Yoğun Bakımda Yatan Kanser Hastaları ve Palyatif Bakım Hastalarında Ağrı Tedavisi
Özet
Yoğun bakımda izlenen kanser hastalarında ağrı tedavisi, hem hastanın konforu hem de yaşam kalitesinin korunması açısından temel bir gerekliliktir. Kanser ağrısı genellikle karmaşık bir yapıya sahiptir ve somatik, visseral ve nöropatik bileşenleri bir arada barındırabilir. Bu nedenle tedavi multimodal bir yaklaşım gerektirir. Opioidler, özellikle orta ve şiddetli ağrının kontrolünde ilk sırada yer alır ve doz ayarlamaları hastanın klinik durumuna göre dikkatle yapılmalıdır. Nöropatik bileşeni baskın olan ağrılarda antikonvülsanlar (gabapentin, pregabalin) ve antidepresanlar (amitriptilin, duloksetin) gibi adjuvan analjezikler etkin olabilir. Steroidler, antiinflamatuvar etkileriyle bazı ağrı tiplerinde fayda sağlayabilir. Ayrıca ketamin gibi NMDA reseptör antagonistleri, refrakter kanser ağrısında analjeziye katkı sunabilir. İnfüzyon pompaları, transdermal uygulamalar ve gerektiğinde sedatif ajanlar, yoğun bakım koşullarında farmakolojik yönetimi kolaylaştırır. Uygun tedavi stratejileriyle kanser ağrısının kontrol altına alınması, yalnızca fiziksel rahatlama değil, aynı zamanda insana yakışır bir bakım sürecinin sağlanması açısından da kritik önemdedir.
Pain management in critically ill cancer patients is a cornerstone of palliative care in the intensive care unit (ICU) setting. Cancer-related pain often presents with complex pathophysiology, involving somatic, visceral, and neuropathic components. Effective treatment requires a multimodal approach, with opioids remaining the mainstay for moderate to severe pain. Dosing should be individualized based on organ function, previous opioid exposure, and the patient’s clinical stability. In cases with a significant neuropathic component, adjuvant analgesics such as anticonvulsants (e.g., gabapentin, pregabalin) and antidepressants (e.g., tricyclics, SNRIs) may provide additional benefit. Corticosteroids can offer relief in pain related to inflammation, edema, or tumor infiltration. For refractory cancer pain, agents like ketamine—an NMDA receptor antagonist—may be considered. Various administration routes, including intravenous infusions and transdermal systems, can be tailored to the ICU environment. The integration of these pharmacologic strategies not only improves symptom control but also supports dignity and quality of life in the terminal phase of illness. Comprehensive pain management for cancer patients in the ICU reflects both ethical responsibility and clinical excellence.
Referanslar
K. Puntillo vd., “Evaluation of pain in ICU patients”, Chest, c. 135, ss. 1069-1074, Nis. 2009, doi: 10.1378/chest.08-2369.
G. Brozović, N. Lesar, D. Janev, T. Bošnjak, ve B. Muhaxhiri, “CANCER PAIN AND THERAPY”, Acta Clin Croat, c. 61, ss. 103-108, Eyl. 2022, doi: 10.20471/acc.2022.61.s2.13.
J. Gibbins, R. Bhatia, K. Forbes, ve C. M. Reid, “What do patients with advanced incurable cancer want from the management of their pain? A qualitative study”, Palliat Med, c. 28, ss. 71-78, 2014, doi: 10.1177/0269216313486310.
C. Gélinas, M. Fortier, C. Viens, L. Fillion, ve K. Puntillo, “Pain assessment and management in critically ill intubated patients: A retrospective study”, 2004, American Association of Critical Care Nurses. doi: 10.4037/ajcc2004.13.2.126.
E. Basch vd., “Symptom monitoring with patient-reported outcomes during routine cancer treatment: A randomized controlled trial”, Journal of Clinical Oncology, c. 34, ss. 557-565, Şub. 2016, doi: 10.1200/JCO.2015.63.0830.
