Vincristine-Related Peripheral Oncology-Specifi c Pain
9.8.2 Osteonecrosis
Osteonecrosis ON is a painful and potentially crippling condition typifi ed by ischemic and necrotic changes in bone. In children, ON is com- monly associated with corticosteroid exposure in ALL and lymphoma but can occur independent of steroid therapy in cancers involving bone or bone marrow Vora 2011 . Additional risk factors for ON include age 10 years, obesity, Caucasian race, treatment intensity and asparaginase use Mattano et al. 2000 ; Niinimaki et al. 2007 ; Kawedia et al. 2011 . While many children treated for ALL have evidence of ON on mag- netic resonance imaging MRI, symptomatic ON incidence is 20 Mattano et al. 2000 ; Kawedia et al. 2011 ; Hyakuna et al. 2014 . Pain from ON ranges from mild intermittent pain to chronic debilitating pain. Analgesic treat- ment for ON should follow the general guide- lines of the WHO pain ladder see Sect. 9.4.1 starting with NSAIDs, if appropriate. COX2 inhibitors such as celecoxib may be preferable in patients for whom antiplatelet effects are a con- cern. Intermittent short-acting opioids may be suffi cient for patients who cannot tolerate NSAID therapy. Patients with persistent pain requiring multiple doses of opioids per day benefi t from long-acting opioids. In patients with chronic pain, methadone is an attractive option given its resistant nature to opioid tolerance. Patients who develop chronic pain from ON may best be served by a chronic pain management specialist. Bisphosphonate therapy has been recently investigated as a method for reducing pain in patients with ON. An Australian study risk strati- fi ed a small population of children with ON and found reduction in pain amongst “severe risk” patients who received monthly IV pamidronate versus “moderate risk” patients receiving oral bisphosphonates and “mild risk” patients receiv- ing calciumvitamin D supplementation Kotecha et al. 2010 . A Canadian study similarly found that 1417 77 patients with symptomatic ON noted pain relief with a 3-day course of IV pami- dronate given every 4 months Leblicq et al. 2013 . A study investigating zoledronic acid in children has demonstrated similar results Padhye et al. 2013 . Referral to an orthopedic surgeon experienced in ON management can be benefi cial, especially for patients with signifi cant debilitating symptoms. Surgical options which can improve functionality and reduce pain include core decom- pression and joint replacement. Other suggested supportive care measures for ON include physical therapy, weight loss, and treatment of vitamin D defi ciency, if present Vora 2011 .9.8.3 Post-lumbar Puncture
Headache Lumbar puncture LP is a common diagnostic and therapeutic procedure in pediatric oncology. Although relatively uneventful, the most common adverse effect of LP is a post-procedure headache. Typically occurring within 72 h of the procedure, symptoms of post-LP headache include throbbing pain in the bilateral occipital and frontal regions that is exacerbated by vertical position and Valsalva and palliated by lying fl at. Most head- aches resolve within 7 days, but some last for sev- eral weeks. The headache is thought to be caused by leakage of cerebrospinal fl uid CSF and sub- sequent loss of CSF pressure. It is theorized that loss of CSF pressure leads to traction on pain- sensitive intracranial structures or an increase in cerebrovascular blood volume with resultant vasodilation, either of which could cause head- ache Turnbull and Shepherd 2003 . In children, the incidence of post-LP headache has been reported to be between 6 and 15 and has been shown to occur in even young children although is much more common in adolescents Kokki et al. 1999 ; Lee et al. 2007 ; Crock et al. 2014 . Various methods have been proposed to reduce the occurrence of post-LP headache. General guidelines suggest that LP performed with cutting needles should have the beveled edge oriented parallel to the dural fi bers, which run longitudi- nally Janssens et al. 2003 . Post- procedure bed rest has been suggested, but not found to be help- ful Lee et al. 2007 . Studies investigating the use of smaller gauge needles have not found signifi - cant differences in incidence Ebinger et al. 2004 ; Crock et al. 2014 . Use of an atraumatic, or “pen- cil-tip,” needle i.e., Whitacre, has been shown to signifi cantly reduce the incidence of post-LP headache although one study found no difference Kokki et al. 1999 ; Thomas et al. 2000 ; Apiliogullari et al. 2010 . When a post-LP headache occurs, various methods have been employed to treat pain not responsive to NSAIDs or opioids. Oral and IV caffeine has been most widely studied in adults and shown to reduce pain when compared to placebo Sechzer and Abel 1978 ; Camann et al. 1990 . It is hypothesized that caffeine causes relief by decreasing cerebrospinal pressure via cerebrovascular vasoconstriction Janssens et al. 2003 . Dosing of caffeine ranges from 300 to 500 mg in adult studies Lee et al. 2007 ; Basurto Ona et al. 2011 . The effectiveness of caffeine has not been reported in pediatrics, but dosing has been suggested at 100 mg for chil- dren aged 6–10 years and 200 mg for children 10 years McGhee et al. 2011 . In studies with small sample sizes, gabapentin and the combi- nation of caffeine and ergotamine have been shown to reduce pain measured on a visual ana- log scale when compared with placebo Dogan 2006 ; Erol 2011 . Hydration, although men- tioned in supportive care for post-LP headache, has not demonstrated effectiveness when stud- ied Janssens et al. 2003 ; Lee et al. 2007 . A Cochrane review concluded that there is no evi- dence that sumatriptans are effective Basurto Ona et al. 2011 . Severe post-LP headache refractory to medi- cal management can be treated with an epidural blood patch EBP. The procedure involves obtaining access to the epidural space in the area of the previous LP. The patient’s peripheral blood, obtained under sterile technique, is then inserted into the epidural space. The purpose of the procedure is to create pressure to seal the dural tear and prevent further CSF leakage Turnbull and Shepherd 2003 . Kokki and col- leagues 2012 reviewed 41 cases of EBP proce- dures in children and found that 90 had immediate and complete pain relief, with 85 noting permanent relief. In pediatric oncology, blood patches should be considered cautiously given infectious risks for immunosuppressed patients and the theoretical risk of introduction of tumor cells into the CSF.9.8.4 Mucositis Pain
Pathogenesis and management of mucositis is discussed in Chap. 11 . General pain practices described here are necessary interventions for patients experiencing oral mucositis.9.9 Summary
The large majority of pediatric oncology patients will suffer from pain at some point during their treatment course secondary to the underlyingParts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
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