Page 1657 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 91 Pain Management and Antiemetic Therapy in Hematologic Disorders 1475

controlled trial comparing hypnosis with cognitive-behavioral therapy size. Use should be avoided over areas of broken skin and in patients
in relieving mucositis after a bone marrow transplant, patients using undergoing radiation therapy. Extended application of lidocaine
hypnosis reported a significant reduction in pain control compared patches has been safely applied for up to 24 hours/day for up to 4
with patients who used cognitive-behavioral techniques. 12 days with minimal systemic absorption in healthy volunteers and in
In the absence of a formal hypnotic induction, words used by a patients with PHN.
practitioner to describe procedures are very important. For example,
suggesting that the numbness and coolness of a local anesthetic will
persist may diminish the discomfort of a bone marrow biopsy. Using Neuromodulation
the phrase: “You will feel something; I’m not sure what you will feel
because everyone feels this a little differently” in place of “This is Transcutaneous electrical nerve stimulation (TENS) devices are
going to hurt a lot!” gives the patient permission to alter the sensation indicated for patients with dermatomal pain, such as PHN or radicu-
and may also diminish the experience of pain. 13 lopathy from spinal cord compression. 9,16 For optimal effect, a
physiatrist or physical therapist familiar with the device should train
the patient in its use. The efficacy of TENS therapy for patients with
Meditation cancer pain remains controversial.

Meditation has long been utilized as a method for controlling pain.
Given the wide range of meditation practices and methods, it has his- Radiation Therapy
torically been difficult to conduct evidence-based research into the
effectiveness of medication. Some research has shown that using medi- Radiation therapy is commonly used in the management of painful
tation to increase focus and clarity does improve pain symptoms and bone lesions, spinal cord compression, bulky lymphadenopathy, and
appears to correlate with decreased pharmacologic requirements. 14 symptomatic splenomegaly in patients with hematologic malignan-
cies. 9,17 Radiotherapy is the treatment of choice for local metastatic
bone pain in most situations, although patients with underlying
Cognitive-Behavioral Techniques and Counseling pathologic fractures may require surgical fixation before radiotherapy.
Randomized trials have shown that single-fraction radiotherapy is as
The cognitive-behavioral approach addresses a number of psychoso- effective as multifraction radiotherapy in relieving pain caused by
cial and behavioral factors that contribute to patients’ experience of metastases. However, there are higher rates of retreatment, and single-
pain. 7,9,15 These techniques have demonstrated clinical utility for fraction radiotherapy may not prevent pathological fractures or spinal
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patients with a wide range of chronic pain syndromes. Psychological cord compression. In patients with poor performance status or a
counseling as part of a multidisciplinary approach to pain treatment short life expectancy, a single dose (8 Gy) of radiation or a hypofrac-
provides education, support, and skill development for patients with tionated course (20 Gy/5 fractions) may be preferable and less
pain. It can improve patients’ abilities to communicate their pain to burdensome.
health care personnel and may be effective in overcoming anxiety and
depression. Spiritual counseling may help patients who have lost
hope, can find no meaning in their lives, or believe they are being Vertebroplasty and Kyphoplasty
9
punished or have been forsaken by God. They may interpret their
pain in light of these feelings. Through counseling, they can regain Vertebroplasty and kyphoplasty are both minimally invasive tech-
a sense of worth and belonging. As they recast the pain in its true niques used to stabilize vertebral compression fractures and reduce
light, its intensity is often diminished. pain. Vertebroplasty is a procedure in which bone cement, usually
polymethylmethacrylate, is injected into the vertebral body. With
kyphoplasty, a balloon is first inserted into the vertebral body fol-
Cutaneous Techniques lowed by inflation and then deflation before cement is added. Balloon
kyphoplasty has been shown to stabilize pathologic vertebral fractures
Acupuncture, massage, vibration, and applying cold or heat to the caused by multiple myeloma and significantly reduce pain. 18
skin over injured areas are often very effective. Cold wraps, ice packs,
or cold massage using a cup filled with water that has frozen into a
solid piece of ice relieve the pain of muscles that are in spasm from Anesthetic Techniques
nerve injury. Heat from heating pads, hot wraps, or paraffin treat-
ments can soothe injured joints but should not be used over areas of Trigger-point injections, nerve blocks, and neurolytic procedures are
vascular insufficiency. useful for acute and chronic localized pain. After excisional biopsy of
EMLA, a cream containing two topical anesthetics (2.5% lido- an axillary lymph node, for example, a burning, constricting pain in
caine and 2.5% prilocaine) is used, especially in children, to decrease the posterior arm and chest wall may develop; this pain is often
the pain of superficial cutaneous procedures (e.g., venous cannulation promptly relieved by trigger-point injection.
or skin anesthesia before lumbar puncture, bone marrow aspiration, Lymphoma or multiple myeloma may involve the spine and lead
9
or biopsy). In adults, it is used before access of implanted vascular to vertebral collapse or pain from progressive disease that is refractory
access devices or CNS ports. To achieve anesthesia, the EMLA cream to antineoplastic therapy. Such pain is often particularly difficult to
must be applied 1–1.5 hours before the planned procedure in a manage. Insertion of temporary or permanent indwelling epidural or
mound under a semipermeable dressing such as Opsite or Tegaderm. intrathecal catheters to deliver opioids, local anesthetic agents, cloni-
When EMLA is used as directed, methemoglobinemia has not been dine, or combinations of these and other agents can be very effective,
a problem even in infants as young as 3 months old. Skin blanching especially in relieving lower thoracic or lumbar spine pain, as well as
19
occurs, sometimes exceeding or equaling the frequency of that found pelvic and lower extremity pain. Reviews of the indications for and
with placebo moisturizing cream placed under the occlusive dressing. techniques of the anesthetic and neurolytic procedures are available. 4
ELA-Max, a cream containing 4% lidocaine, is available over the
counter and is an alternative to EMLA cream. Because it does not
contain prilocaine, there is no risk of methemoglobinemia. PHARMACOTHERAPY
Lidocaine patches can be used over areas of hyperesthesia, as can
occur in patients with postherpetic neuralgia (PHN) or nerve entrap- Drugs useful for pain relief include nonopioid analgesics, opioids,
9
ment by vertebral body collapse. The patch is applied to the affected and adjuvant analgesics. Most patients require a combination of
area for no more than 12 consecutive hours a day and can be cut to medications for optimal pain relief (Fig. 91.1). 20