M. I. Bennett, “Mechanism-based cancer-pain therapy”, Pain, c. 158, ss. S74-S78, 2017, doi: 10.1097/j.pain.0000000000000825.
B. M. Scarborough ve C. B. Smith, “Optimal pain management for patients with cancer in the modern era”, CA Cancer J Clin, c. 68, ss. 182-196, May. 2018, doi: 10.3322/caac.21453.
T. Meuser, C. Pietruck, L. Radbruch, P. Stute, K. A. Lehmann, ve S. Grond, “Symptoms during cancer pain treatment following WHO-guidelines: A longitudinal follow-up study of symptom prevalence, severity and etiology”, Pain, c. 93, ss. 247-257, 2001, doi: 10.1016/S0304-3959(01)00324-4.
R. Sutradhar, A. Lokku, ve L. Barbera, “Cancer survivorship and opioid prescribing rates: A population-based matched cohort study among individuals with and without a history of cancer”, Cancer, c. 123, ss. 4286-4293, Kas. 2017, doi: 10.1002/cncr.30839.
C. G. Virgen vd., “Pharmacological management of cancer pain: Novel therapeutics”, Aralık 2022, Elsevier Masson s.r.l. doi: 10.1016/j.biopha.2022.113871.
G. Şenel, G. Oǧuz, N. Koçak, Ş. Karaca, M. Kaya, ve N. Kadioǧullari, “Opioid use and the management of cancer patient pain in palliative care clinic”, Agri, c. 28, ss. 171-176, Eki. 2016, doi: 10.5505/agri.2016.07830.
H. Breivik vd., “Cancer-related pain: A pan-European survey of prevalence, treatment, and patient attitudes”, Annals of Oncology, c. 20, ss. 1420-1433, 2009, doi: 10.1093/annonc/mdp001.
M. J. Seya, S. F. A. M. Gelders, O. U. Achara, B. Milani, ve W. K. Scholten, “A first comparison between the consumption of and the need for opioid analgesics at country, regional, and global levels”, J Pain Palliat Care Pharmacother, c. 25, ss. 6-18, Mar. 2011, doi: 10.3109/15360288.2010.536307.
B. M. Scarborough ve C. B. Smith, “Optimal pain management for patients with cancer in the modern era”, CA Cancer J Clin, c. 68, ss. 182-196, May. 2018, doi: 10.3322/caac.21453.
“Geriatric Palliative Care”, https://books.google.com.tr/books?hl=en&lr=&id=VOgkAwAAQBAJ&oi=fnd&pg=PP1&ots=Mq52yHC6f7&sig=vC0jhbrZTasvDrUkTz1QrBhxZ5M&redir_esc=y#v=onepage&q&f=false.
B. S. Husebo, C. Ballard, R. Sandvik, O. B. Nilsen, ve D. Aarsland, “Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial”, BMJ, c. 343, Tem. 2011, doi: 10.1136/bmj.d4065.
M. Shkodra ve A. Caraceni, “Treatment of Neuropathic Pain Directly Due to Cancer: An Update”, Nisan 2022, MDPI. doi: 10.3390/cancers14081992.
L. F. Dunkić, V. Hostić, ve A. Kustura, “PALLIATIVE TREATMENT OF INTRACTABLE CANCER PAIN”, 2022, Dr. Mladen Stojanovic University Hospital. doi: 10.20471/acc.2022.61.s2.14.
E. T. Løhre, G. Jakobsen, T. S. Solheim, P. Klepstad, ve M. Thronæs, “Breakthrough and Episodic Cancer Pain from a Palliative Care Perspective”, Current Oncology, c. 30, ss. 10249-10259, Ara. 2023, doi: 10.3390/curroncol30120746.
G. W. Pasternak, “Opiate pharmacology and relief of pain”, Haziran 2014, American Society of Clinical Oncology. doi: 10.1200/JCO.2013.53.1079.
S. Mercadante vd., “Low morphine doses in opioid-naive cancer patients with pain”, J Pain Symptom Manage, c. 31, ss. 242-247, Mar. 2006, doi: 10.1016/j.jpainsymman.2006.01.001.
