31206851 Pain Thai Guideline

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Transcript of 31206851 Pain Thai Guideline

ISBN : 974-422-086-4 1 : 2547 : 4,000 :

50 80 (Palliative care) 90

( ) 2547

Age-Standardized Incidence Rates (ASR) .. 2535-2537 151.3 123.8 .. 2538-2540 149.2 125.0 .. 2536 32,801 30,940 35,539 38,467 .. 2539 (Cancer in Thailand Vol. III, 1995-1997) .. 2542 36,091 .. 2543 39,480 .. 2546 47,200 80 60-90 70 90 18 13 6 Adjuvants

( ) 2547

.................................................................................................................... .......................................................................................................... ........................................................................................................ ........................................................................ ............................................................................ ............................................................................................ .................................................................................................. ............................................................................................. Nociceptive pain ...................................................... Neuropathic pain ..................................................... .............................................................................. Opioids .................................................... Opioids........................................................... NSAIDs paracetamol.......................................................................... NSAIDs ................................................................................ NSAIDs ..................................................... ........................................................................................................ ....................................................................... ................................ ........................................................ ........................................................... ............................................................................................................. Brief Pain Inventory.................................................................................... ......................................................................................................... ........................................................................................................... 1 2 2 2 4 6 13 14 15 15 16 16 21 24 26 26 27 29 29 31 31 34 34 38 40

1 Nociceptive Neuropathic pain............. 3 Equianalgesic Doses for Converting Morphine to Transdermal Fentanyl ....................................................................... 8

2 18 20

4 NSAIDs .......................................................................... 25 5 Adjuvants Coanalgesics ............................................. 28-29 6 opioids 37

1 ........................................... 2 .................................... 3 ..................................... 4 .................................. 4 10 11 12

5 ........................................................ 32-33

.. 2542 .. 2546 .. 2544 68.4 .. 2545 73.3 (Cancer in Thailand Vol. III, 1995-1997) .. 2533 57,968 .. 2539 74,000 (Palliative Care) 90 (United States Department of Health and Human Services, 1994) (WHO, 1998 b)

1

1. / 2. 3.

. 1. 78 vasospasm, venous thrombosis, tumor emboli lymphangitis 2. 19 (mucositis)

2

steroid (steroid pseudorheumatism) steroid femur humerus brachial plexus lumbosacral plexus (post radiation myelopathy)

3. 3 migraine, tension headache . 6 Shock, Denial, Anger, Bargain, Depression Acceptance ( 1) antidepressants (psychotherapy)

3

Shock ShockAcceptance Acceptance

Denial Denial

Depression Depression

Anger Anger

Bargain Bargain

1

2 1. 2 1.1 Nociceptive pain Nociceptive pain 1.1.1 Somatic pain mucositis 1.1.2 Visceral pain somatic visceral pain referred pain 1.2 Neuropathic Neurogenic pain neuropathic pain neuritis plexopathy post-surgical syndrome (post-mastectomy, post-amputation ) postherpetic neuralgia

4

2. 2 (acute pain) (chronic pain) acute chronic pain acute pain chronic pain chronic pain 2.1 (acute pain) 2.1.1 Acute cancer - related pain (pathological fracture) 2.1.2 Acute pain associated with cancer therapy (radiation dermatitis), 2.2 (chronic pain) 2.2.1 Chronic pain caused by cancer progression 90 2.2.2 Chronic pain associated with cancer therapy neuropathic pain 2.2.3 Pre - existing chronic pain and cancer - related pain ( trigeminal neuralgia) 2.2.4 Drug addiction and cancer - related pain 2.2.5 Dying patient with pain

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(Pain Assessment) (sensory domain) (affective domain) (cognitive - evaluative domain) 1. 1.1 1.1.1 Numerical rating scale (NRS) Verbal rating scale (VRS) ? 0 10 0 1 2

3

4

5

6

7

8

9 10

Visual analog scale (VAS) 10 ..

Categorical scale Verbal descriptive scale ? 0 1-3 4-6 7-10

6

Wong - Baker faces pain rating scale 3 numerical rating scale

0

2

4

6

8

10

1.1.2 Body chart () 1.1.3 3 Somatic pain (aching) (stabbing) (throbbing) (pressure) Visceral pain (cramping) (gnawing) (sharp) Neuropathic pain (burning) (electrical, shooting) (tingling) (pins and needles) (radiating pain radicular pain) (allodynia) (periodic) neuropathic pain nociceptive pain

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1 Nociceptive Neuropathic pain Nociceptive pain (somatic and visceral)

Neuropathic pain

constant and well localized vague in distribution and quality aching, throbbing, gnawing, deep dull aching, dragging, squeezing, pressure - like

may be constant, steady, and spontaneously maintained, intermittent shock-like, shooting, lancinating, electrical, burning, tingling, numbing, pressing, squeezing, itching, dysesthesia*, hyperalgesia**, allodynia***, hyperesthesia****, hyperpathia*****

* ** *** **** *****

Dysesthesia Hyperalgesia Allodynia Hyperesthesia Hyperpathia

1.1.4 breakthrough pain incident pain breakthrough pain incident pain (prn) 1.1.5 1.2 1.2.1 1.2.2 1.2.3 1.2.4

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1.3 1.3.1 1.3.2 1.3.3 1.3.4 1.4 neuropathic pain 2. pain behavior 3. 3 3.1 3.2 electrodiagnostic neurophysiologic test 3.3 hematologic, biochemical, metabolic endocrine blood chemistries

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Universalscreening Universal screening (VAS 1-3) (VAS 1-3) (VAS 4-6) (VAS 4-6) (VAS 7-10) (VAS 7-10)

Nociceptive Nociceptive Nouropathic Neuropathic Somatic Somatic Visceral Visceral Refered Refered

2 (breakthrough pain) prn WHO Analgesic Ladder nociceptive neuropathic pain

10

1-3 1-3 opioids

4-6 4-6 / opioids*

7-10 7-10 /

paracetamol NSAIDs / 24-72 24-72

opioids

24-48 24-48

24 24

* opioids immediate release form morphine

3 WHO Analgesic Ladder

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P6 P6

P P3 3 - -

2 PP2 P14 P14

Nerve blocks Nerve Coanalgesic Coanalgesic

Coanalgesic -- Coanalgesic - Cognitive & behavioral modalities - Cognitive & behavioral modalities

NSAIDs opioids NSAIDs opioids Bisphosphonates Bisphosphonates Nerve block Nerve block

P16 16 P

Neuropathicpain Neuropathc pain Antidepressant/Anticonvulsant Nerve block Nerve stimulation Neurolytic procedures

Nerve block Neuroablative surgery Neurolytic

Mucositis Opioids Opioids Transdermal IV Transdermal IV Corticosteroids Corticosteroids

Mucositis

P =

4

12

1. 2. WHO Analgesic Ladder ( 1) 3. breakthrough pain 4. 5. Co-analgesic 5.1 Antidepressant : amitriptyline, nortriptyline 5.2 Antianxiety : lorazepam 5.3 Anticonvulsant : carbamazepine, gabapentin, oxcarbazepine 6. opioids non-opioids corticosteroids opioids 7. 8. Neuropathic pain tricyclic antidepressants anticonvulsants opioids non-opioids opioids neuropathic pain 9. 10. 11. 12. 13. /

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Pain Pain persisting persisting oror increasing increasing MODERATE PAIN MODERATE