pain syndrome & stem cell transplantation
TRANSCRIPT
PAIN SYNDROME &HSCT
Hedayati Asl A.Mahak Cancer Children’s Hospital
Stem Cell Transplantation Department
Patients stress in BMT Death: death and dying Dependence: Dependency from family,
friends, Disfigurement: Physical disfigurements Disabilities: Hindrance of roles and tasks Disruption: Disruption of relationships Discomfort: Pain and other physical stressors Disengagement: Returning from the role as a
patient
Severe pain syndromes may be recorded during all phases of hematopoietic stem cell transplantation (HSCT) for hematological malignancies: from stem cell mobilization to the long-term post transplant period.
Several pain syndromes of different pathophysiology and severity have been reported. Stem cell donors may experience pain from mobilization of hematopoietic stem cells or collection of bone marrow.
Although the major cause of pain in the setting of HSCT is injury to mucosal tissues induced by the conditioning regimen, pain from several other causes has been reported.
A “faces” scale used to monitor pain and pain management
efficacyin children between ages 3 and 7
years
Recipient
The major cause of pain in HSCT recipients is a result of injury to mucosal tissues induced by the conditioning regimen.
Diagnostic procedure-related causes
Deep somatic pain BM aspiration and biopsy; BM harvest; headache following lumbar puncture
Superficial somatic pain Venepuncture; needle insertions; CVC positioning
Iatrogenic pain syndromes Deep somatic pain BM expansion and/or
sensitization by G-CSF; treatment-induced osteoporosis and fractures; BM necrosis
Superficial somatic pain CHT and/or RT-induced oral mucositis
Visceral pain CHT-induced cystitis; CHT/RT-induced GIM; HC
Neuropathic pain Drug-related neuropathies (vincristine, bortezomab, sirolimus, tacrolimus, cyclosporine)
Transplant complication-related causes
Deep somatic pain BM expansion and/or sensitization related to the engraftment; pneumonia; pleuritis; deep abscess
Superficial somatic pain Oral ulcers and skin lesions associated with acute and chronic GVHD; superficial abscess; ocular lesions associated with chronic GVHD
Visceral pain Gastrointestinal GVHD; neutropenic enterocolitis; visceral involvement by HZV and CMV
Neuropathic pain HZV outbreak and PHN (post-herpetic neuralgia)
Skin manifestations of acute GVHD
Skin lesions in a patient with severe acute graft-versus-host disease (GVHD). There is swelling, generalized erythroderma, and bullous formation.
Daily mean morphine dose for adolescents with mucositis pain
during HCT. Morphine delivered by physician-prescribed continuous infusion (CI) or by PCA (patient-controlled
analgesia).
Cyclosporine-induced pain syndrome in a child undergoing hematopoietic stem cell transplant
Calcineurin-induced pain syndrome CIPS is hypothesized to result from
calcineurin-induced vascular changes that disturb bone perfusion and permeability, leading to intraosseous vasoconstriction and bone marrow edema.
Symptoms were most acute during the infusion, when whole blood cyclosporine concentrations were likely to be the highest.
CIPS Interventions aimed at reducing pain
associated with CIPS may include the initiation of calcium-channel blocker therapy and conversion to an alternative calcineurin inhibitor.
Bone scan increased tracer uptake of the foot bone
MRI demonstrated bone marrow edema in the painful bones
CIPS Treatment symptoms were resolved when tacrolimus was
substituted for cyclosporine and amlodipine was initiated.
the increasing use of PCA (patient-controlled analgesia) for these patients justifies further investigation to standardize its utilization.
TCA administration in HSCT
There is considerable concern about the use of TCAs in the HCT patient, as many TCAs appear to have marrow suppressant effects
Clinical experience indicates that up to 25% of HCT patients will have significant marrow suppression in the early engraftment period with either TCAs or the newer selective serotonergic reuptake inhibitors (SSRIs).
If TCAs are used, it is desirable to begin with a low dose, e.g. 10 mg amitriptyline, and titrate upwards against side-effects, which often are the limiting factors.
pain management
Although recent advances in the conditioning regimen have reduced the painful complications of HSCT, pain and its treatment remains a major issue in the global management of HSCT patients.
pain management the key elements of pain management in
HSCT patients remain the competence of and the empathy provided by a multidisciplinary team working together to provide the best available means to effect pain relief inpatients with this debilitating condition.