A Case Study in Neuropathic Pain .


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Targets. Before the hour's over the learner will be capable to:Define neuropathic painList no less than 2 sorts of Pain receptorsList no less than 4 unique sorts of adjuvant torment medicationsList the instruments of activity, advantages, and reactions of these 4 medicationsList 2 new/diverse adjuvant torment drugs.
Transcripts
Slide 1

A Case Study in Neuropathic Pain June 3, 2009 Palliative Care Team Drs. St. Godard, Loiselle, Hohl and Pilkey

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Objectives By the finish of great importance the learner will have the capacity to: Define neuropathic torment List no less than 2 sorts of Pain receptors List no less than 4 distinct sorts of adjuvant agony pharmaceuticals List the systems of activity, advantages, and reactions of these 4 meds List 2 new/unique adjuvant torment prescriptions

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Talk Outline Case Study – Dr. Ted St. Godard & Dr. Joel Loiselle Pathophysiology of Neuropathic Pain – Dr. Jana Pilkey Adjuvant Medications – Dr. Chris Hohl What\'s new/extraordinary in Neuropathic Pain – Dr. Jana Pilkey

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History Ms. G. D. 55 y.o with bosom disease Mets to bone Pain to left arm

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History 2 week hx of intensifying torment Mid back – dull hurt, Pressure Burning to L hand and arm Since 1997 brachial plexus neuropathy "Sticks and needles" "Like dunked in corrosive" Morphine for 4 weeks not helping

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Cancer History Breast malignancy dx 1997 Lumpectomy, tamoxifen x 2 yrs Mastectomy 1999 and LN dismemberment Oophorectomy 1999 Multiple courses of chemo 2008-mets to c-spine, ribs, sternum. Sept 2008 – Rx to spine Phx: PUD

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Physical Exam & Investigations Temp 37.2 Hr 100 Rr 18 Sao2 – 90% on RA BP 150/88 Lab work typical all through

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Course in Hospital Admission orders: Methadone 5mg offer Dex 10mg offer Pariet 20mg po od Dilaudid 8 mg subcut q4h and q1prn Fentanyl 50 for each IPP

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Course in Hospital Dec 30 Myoclonus saw – hydrated Rotated to fentanyl fix Methadone expanded Jan 14 CT head – mets to R cerebellum and R frontal flap Pain better-on methadone 40 offer, dex 8 offer Starts 12 rdtx to entire cerebrum

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Course in Hospital Jan 27 Pain Crisis Severe unbearable blazing agony From neck to top of R shoulder Crying, shouting BT HM insufficient Slept with 5mg versed Methadone expanded Ketamine included 2.5 mg subcut tid Pregabalin included 50mg offer Lidocaine 2% gel to bear qid prn

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Potentially valuable Peripheral Nerve Block in this Case Interscalene piece -Performed at root level - "Single shot" - just endures 12 h. - Catheter strategies hard to look after (dislodging). - Disease degree limits soporific stream. - Risk of draining/epidural hematoma is restrictive for this situation.

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Neuraxial (Intraspinal) squares Epidural: equivalent to reciprocal fringe nerve piece catheter outside dura would be set at C7/T1 Intrathecal = Spinal catheter enters CSF in lumbar storage can be guided to high thoracic level as required for upper appendage torment

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Contraindications to Neuraxial Analgesia in this Case Extent of Disease including C-spine: Risk of epidural hematoma if needle at C7-T1. Poor CSF stream blocks spread of analgesics Brain Metastasis: Posterior Fossa-expanded danger of "coning" Relative contraindication Remember coagulopathy (Plt <100; INR >1.3) and requirement for continuous anticoagulation are contraindications.

Slide 14

Course in Hospital Consult to Dr J. Loiselle Nerve-square or epidural excessively hazardous given delicacy of spine and cerebellar mets Jan 28 Pain proceeds On Methadone 60mg offer Starts fentanyl 50mcg/hr IV HM ceased – jerking Ketamine 5 mg subcut tid

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Course in Hospital Jan 28 Family worried about sedation on fentanyl Jan 29 RR 7 - fentanyl halted, Pain again serious Fentanyl IV not restarted at family ask for Ativan began Jan 30 – Mini Case meeting Ketamine IV @ 2.5mg/hr Gabapentin being brought down

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Course in Hospital Jan 31-Feb 5 – great agony control Feb 6 – tearful and tired, torment with development Feb 9 – increment in ketamine IV 3.52mg/hr Feb 13 – increment in ketamine IV 6mg/hr Feb 17 – diminish po consumption – decaying – ketamine 7.5mg/hr

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Course in Hospital Feb 19 – pt wishes she could rest until death – tired of attempting to "hold the torment in" Feb 23 – inert Feb 26 – anticipation hrs to days/talked about sedation Feb 28 – trouble keeping up sedation Mar 4 – kicked the bucket quieted and agreeable

Slide 18

What is Neuropathic Pain? Torment started or brought on by an essential injury or brokenness in the sensory system Characterized by : Burning, Tingling, Electric ,Shooting Pain

