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
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