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Dr. Marlar Thin M.B.,B.S ,M.Med.Sc, Dr.Med.Sc (Anaes), Fellowship in Clinical Pain Management (Bkk) Senior Consultant Anaesthesiologist, Yangon Specialty hospital
D r . M a r l a r T h i n M . B . , B . S , M . M e d . S c , D r . M e d . S c ( A n a e s ) ,
F e l l o w s h i p i n C l i n i c a l P a i n M a n a g e m e n t ( B k k ) S e n i o r C o n s u l t a n t A n a e s t h e s i o l o g i s t ,
Y a n g o n S p e c i a l t y h o s p i t a l
Anaesthesiologists
knowledge and comfort level with application of potent analgesic and consciousness-altering pharmacology
Familiar with pain, sedation and nausea control
Titrating and monitoring skills
Good knowledge and skills in nerve blocks
able to manage the critically ill patients
- Valuable involement to palliation care teams
- Contribute to improvements in the important end-of-life outcome of safe and comfortable dying
• Severe uncontrolled pain is one of the most common problem in cancer patients
• Despite optimized use of systemic analgesics, 10-30 % of those with advanced cancer still have inadequate pain control and require further treatment
Interventional pain therapies have marked analgesic efficacy for otherwise intractable pain but therapies are often underutilized or withheld till the end of life.
• Interventional therapies range from the simple to the complex procedures
Croft P et al (2010) Chronic pain epidemiology
Impact of chronic pain on Quality of life and disability
Commonest pain syndrome present to PTC, YGH …. 1st - Musculoskeletal pain 2nd – Cancer pain 3rd – Non malignant Neuropathic pain 4th – Headache and orofacial pain 5th – Psychiatric disorders in pain
Comprehensive assessment Interactive diagnosis Holistic approach Tailored Mx (no “one size fits for all”) “Start Low, Go Slow” Multidisciplinary/ interdisciplinary care (Cohesive team)
GOAL : Pain relief and restoration of work productivity to the patient
(Quality Of Life )
APPROACH …
APPROACH …
Materials: Drugs / Techniques
Non opioid analgesics opioid analgesics adjuvants
Cancer pain Chronic Non Cancer pain
Intervention procedures
APPROACH … WHO Analgesic ladder → Plateform
Leung L(2012) From ladder to platform: a new concept for pain management. J prim health care 2012;4(3):254–258.
A to G = non pharmacological method
H= muscle relaxant, I = intervention , J= support gp
K,L,M = adjuvant (AD,ACs, cannabinoids) , N= CBT
O = Sx
SHIFTING PARADIGMS …
Advances and sophistication: in imaging, nerve location and pharmacology
evidence based practice, and revolutionary advances
in pain treatment
older blind techniques of nerve localization
use of - electrical and ultrasound guided nerve locator. - imaging, - radioopaque dyes for exact localization
Pain treatment
continuous plexus and nerve blocks repetitive intermittent blocks
• radiofrequency ablations, • intrathecal drug delivery • spinal cord stimulators • Discography • Annuloplasty, nucleoplasty
neurolytic blocks of - vital nerves, - ganglia and - central neuraxis
INTERVENTIONAL PAIN SPECIALIST
SHIFTING PARADIGMS …
Procedures done at Pain Clinic (YGH & NYGH) in recent years (end of 2008 onwards )....
IN MYANMAR …
- Done mostly for - Commonest – Cancer pain :
- Metastatic CA lung, CA cervix, Ca breast, Ca prostate
- Others : trigmeinal neuralgia, PHN
Procedures that we did in recent years
( 20009 on wards ..) • Somatic nerve blocks with LA and additives
• Common: ICNB, PVNB, trigeminal nerve block (Gasserian / V1,2,3 block)
• Others : femoral , pudental, saddle block, superficial cervical plexus block, IS Brachial block (continuous), supraclavicular block
By Landmark techniques ….
IN MYANMAR …
• Sympathetic nerve blocks : • Stellate ganglion block • Neuraxial blocks:
• Intrathecal morphine • Epidural block
• Trigger point injection
By Landmark techniques ….
IN MYANMAR …
INTERVENTION PROCEDURES Chronic LBP, Spinal radicular pain
Raj P (2008) Interventional pain management: Image guided procedures
WHO class I: non opioids
WHO class II: weak opioids
WHO class III: Strong opioids
Intrathecal opioids
Neurostimulation
Adhesiolysis/epiduroscopy
Pulsed RF
Steroid injection
- Epidural Steroid injection
Evidences for LBP …....
