Edema in cancer patients
Indications for use of painkillers in cancer patients:
- palliative therapy of pain in the final tumor diseases, relapses of tumors metastases to the skeleton, pathological fractures, tumor necrosis in the mucosa (ulceration)
- compression of nerves with tumors
- infiltration of internal organs / metastases (intestinal obstruction) or infiltration of soft tissues
- pain caused by defeat of the liver capsule, ascites, cerebral edema, lymphatic and venous edema
- iatrogenic pain in cancer patients: postoperative scars, nerve damage, tissue fibrosis after radiation therapy (nerve plexus fibrosis, osteoradionecrosis, mucositis, neuropathy), tumor embolization, chemotherapy.
Diagnosis of pain in cancer patients
Anamnesis (underlying disease, stagediseases, concomitant diseases), recommend a painful diary (duration, intensity, localization, pain irradiation, factors that increase or decrease pain, concomitant symptomatology)
Clinical and neurological examination: neurological prolapse, blood circulation, motor skills, sensitivity
Depending on the shape and localization of pain, additional special diagnostics (for example, to exclude relapse, metastasis, the possibility of causal therapy: irradiation or surgery)
General principles of pain management in cancer patients
- with constant pain regular receptionmedicines (write a patient a plan for taking medications), breaks in medication and the appointment of "with pain" are undesirable (except for cases of taking medication with extreme painful peaks)
- long-acting drugs (retarded), preferably oral, rectal or percutaneous application
- sufficiently high dosage (do not be afraid of highdosages, before prescribing a combination of drugs, it is necessary to bring the dosage of the first drug to the maximum dose), do not use in combination medicines from an identical chemical group
The stages of treatment of pain in cancer patients
Stage 1: Normal analgesics (non-opioid analgesics): oral or rectal application
Step 2: Stage 1 + weak opioids: oral or rectal application
Step 3: Strong opiates + step 1: oral, rectal or percutaneous application
Invasive therapy: intravenous, intramuscular subcutaneous, epidural, intrathecal or regional blockade
Preparations for the treatment of pain in cancer patients
Normal analgesics (maximum in parenthesesday doses): acetylsalicylic acid (Aspirin 6000 mg), paracetamol (Benuron, 3000 mg), metamizole (Novalgin, 5000 mg), diclofenac (Voltaren 300 mg), ibuprofen (Brufen 2400 mg) indomethacin (Amuno, 200 mg), naproxen (Praxen, 1250 mg).
Weak opiates: tramadol (Tramal, 600 mg), tilidine + naloxone (Valoron, 600 mg).
Strong opiates: morphine (MST, 900 mg) buprenorphine (Temgesic sublinqual 18 mg), fentanyl (700 pg / hour, every 72 hours or at the earliest 48 hours after the replacement of the patch).
Additional drugs for the treatment of pain in cancer patients
antimetics (Metoclopramid, Paspertin) withnausea / vomiting, laxatives (Bisacodyl, Dulcolax) with constipation, spasmolytics (Butilscopolamin, Buscopan, Metamizol) with colic, carbamazepine (Tegretal) with phantom pains, glucocorticoids in inflammatory processes / edema of the brain / spinal cord compression / partial intestinal obstruction, calcitonin at metastases in the skeleton, H2 blockers (Ranitidin) or sucralfate for the protection of the gastric mucosa
antidepressive, especially, amitriptyline (Sarotenretard capsules 25 mg before bed with a gradual increase in the dose to 25-25-50-50 mg) modulate the feeling of pain and simultaneously improve depressive symptoms or antipsychotics for example, levomepromazine (Neurocil, slowly raising the dose to 300 mg / day)
Invasive pain therapy in cancer patients :
in / in, / m or subcutaneously opioids: morphine (max 50 mg every 4 hours) to eliminate painful peaks epidural anesthesia with opiates through the subcutaneous tissue located catheter or under the skin implanted port: 14 mg dissolved in physiological saline solution
regional blockades: Plexus coeliacus and intercostal blockades as chemical neurolysis (5% phenol), intrapleural blockade with bupivacaine (Carbostesin 0.5%)
therapeutic gymnastics, physiotherapy, lymphatic drainage. TENS (percutaneous electrical stimulation of nerves, psychological support.
Operative treatment of pain in cancer patients
It is shown, if there are final diseases andfailure of all other analgesic methods. DREZ damage (dorsal root entry zone) is applied: coagulation of afferent painful pathways in the region of the entry of nerve roots into the spinal cord chordotomy (intersection in the spinal cord Tractus spinothalamicus), intrathecal neurolysis, thermocoagulation Ganglion trigeminale Gassen.
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