What is the general approach to patient care in Onco (Oncology) Anaesthesia, Critical Care, and Interventional Pain Management?

General Approach to Patient Care in Oncology Anesthesia, Critical Care, and Interventional Pain Management

The comprehensive approach to oncology patient care requires a multidisciplinary team focused on pain management through pharmacologic interventions, interventional procedures, and specialty consultations to optimize morbidity, mortality, and quality of life outcomes. 1

Pain Assessment and Management

• Pain management is the cornerstone of oncology patient care, requiring routine assessments and a systematic approach tailored to individual patient needs 1
• Cancer pain can be successfully controlled in most patients with appropriate techniques and safe medications when guidelines are systematically applied 1

Pharmacologic Interventions

• NSAIDs and acetaminophen serve as foundational analgesics, particularly important in treating neuropathic pain resistant to opioids 1

  • Monitor for NSAID toxicities with baseline blood pressure, BUN, creatinine, liver function studies, CBC, and fecal occult blood every 3 months 1
  • Discontinue NSAIDs if hypertension develops or worsens 1
  • Consider gastrointestinal protection with proton pump inhibitors in patients with risk factors (peptic ulcer disease, advanced age, male gender, concurrent corticosteroid therapy) 1

• Opioid management should follow WHO analgesic ladder, starting with weak opioids (tramadol, dihydrocodeine) and progressing to strong opioids (morphine, oxycodone, fentanyl) as needed 1

  • Monitor for and manage opioid side effects to maintain quality of life 1

Interventional Pain Management

• Major indications for interventional consultation include: 1

  • Pain likely to be relieved with nerve blocks (e.g., celiac plexus block for upper abdominal pain)
  • Failure to achieve adequate analgesia without intolerable side effects

• Commonly used interventional procedures: 1

  • Regional infusions requiring infusion pumps
  • Neurodestructive procedures for well-localized pain syndromes:
    • Head and neck: peripheral nerve blocks
    • Upper extremity: brachial plexus neurolysis
    • Thoracic wall: epidural neurolysis, intercostal neurolysis
    • Upper abdominal pain: celiac plexus block, thoracic splanchnicectomy
    • Midline pelvic pain: superior hypogastric plexus block
    • Rectal pain: intrathecal neurolysis, midline myelotomy

• Advanced interventional techniques for refractory pain: 1

  • Neurostimulation procedures for cancer-related symptoms like peripheral neuropathy
  • Radiofrequency ablation for bone lesions
  • Percutaneous vertebroplasty/kyphoplasty for vertebral pain

Critical Care Considerations

• Oncology patients in critical care settings require specialized attention to:
  • Medication interactions between cancer therapies and critical care medications 1
  • Immunocompromised status affecting infection risk and management
  • Organ dysfunction from cancer or treatment toxicities

Multidisciplinary Approach

• Medical oncologists provide a comprehensive and systemic approach to treatment while ensuring evidence-based, safe, and cost-effective use of cancer drugs 2
• Specialty consultations should be considered for: 1
  • Physical therapy and occupational therapy for functional improvement
  • Psychosocial support services for addressing psychological aspects of pain
  • Substance abuse evaluation when concerns about medication misuse arise

Treatment of Resistant and Neuropathic Pain

• Neuropathic pain often responds poorly to opioid analgesics alone and may require: 1
  • Co-analgesics (antidepressants, anticonvulsants)
  • Subanesthetic doses of ketamine for intractable pain
  • Invasive anesthetic or neurosurgical treatments in refractory cases

Psychosocial Support

• Biopsychosocial screening programs are essential for comprehensive care 3
  • Tools like the Edmonton Symptom Assessment System (ESAS) help identify psychological distress
  • Address patient concerns about recurrence and self-monitoring behaviors

Surgical Interventions

• Surgery may have specific efficacy in relieving pain caused by: 1
  • Impending or evident fractures
  • Obstruction of hollow organs

Quality Improvement

• Enhanced morbidity and mortality meetings can improve patient safety education and outcomes in specialty training 4
• Continuous reassessment of treatment efficacy through documented pain ratings ensures optimal pain control 1

Contraindications and Cautions for Interventional Approaches

• Interventional procedures may be contraindicated in patients with: 1
  • Infection
  • Coagulopathy
  • Very short or lengthy life expectancy
  • Distorted anatomy
  • Medications that increase bleeding risk (e.g., antiangiogenesis agents like bevacizumab)