A Case Study in Neuropathic Pain .

Uploaded on:
Category: Sales / Marketing
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.
Slide 1

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

Slide 2

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

Slide 3

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

Slide 4

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

Slide 5

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

Slide 6

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

Slide 7

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

Slide 8

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

Slide 9

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

Slide 10

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

Slide 11

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.

Slide 12

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

Slide 13

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

Slide 15

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

Slide 16

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

Slide 17

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

Slide 19

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)

Slide 21

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

Slide 22

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)

Slide 23

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)

Slide 24

The Dorsal Root Ganglion

Slide 26

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

Slide 27

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

Slide 28

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

Slide 29

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

Slide 31

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

Slide 33

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)

Slide 34

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)

Slide 35

A Comparison of Adjuvants

Slide 36

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.

View more...