Page 1656 - Hematology_ Basic Principles and Practice ( PDFDrive )

1474 Part VIII Comprehensive Care of Patients with Hematologic Malignancies

TABLE Common Pain Syndromes in Hematologic better.” Using, for example, a scale of 0 (no pain) to 10 (the worst
91.1 Malignancies pain one can imagine), a decrease in pain intensity from 10 to 8
indicates that the patient could benefit from additional dose titration,
Procedure-Related Pain but a decrease from 10 to 3 suggests that the current dose is effective.
Deep somatic Bone marrow aspiration, biopsy, and harvest A pain goal should be assessed by asking the patient, “What level of
pain Headache following lumbar puncture pain would be acceptable to you?” The ongoing assessment should
Superficial Venepuncture (needle insertions) also pay attention to changes in the phenomenology of the pain, new
somatic pain Central catheter placement/positioning occurrences of pain, or a change in the location of pain—all of which
Therapy-Related Pain may suggest progression of disease in the patient with a hematologic
Deep somatic Bone marrow expansion and/or sensitization by disorder.
The successful outcome of pain therapy should be more than
pain granulocyte colony-stimulating factor, osteoporosis simply the lowering of pain intensity scores, but the impact on func-
(e.g., from corticosteroids use), myalgias (e.g., tion, the minimization of side effects from treatment, and the preven-
from corticosteroid withdrawal), myopathy
tion of opioid misuse. Passik and Weinreb developed a useful mnemonic
Superficial Oropharyngeal mucositis (e.g., from chemotherapy or device for the assessment of pain therapy in chronic nonmalignant
somatic pain radiotherapy) pain known as the “4 As”: analgesia, activities of daily living, adverse
Visceral pain Enteritis, typhlitis, hemorrhagic cystitis events, and aberrant drug-taking behaviors (e.g., repeated dose escala-
Neuropathic Drug-related neuropathies (e.g., from chemotherapy tion or noncompliance, hoarding drugs, or acquiring drugs from other
11
pain agents) medical sources). By focusing on these relevant domains in the
continued assessment of the pain therapy, the clinician is able to
Headache Drug related (e.g., due to tretinoin) determine if the therapy makes a true difference in the patient’s life,
Pain From Hematologic Malignancy stabilizes or improves psychosocial functioning, manages side effects,
Somatic pain Bone infarct or necrosis, osteomyelitis, compression and provides a means of assessing for aberrant drug behaviors. Ulti-
fracture, hemarthrosis mately, the goal should be to lower the pain to a level acceptable to the
Visceral pain Tumor involvement, splenomegaly, patient and to improve the patient’s level of functioning.
lymphadenopathy, or lymphadenitis
Neuropathic Paraproteins with antimyelin properties, amyloid THERAPY DIRECTED AT THE UNDERLYING ETIOLOGY
pain infiltration, peripheral nerve compression, spinal
cord compression
A major component of pain therapy is to ameliorate the underlying
Mixed pain Headache, meningeal infiltration or infection, brain cause of the pain, when possible. Surgery, chemotherapy, radiation
metastasis, or primary tumor therapy, immunosuppression, and antibiotics may all be used. Atten-
tion to patient comfort should be maintained regardless of the
diagnostic or treatment interventions proposed.
TABLE Classification of Pain Syndromes in Sickle Cell
91.2 Disease
NONPHARMACOLOGIC METHODS OF
Pain secondary to the disease itself
Acute pain syndromes PAIN MANAGEMENT
Acute chest syndrome
Calculus cholecystitis (pigment stones) Cognitive-Behavioral Interventions
Hand–foot syndrome (in children)
Hepatic crisis Education and Reassurance
Priapism
Pulmonary infarction Patients with serious hematologic disorders are often required to
Recurrent acute painful episode undergo extensive diagnostic testing, which can include painful
Splenic sequestration (in children) procedures. A rehearsal of the planned test or procedure, including a
Chronic pain syndromes discussion (or view) of the appearance of the room and the length of
Arthropathies or arthritis time to be spent in the test apparatus, can minimize the patient’s
Avascular necrosis anxiety. Such explanations, offered preoperatively, lessen the need for
Chronic osteomyelitis postoperative medication and shorten the patient’s hospital stay. If
Intractable chronic pain conscious sedation is not planned, a pleasant distraction may be
Leg ulcers helpful to divert attention from certain procedures (e.g., bone marrow
Neuropathic pain aspiration or biopsy) that take place in the physician’s office or in the
Pain secondary to therapy patient’s room. For example, a physician might present a patient with
Loose prosthesis (in patients after arthroplasty for avascular an electronic tablet–guided relaxation training session while the
necrosis) physician is preparing for a procedure. The patient is able to utilize
Opioid withdrawal the relaxation techniques recently acquired during the procedure in
Postoperative pain order to diminish pain. 12
Pain caused by comorbid conditions
Courtesy Ballas SK: Pain management of sickle cell disease. Hematol Oncol
Clin North Am 19:785, 2005. Hypnosis
Hypnosis can be a useful adjunct in the management of pain, includ-
Continued Assessment ing for patients undergoing painful procedures. The hypnotic trance,
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a state of heightened and focused concentration, allows one to
A standardized measurement tool, such as a verbal rating scale (VRS) manipulate the perception of pain and diminish sleeplessness, anxiety,
or a visual analog scale (VAS), should be consistently used during and anticipation of discomfort. Hypnotic training of patients with
follow-up visits. 1,7,10 These measurements are thought to be more sickle cell anemia or hemophilia decreases the frequency and pain
accurate than mere qualitative descriptors, such as: “The pain is intensity of painful crises or bleeding episodes, respectively. In a