • IV Morphine 3 mg bolus 110170 mg/day • Ketamine continuing 7 mg/hr • Gabapentin increasing to 300 mg tds

  31. D6-10 Advice • Stepwise adjustments • MS Contin 200 mg/day • IV Morphine 3 mg bolus 110170 mg/day • Ketamine continuing 7 mg/hr • Gabapentin increasing to 300 mg tds • Planning for pre/post radiotherapy analgesia • Titration, rotation, additional antineuropathic Rxs, intrathecal

  32. D11-12 Exacerbation • Transfer to Mater for Radiotherapy planning session – on/off 5 beds • Severe exacerbation back/hip pain • No improvement over 24 hours • IV Morphine PCA 300 mg/day 25 mg/hour

  33. D13 Reassessment • Evident that pain will prevent daily TF to Mater for radiotherapy next week • Added Methadone 5 mg bd PO with view to gradual cross-over rotation • Rotation to Hydromorphone PCA with 600  800 mcg bolus • Ketamine increased to 10 mg/hr • Plan / consent for semi-urgent IT

  34. Intrathecal Analgesia • Benefits • Systematic Review – Walker et al. Anesth Analg 2002 • Improved analgesic efficacy with fewer adverse effects • LA + opioid combinations improve control of incident pain • Clonidine + opioid combinations improve neuropathic pain

  35. Intrathecal Analgesia • Benefits • Systematic Review – Walker et al. Anesth Analg 2002 • Improved analgesic efficacy with fewer adverse effects • LA + opioid combinations improve control of incident pain • Clonidine + opioid combinations improve neuropathic pain • Risks and consequences (unquantifiable) • Patient – Anticoagulation / tumour / immunocompromise • Procedure – GA / nerve damage / haem / infectn / CSF leak • Functional – catheter obstruction / migration • Drug – local or systemic toxicity / adverse effects

  36. Retrospective over 8 years  11 children • PNET, rhabdomyosarcoma, osteogenic sarcoma, solid tumours

  37. Consent Big Family A F M SF 18 12 30kg 7 1

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