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Pain Receptors A delta Mechanical sensation eg. Cut, prick C filaments Diffuse, react to numerous boosts Burning sensation Sleeping receptors Active in harmed tissue just Acquire mechanical affectability (Almeida 2004)

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Nociceptors Damaged tissue discharges: Serotonin, Substance P, Bradykinin, Prostaglandin Involved in intense & constant torment Influenced by endorphins

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Sensitization Can be a tissue level (essential) or At CNS level (auxiliary) Results in: edge of initiation after damage force of a reaction to a poisonous jolt development of unconstrained action (Aguggia 2003)

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Sensitization Primary refinement Sympathetic movement and Inflammatory Mediators (Chong 2003) Secondary sharpening CNS changes in spinal line and mind NMDA receptors enacted "Twist up" = expanded abundancy and recurrence summation in neurons after delayed incitement (Chong 2003) Blocked by NMDA opponents, against inflammatories (McHugh 2000)

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The Dorsal Root Ganglion

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Tricyclic Antidepressants (TCAs) 40-60% adequacy for halfway help (NNT~2.5-3) Start 10-25 mg/d and  10-25mg every week Best impacts: 50-150 mg/day Mechanism: NE & 5HT reuptake bar +/ - NMDA opposition, +/ - Na channel barricade Anticholinergic impacts Secondary amine better endured

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Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Venlafaxine Start 37.5 mg/day Increase by 37.5 mg week by week Effective @ 150-225 mg/d Lower dosages – comes about conflicting Short versus XR prepares Duloxetine NNT ~4-5 (~7 for SSRI) Start & effectual @ 60mg/day Antidepressant & anxiolytic Favorable symptom profile Limited long haul information

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ά 2-δ Ligands (Gabapentinoids) Bind to ά 2-δ subunit of voltage gated Ca channels  glutamate, NE, substance P discharge NNT ~3.5-4.5 Gabapentin Few medication connections Dizziness & lethargy Exacerbate psychological debilitation Start 100-300mg TID Titrate to 1800-3600 mg/d Peak impact in >2 weeks Pregabalin No medication collaborations Similar reactions to gaba Start 50-150mg isolated Q8-12H Titrate 50-150mg/day week after week Goal 300-600 mg/d in 1-2 weeks Peak impact in 2 weeks

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Opioids 20-30% agony lessening, NNT ~2.5 Provides fast alleviation Rapid titration No roof impact Multiple structures & conveyance strategies More symptoms than 1 st line medicines Risk of abuse and mishandle (5%)

Slide 30

Methadone μ - receptor agonist + NMDA foe Very long half-life, variable in people Slow titration: begin 2.5mg TID Increase 50-100% each 48-72 hours ~5:1 to ~30:1 morphine equivalency (contingent upon measurement) Little writing support, ++ down to earth bolster

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NMDA Antagonists Ketamine Start 2.5-5mg PO TID Titrate by 50-100% measurement to 1-2 mg/kg/day Start IV mixture @ 0.05-0.1mg/kg/hr IV bolus @ 0.1-0.2 mg/kg/dosage more than 20 minutes No NNT information Poor execution in studies, great viability by and by Topical or wash arrangements conceivable *opioid saving impacts

Slide 32

Other/New Things to Try IV Lidocaine And po Mexilitine Cochrane Review 2005 Good quality proof in neuropathic torment Both reduction VAS by 11 on 1-100 scale 47% of individuals in trials had a 30% diminishing in torment (22% in fake treatment) 35% had Side –effects Numbness, dazedness, weakness, metallic taste Authors finish up comparative viability to different adjuvants and great security profile

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Other/New Things to Try Capsaicin – High measurement fix in PHN (640mcg/cm2) 1 – 60 min application Lasts up to 12 weeks Mean decline in torment score of 29.6% Side-impacts – Pain and erythema at site (Backonja – Lancet Neurology, 2008) Cannabis – Sativex - Neuropathic torment with Allodynia Improvements of 1.43 on 10 point VAS Good wellbeing profile – SE incorporate GI disturb & sluggishness (Nurmikko – Pain 2007)

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Other/New Things to Try Intrathecal Ziconotide N-sort Ca Channel blocker (NCCB) Median measurement 6.48mcg/day Improved VASPI scores in 53.1% Decreased opioid use in 9% Very costly Side Effects: Memory misfortune, wooziness, nystagmus, drowsiness, stride, CK rise (Pommer - J Pain Symptom – 2009)

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A Comparison of Adjuvants

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Summary/Objectives By the finish of great importance the learner will have the capacity to: Define neuropathic torment List no less than 2 sorts of Pain receptors List no less than 4 unique sorts of adjuvant torment meds List the systems of activity, advantages, and symptoms of these 4 prescriptions List 2 new/extraordinary adjuvant torment drugs

Slide 37

Recommended References Cruccum, G. Treatment of difficult neuropathy. Current Opions in Neurology . 2007; 20; 531-535. Dworkin, R. et al. Pharmacologic administration of neuropathic torment: confirm based suggestions. Torment. 2007; 132; 237-251. Gilron, I. et al. Neuropathic torment: a functional guide for the clinician. CMAJ . 2006; 175(3); 265-275.

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