TFESI (1 C)
Caudal (1A/B, 1B/C)
IL approach (1C, 2C, 2B)
Short term relief (< 6 wks)
Strong Strong Strong
Long term relief (> 6 wks)
Moderate Moderate limited
Pain Physician: January 2007 10:185-212
Intervention procedures…
- Intra-articular Steroid injection
(eg) Facet joint injection (eg) SI joint injection
INTERVENTION PROCEDURES…
Pulse RF Continuous RF
(eg) MBB in facet joint pain (eg) Pulse DRG
INTERVENTION PROCEDURES…
Neuromodulation
INTERVENTION PROCEDURES…
INTERVENTION PROCEDURES… Neuropathic pain (eg) – Nerve block / RFA (eg) for Trigeminal neuralgia,
- Sympathetic block :
(eg) Stellate ganglion block for pain originated from H&N, upper limb (CRPS)
INTERVENTION PROCEDURES… Musculoskeletal pain
– Dry needling
– Trigger point injection
– Piriformis injection
– Botox injection
Vadalouca A et al (2011) Pain Practice: Pharmacological Treatment of Neuropathic Cancer Pain: A Comprehensive Review of the Current Literature
Integration of interventions according to the WHO analgesic ladder
during Neuropathic Cancer Pain treatment
INTERVENTION PROCEDURES…
INTERVENTION PROCEDURES… Commonly performed procedural interventions
for refractory cancer pain
• Neuraxial techniques: – epidural with LA and opioids
(tunneled Epidural catheter)
– intrathecal infusion therapies
• - external delivery
• - implantable drug delivery systems (IDDSs); – Neuraxial neurolytic interventions with alcohol
or phenol in selected terminal cancer pain
Christo PJ (2008) Interventional Pain Treatments for Cancer Pain
INTERVENTION PROCEDURES… • Somatic blocks
• Sympathetic blocks : Chemical neurolysis – celiac plexus,
– superior hypogastric plexus (SHP), and
– ganglion impar
Coeliac plexus block for CA pancreas (at yangon special ty hospital )
Lidocaine – Ketamine Infusion in Neuropathic Pain Patient (CA lung with brachial plexus neuropathy)
SHORTCOMINGS …
• Referral rates from palliative medicine to pain clinics were low
• 31% respondents received >12/year
• Joint consultations rare
• 25% pain anaesthetists had time allocated for palliative medicine
• Total interventions estimated at <1,000/year
Kay et al. Provision for advanced pain management techniques in adult palliative care: a national survey of anaesthetic pain specialists. Palliative Medicine 2007; 21:279-284
SHORTCOMINGS …
• Legislation
• Availability of drugs
• Professional – Unwilling to consult
– Refer difficult cases only
• Financial
• Unwillingness to change
SHORTCOMINGS …
• Materials (Drugs)
HAVE NEED
Weak opioids Strong opioids - Injection form - Fentanyl patch (not always) - Methadone (for drug
addicted patient)
Strong opioids - Oral forms - immediate release - slow release - Fentanyl patch (regularly) - Methadone for chronic
pain
- Preservative free Morphine
- How to control severe cancer pain ???
HAVE NEED
Adjuvants - Anticonvulsants - Antidepressants - Ketamine - Preservative free
lidocaine
Contrast agents
- SNRI (duloxetine, venlafexine, desven)
- Clonazepam - Centrally acting m/s
relaxant - Capsaicin cream
- How to control the spasticity due to central pain (eg) SCI
SHORTCOMINGS …
SHORTCOMINGS …
• Materials (Equipments) for interventions
What We Have !! Contrast agents
Steroids
Spinal / Epidural needles
Can do --- - common procedures for LBP and radiculopathy - somatic blocks - sympathetic blocks
Alcohol, phenol
PCA
Don’t Have !!
IDDS
S/C infusion pump
Neurostimulation
Epiduroscopy
Hypertonic saline
RF machine
SHORTCOMINGS …
SHORTCOMINGS …
–neuropathic pain,
–chronic non cancer pain,
–cancer pain,
–intervention pain management
Guidelines ….
NICE Guideline 2010 WHO guidelines
SHORTCOMINGS …
TAKE HOME MESSAGE • Role of Anaesthesiologist
PAIN
Surgical Anaesthesia
Critical Care Medicine Trauma /
Emergency medicine
Palliative care
Clinical Research
