Pain syndrome & Stem Cell Transplantation

PAIN SYNDROME &HSCT

Hedayati Asl A.Mahak Cancer Children’s Hospital

Stem Cell Transplantation Department

Patients stress in BMT Death: death and dying Dependence: Dependency from family,

friends, Disfigurement: Physical disfigurements Disabilities: Hindrance of roles and tasks Disruption: Disruption of relationships Discomfort: Pain and other physical stressors Disengagement: Returning from the role as a

patient

Common sources of pain in bone marrow transplantation

Severe pain syndromes may be recorded during all phases of hematopoietic stem cell transplantation (HSCT) for hematological malignancies: from stem cell mobilization to the long-term post transplant period.

Several pain syndromes of different pathophysiology and severity have been reported. Stem cell donors may experience pain from mobilization of hematopoietic stem cells or collection of bone marrow.

Bone Marrow Harvesting

Although the major cause of pain in the setting of HSCT is injury to mucosal tissues induced by the conditioning regimen, pain from several other causes has been reported.

Pain in ……

Pain scales

A “faces” scale used to monitor pain and pain management

efficacyin children between ages 3 and 7

years

Auto Transplant

Allotransplant

ALL PSCT

Sedation before Transplantation

Peripheral Stem Cell Harvesting under Anesthesia

Recipient

The major cause of pain in HSCT recipients is a result of injury to mucosal tissues induced by the conditioning regimen.

HSCT-related pain syndromes:

Their origins and pathogenesis

Diagnostic procedure-related causes

Deep somatic pain BM aspiration and biopsy; BM harvest; headache following lumbar puncture

Superficial somatic pain Venepuncture; needle insertions; CVC positioning

Iatrogenic pain syndromes Deep somatic pain BM expansion and/or

sensitization by G-CSF; treatment-induced osteoporosis and fractures; BM necrosis

Superficial somatic pain CHT and/or RT-induced oral mucositis

Visceral pain CHT-induced cystitis; CHT/RT-induced GIM; HC

Neuropathic pain Drug-related neuropathies (vincristine, bortezomab, sirolimus, tacrolimus, cyclosporine)

Transplant complication-related causes

Deep somatic pain BM expansion and/or sensitization related to the engraftment; pneumonia; pleuritis; deep abscess

Superficial somatic pain Oral ulcers and skin lesions associated with acute and chronic GVHD; superficial abscess; ocular lesions associated with chronic GVHD

Visceral pain Gastrointestinal GVHD; neutropenic enterocolitis; visceral involvement by HZV and CMV

Neuropathic pain HZV outbreak and PHN (post-herpetic neuralgia)

Graft versus host disease (GVHD)

Skin manifestations of acute GVHD

Skin lesions in a patient with severe acute graft-versus-host disease (GVHD). There is swelling, generalized erythroderma, and bullous formation.

Daily mean morphine dose for adolescents with mucositis pain

during HCT. Morphine delivered by physician-prescribed continuous infusion (CI) or by PCA (patient-controlled

analgesia).

Cyclosporine-induced pain syndrome in a child undergoing hematopoietic stem cell transplant

Calcineurin-induced pain syndrome CIPS is hypothesized to result from

calcineurin-induced vascular changes that disturb bone perfusion and permeability, leading to intraosseous vasoconstriction and bone marrow edema.

Symptoms were most acute during the infusion, when whole blood cyclosporine concentrations were likely to be the highest.

CIPS Interventions aimed at reducing pain

associated with CIPS may include the initiation of calcium-channel blocker therapy and conversion to an alternative calcineurin inhibitor.

Bone scan increased tracer uptake of the foot bone

MRI demonstrated bone marrow edema in the painful bones

CIPS Treatment symptoms were resolved when tacrolimus was

substituted for cyclosporine and amlodipine was initiated.

Cyclosporine Monitor

the usefulness of transdermal opioids in patients with mucositis warrants thorough investigation.

the increasing use of PCA (patient-controlled analgesia) for these patients justifies further investigation to standardize its utilization.

Dosing data for acetaminophen andnonsteroidal anti-inflammatory drugs

(NSAIDs)

TCA administration in HSCT

There is considerable concern about the use of TCAs in the HCT patient, as many TCAs appear to have marrow suppressant effects

Clinical experience indicates that up to 25% of HCT patients will have significant marrow suppression in the early engraftment period with either TCAs or the newer selective serotonergic reuptake inhibitors (SSRIs).

If TCAs are used, it is desirable to begin with a low dose, e.g. 10 mg amitriptyline, and titrate upwards against side-effects, which often are the limiting factors.

Dose equivalents and starting doses for opioid analgesics

pain management

Although recent advances in the conditioning regimen have reduced the painful complications of HSCT, pain and its treatment remains a major issue in the global management of HSCT patients.

pain management the key elements of pain management in

HSCT patients remain the competence of and the empathy provided by a multidisciplinary team working together to provide the best available means to effect pain relief inpatients with this debilitating condition.

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