N. E. Goldstein ve R. S. Morrison, Evidence-Based Practice of Palliative Medicine. Elsevier Inc., 2012. doi: 10.1016/C2009-0-62811-7.
A. Caraceni vd., “Use of opioid analgesics in the treatment of cancer pain: Evidence-based recommendations from the EAPC”, Şubat 2012. doi: 10.1016/S1470-2045(12)70040-2.
K. A. Lee, N. Ganta, J. R. Horton, ve E. Chai, “Evidence for neurotoxicity due to morphine or hydromorphone use in renal impairment: A systematic review”, J Palliat Med, c. 19, ss. 1179-1187, Kas. 2016, doi: 10.1089/jpm.2016.0101.
A. Howard ve J. M. Brant, “Pharmacologic Management of Cancer Pain”, Haziran 2019, W.B. Saunders. doi: 10.1016/j.soncn.2019.04.004.
G. van der Wal, J. E. H. M. Hoekstra-Weebers, R. Otter, K. Postema, R. Sanderman, ve C. van der Schans, “Oncologist Symptom Management and Supportive Care Adjuvant Analgesics in Cancer Pain Management”, Oncologist, c. 11, ss. 184-196, 2006.
E. E. Prommer, “Pharmacological management of cancer-related pain”, Cancer Control, c. 22, ss. 412-425, Eki. 2015, doi: 10.1177/107327481502200407.
S. Sharma, M. R. Rajagopal, G. Palat, C. Singh, A. G. Haji, ve D. Jain, “A Phase II Pilot Study to Evaluate Use of Intravenous Lidocaine for Opioid-Refractory Pain in Cancer Patients”, J Pain Symptom Manage, c. 37, ss. 85-93, Oca. 2009, doi: 10.1016/j.jpainsymman.2007.12.023.
S. Mercadante, E. Arcuri, W. Tirelli, ve A. Casuccio, “Analgesic effect of intravenous ketamine in cancer patients on morphine therapy: A randomized, controlled, double-blind, crossover, double-dose study”, J Pain Symptom Manage, c. 20, ss. 246-252, Eki. 2000, doi: 10.1016/S0885-3924(00)00194-9.
K. Sikora vd., “Essential drugs for cancer therapy: A World Health Organization consultation”, Annals of Oncology, c. 10, ss. 385-390, 1999, doi: 10.1023/A:1008367822016.
T. Yamashita vd., “Duloxetine inhibits microglial P2X4 receptor function and alleviates neuropathic pain after peripheral nerve injury”, PLoS One, c. 11, Eki. 2016, doi: 10.1371/journal.pone.0165189.
G. Egeo, L. Fofi, ve P. Barbanti, “Botulinum Neurotoxin for the Treatment of Neuropathic Pain”, Ağustos 2020, Frontiers Media S.A. doi: 10.3389/fneur.2020.00716.
G. K. Ellis vd., “Randomized trial of denosumab in patients receiving adjuvant aromatase inhibitors for nonmetastatic breast cancer”, Journal of Clinical Oncology, c. 26, ss. 4875-4882, Eki. 2008, doi: 10.1200/JCO.2008.16.3832.
A. Bhaskar, “Interventional pain management in patients with cancer-related pain”, 2020, Bellwether Publishing, Ltd. doi: 10.1080/00325481.2020.1807796.
G. P. Kurita, P. Sjøgren, P. Klepstad, ve S. Mercadante, “Interventional techniques to management of cancer-related pain: Clinical and critical aspects”, Cancers (Basel), c. 11, Nis. 2019, doi: 10.3390/cancers11040443.
Y. S. Jeon vd., “Efficacy of epidural analgesia in patients with cancer pain: A retrospective observational study”, Mayıs 2012. doi: 10.3349/ymj.2012.53.3.649.
D. Koyyalagunta ve A. W. Burton, “The role of chemical neurolysis in cancer pain”, Ağustos 2010. doi: 10.1007/s11916-010-0123-9.
