1Surfing in a TsunamiSurfing in a TsunamiLiving with Cancer Pain in Childhood – Susie Lord, Pain Grand Rounds Nov 2009Living 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 4th ventricle lesion

Surgical debulking

Medulloblastoma

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

Cancer Treatment

Surgical resection

Radiotherapy brain and spine

Chemotherapy

5 year survival approx 80%

Billy’s surveillance scans @ 1 yr clear

Onset of Pain

18 months after Dx low back pain

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

Chemotherapy

After discussion with family

Paediatric Oncology Day Unit

Ronald McDonald House

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

Consultations

Family (ies) re progress

Radiation Oncology

Pain Service

Consult Agenda

Assessment

? Role of anti-neuropathic Rx

? Role of neuraxial analgesia

? Keen to go home < 1 week

Biopsychosocial AssessmentBiopsychosocial 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

18

F M SF

1230kg

7 1

Big Family

A

Pain History

Back pain

Leg pain

Jaw pain

Pain History

Back painBilateral lumbosacral spinal painDeep aching 3/10 incident pain 5/10Yesterday shooting character 9-10/10

Leg pain

Jaw pain

Pain History

Back painBilateral lumbosacral spinal painDeep aching 3/10 incident pain 5/10Yesterday shooting character 9-10/10

Leg painLeft knee day 4 right knee, lateral calfAching, hurting 2/10 aggravated by wt bearing

Jaw pain

Pain History

Back painBilateral lumbosacral spinal painDeep aching 3/10 incident pain 5/10Yesterday shooting character 9-10/10

Leg painLeft knee day 4 right knee, lateral calfAching, hurting 2/10 aggravated by wt bearing

Jaw painLeft > right mandible aching 2-3/10Associated numbness in mental nerve territory

Pain History

Back painBilateral lumbosacral spinal painDeep aching 3/10 incident pain 5/10Yesterday shooting character 9-10/10

Leg painLeft knee day 4 right knee, lateral calfAching, hurting 2/10 aggravated by wt bearing

Jaw painLeft > right mandible aching 2-3/10Associated numbness in mental nerve territory

Billy’s Goals

Pain relief

Think clearly

Be mobile

Go home

Current Analgesia

Paracetamol

Oral Morphine SR 160 mg/day

IV Morphine (PCA) 100 mg/day

D4 Advice

Increase PCA bolus dose 1.22mg

Review PCA usage and adjust Morphine SR dosing

Aim to convert PCA oral IR

Start oral Gabapentin in anticipation

Consider Ketamine if more acute

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

Intrathecal

Neuraxial Intro

Systemic treatment being optimised

Radiotherapy might reduce pain

Info just a foundation for future discussions if needed down the track

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

D5 Advice

Continue PCA

Supplemental O2 if SpO2 < 94%

Commence Ketamine Infusion (0.25mg/kg/hour)

Consider opioid rotation

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)

D6-10 Advice

Stepwise adjustments MS Contin 200 mg/day IV Morphine 3 mg bolus

110170 mg/day Ketamine continuing 7 mg/hr Gabapentin increasing to 300 mg tds

D6-10 Advice

Stepwise adjustments MS Contin 200 mg/day IV Morphine 3 mg bolus

110170 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

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

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

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

Intrathecal AnalgesiaIntrathecal 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

Intrathecal AnalgesiaIntrathecal Analgesia

Retrospective over 8 years 11 children

PNET, rhabdomyosarcoma, osteogenic sarcoma, solid tumours

18

F M SF

1230kg

7 1

Big Family

A

Consent

Thanks MD & PA

Intrathecal

D14 Intrathecal Started

Opioid – 50% of systemic dose IT morphine (x 0.01) 3 mg/day

Clonidine – 1mcg/kg/day 30 mcg/day

Bupivacaine – 0.04-0.4mg/kg/hr halve this due to goals 15 mg/day

W3 Intrathecal Titration

Daily IT titration (20%)

Systemic Rx reductions

Radiotherapy transfers

Incident pain management

Pain meaning distress

W4 Community Transition Planning

Attempted to simplify analgesia delivery – challenging

Pumps to allow flexible dosing

Liaison with Level 3 and 2 services

Family meetings / SW

Contingencies

W5-7 Pain Challenges

Tumour load pain escalation and new pains DVT & anticoag marrow failure

Significant opioid tolerance

Opioid-induced hyperalgesia

Relative / variable success

W5-7 Real Challenges

Being able to think and move

Being unable to go home

Existential suffering – Billy

Existential suffering – family

Child-Centred Play

The child initiates and directs all aspects of play

Activity

Equipment

Symbolism

Roles

Principles

Tracking

Reflection

Acknowledging feelings

Returning responsibility

Analgesia…

Window of Opportunity

Thanks Everyone

W4 Community Transition Planning

Attempted to simplify analgesia delivery – challenging

Pumps to allow flexible dosing

Liaison with Level 3 and 2 services

Family meetings / SW

Contingencies

W5-7 Pain Challenges

Tumour load pain escalation and new pains DVT & anticoag marrow failure

Significant opioid tolerance

Opioid-induced hyperalgesia

Relative / variable success

W5-7 Real Challenges

Being able to think and move

Being unable to go home

Existential suffering – Billy

Existential suffering – family

Confidentiality