American Society of Regional Anesthesia and Pain Medicine May 2015 - (Page 19)
Application of Regional Anesthetic Techniques for Cancer Pain
P
ain is one of the most commonly
experienced and feared symptoms faced
by cancer patients. Despite improved
education for those providers who treat cancer
patients and an increased recognition of
the need to closely monitor cancer patients
for their pain experience throughout their
disease, a significant minority of patients
still face poorly managed pain. 1 While most
patients with advanced cancer can achieve
effective analgesia with systemic modalities
alone, up to 24% of patients will have
Susan M. Moeschler, MD
Lindsay L. Warner, MD
Jacob S. Strand, MD
inadequate pain control or will experience an
Assistant Professor of
Resident
Assistant Professor of Medicine
intolerable side effect. 2 It is in this setting that
Anesthesiology
Department of Anesthesiology
Division of Palliative Care
anesthesiologists with expertise in regional
Division of Pain Medicine
techniques and interventional pain procedures
Mayo Clinic, Rochester, Minnesota
can provide significant pain relief for patients.
Increasingly, we are seeing that these
Section Editor: Steven Orebaugh, MD
procedures have significant value and are not
simply useful as a tool of last resort. Whether
used as a temporizing treatment during a pain crisis, as adjuvant An interscalene catheter was placed under ultrasound guidance
therapy during a procedural intervention, or as a bridge to a
and loaded with 0.5% bupivacaine with 1:200,000 epinephrine.
more permanent therapy, these interventions can and should be
An infusion of 0.2% bupivacaine at 6 mL/hr was continued
used early for pain relief in
for 4 days. The patient
cancer-related pain. Herein
reported significant pain
we describe two cases * in
relief (pain scores reduced
which regional techniques
from 8/10 to 0-3/10) and
proved to be a significant
was able to tolerate the
tool in the management
radiation treatment without
of patients with complex
sedation or increased
cancer pain.
pain. Upper extremity
function and sensation
CASE 1
returned to baseline on
Patient 1 was a middleremoval of the catheter.
aged woman with a diagnosis of metastatic squamous cell
The patient's home-going analgesic regimen was restarted as a
cancer of the esophagus who presented with a pathologic
75-mcg/hr fentanyl patch. She did not require any medication for
fracture of the left humerus and resultant severe upper extremity breakthrough pain.
pain. Despite surgical fixation, she continued to have severe left
upper arm pain, thought to be due to residual tumor. She had
CASE 2
exhausted her chemotherapeutic options but was offered a single Patient 2 was a woman in her late 40s with advanced metastatic
fraction of radiation to the tumor for pain control. Unfortunately,
ovarian cancer, who was admitted to the hospital for acute pain.
owing to her significant pain, she was unable to tolerate lying
In addition to her more chronic cancer-related pain that had
flat and still for her radiation simulation. She had unfortunately
been heretofore well controlled, she had developed new left
developed a trust deficit with her primary hospital service due
upper quadrant pain after undergoing percutaneous endoscopic
to several failed trials of opioids, which were either ineffective
gastrostomy (PEG) tube placement. She described the PEG site
or left her feeling overly sedated. Nonopioid adjuvants such as
pain as 10/10 in severity with very focal, stabbing, and electric
acetaminophen and gabapentin had likewise been tried with
characteristics. The pain was also quite constant, as it was
minimal improvement. Pain Medicine and Palliative Care services reproduced with minimal activation of her abdominal musculature,
were ultimately consulted and placement of an interscalene
leading to significantly reduced physical function. Physical
peripheral nerve catheter was recommended as a bridge therapy
examination was notable for a positive Carnett sign** near the PEG
to allow for positioning during radiation therapy and rotation to
site. The PEG tube was replaced in an effort to reduce pain thought
alternative systemic opioid and nonopioid therapies.
to be due to malposition of the tube on her costal margin and
"Anesthesiologists are uniquely
positioned to use skills honed in the
perioperative realm to alleviate complex
cancer-related pain."
American Society of Regional Anesthesia and Pain Medicine
2015
19
3
Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine May 2015
President’s Message
Editorial
Pharmacogenetics in Monitoring of Chronic Pain Patients: Are We There Yet?
Phrenic Nerve Injury and Interscalene Nerve Block: Have We Learned Anything From the Surgical Treatment of Over 150 Cases of Diaphragmatic Paralysis From Multiple Etiologies?
An Exercise in Negotiation: The Success of the Pain Medicine Fellowship Match
Regional Analgesia for Patients with Acute Rib Fractures
Application of Regional Anesthetic Techniques for Cancer Pain
American Society of Regional Anesthesia and Pain Medicine May 2015
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