Percutaneous Cervical Cordotomy - Guidance on Referral Criteria

Transcription

1 Pain Clinic Percutaneous Cervical Cordotomy - Guidance on Referral Criteria SWH Version: Job Title of Responsible Manager: Job Title of Executive Sponsor: Ward / Department: Replacing Document: Approving Committee / Group: V2 Dr JHL Antrobus AMD Surgical Division Pain Clinic Date Approved: 15 th June 2011 Date for Review: June 2014 Percutaneous Cervical Cordotomy - Guidance on Referral Criteria. SWH v1 Surgical Audit and Operational Governance Group Relevant Standard(s): Mesothelioma Framework (Gateway Ref: 7907) Department of Health, Clinical Programmes: Cancer 27 February 2007 Arden Cancer Network Mesothelioma Guidelines - 11 March 2008 Department on Health Specialised Services National Definitions Set: 31 - Specialised Pain Management Services (Adult) NICE Supportive and Palliative Care Guidelines Scottish Intercollegiate Guidelines Network Guideline 106: Control of pain in patients with cancer

2 Table of Contents For long documents ensure that there is a comprehensive table of contents which includes all headings and subheadings. DOCUMENT HISTORY INTRODUCTION PURPOSE AUDIENCE RESPONSIBILITIES / DUTIES PATIENT SELECTION AND REFERRAL Indication Contra-indications Timing of Referral Referral MONITORING COMPLIANCE AUTHOR(S) CONTRIBUTORS EQUALITY IMPACT ASSESSMENT TOOL REFERENCES APPENDICES APPENDIX A PERCUTANEOUS CORDOTOMY PATIENT INFORMATION APPENDIX B MONITORING FORM APPENDIX C PLAN FOR DISSEMINATION OF TRUST DOCUMENTS APPENDIX D APPROVING DOCUMENTS CHECKLIST Write here: v2 May 2011 Page 2 of 11 Printed on 25/11/11

3 Document History Issue Version Date Actioned Page/ Comments status by paragraph Approved V1 8/7/09 SAOGG All Approved version 1 Draft V2 25/5/11 Author Headers Updated to FT logo Appendix A Updated patient information leaflet Approved V2 15/6/11 SAOGG All Write here: v2 May 2011 Page 3 of 11 Printed on 25/11/11

4 1. Introduction Percutaneous cervical cordotomy is a procedure for relief of pain due to cancer, particularly for the relief of unilateral chest pain due to mesothelioma. It may also by applicable to other cancer-related pain that is unilateral and below the level of C4. Referrals for this procedure will be drawn from a wide area. 2. Purpose To provide guidance on the selection of patients for percutaneous cervical cordotomy. 3. Audience Healthcare professionals caring for patients with cancer-related pain, particularly network leads for Mesothelioma, members of Network Site-Specific Groups for Lung Cancer and members of Lung Cancer Multidisciplinary Teams. 4. Responsibilities / Duties All professionals looking after patients with pain from cancer should be aware of the range of neurosurgical and anaesthetic techniques available for the relief of pain and should have access to pain specialists with expertise in nerve blocking and neuromodulation techniques 5. Patient Selection and Referral The procedure is described in the Patient Information Leaflet (Appendix A). It is performed under sedation and local anaesthesia. Patients are usually admitted the day before and stay one night after treatment. 5.1 Indication Uncontrolled pain due to cancer (or increasing pain likely to become uncontrolled) that is unilateral and below C4. Percutaneous cervical cordotomy is particularly indicated for pain due to mesothelioma but may be considered for other unilateral pains e.g. neuropathic or incident pain in a functioning limb. Able to co-operate: the patient will need to lie flat and remain still for approximately one hour. The patient must be able to report sensations associated with nerve stimulation. Limited life expectancy (less than two years) Write here: v2 May 2011 Page 4 of 11 Printed on 25/11/11

5 5.2 Contra-indications Coagulation disorder Severely reduced ventilatory function (FEV 1 < 12 mg/kg body weight). The cordotomy lesion is performed on the opposite side to the pain (the lateral spinothalamic tract is a crossed spinal pathway). Cordotomy may result in reduced diaphragmatic function on the side of the cordotomy lesion, the opposite side to the pain. If lung function on the painful diseased side is significantly reduced, and the patient is dependent on ventilation of the non-diseased side, cordotomy may result in ventilatory insufficiency. Inability of the patient to co-operate. 5.3 Timing of Referral Consider referral as soon as the patient commences strong opioid analgesia (WHO Ladder step 3) particularly if pain is incompletely controlled at tolerated doses of opioid, or opioid side effects are troublesome at doses necessary to control pain. Late referral may result in inability of the patient to co-operate. In advanced disease consider referral for alternative treatment, e.g. intrathecal phenol neurolysis. 5.4 Referral For rapid response, please make an or fax referral in addition to sending a hard copy. If you require further advice or information, please telephone. Telephone: Warwick Hospital Pain Clinic Extension 4738 Fax: Please copy to all three addresses below Hugh.antrobus@swft.nhs.uk Anita.phazey@swft.nhs.uk Karen.greenwood@swft.nhs.uk Postal address: Pain Clinic Warwick Hospital Lakin Road Warwick CV34 5BW 6. Monitoring Compliance See the Monitoring Compliance and Effectiveness Form in the Appendix. 7. Author(s) Dr JHL Antrobus. Consultant, Anaesthesia & Pain Medicine 8. Contributors The assistance of Dr Derek Pounder (St. Mary s Hospital, Portsmouth) and Dr Paul Cook (Pennine Acute Hospitals NHS Trust) is acknowledged with thanks. Write here: v2 May 2011 Page 5 of 11 Printed on 25/11/11

6 9. Equality Impact Assessment Tool Please refer to Development and Control of Trust Documents Procedure on how to complete this table. The document cannot be approved without an assessment being completed. Has an Equality Impact Assessment been carried out? YES Preliminary Stage 1 Equality Impact Assessment (must be completed if required*) What date was Stage 1 completed and published? 29 th September 2009 Has a Full Assessment Stage 2 Equality Impact Assessment Tool been undertaken*? N0-NA If yes, what was the date of assessment and publication of Stage 2 and action plan? N/A 10. References Jackson MB, Pounder D, Price C, et al. Percutaneous cervical cordotomy for the control of pain in patients with pleural mesothelioma. Thorax. 1999; 54(3): Crul BJP, Blok LM, van Egmond J, et al. The present role of percutaneous cervical cordotomy for the treatment of cancer pain. J Headache Pain. 2005; 6: Appendices Appendix A Percutaneous Cordotomy Patient Information Appendix B Monitoring Form Appendix C Plan for Dissemination of Trust Documents Appendix D Approving Documents Checklist Write here: v2 May 2011 Page 6 of 11 Printed on 25/11/11

7 12. Appendix A Percutaneous Cordotomy Patient Information Who is it for? Percutaneous cordotomy may be used to relieve unilateral pain below the level of the neck arising from a variety of causes. It is particularly indicated for unilateral chest pain associated with malignant mesothelioma (asbestos-related lung cancer). Proposed benefit The intention is to reduce your pain so that you may achieve good pain relief on lower doses of morphine (or similar) pain killers. Seven to eight out of ten patients can expect a successful result. Risks Failure. In one patient in five, the pain pathway cannot be found and the procedure terminated without achieving pain relief. Incomplete pain relief. In one patient in twenty the procedure is completed but the desired relief is not achieved. Temporary weakness, usually in the leg, rarely in the arm, may occur. One patient in 5 will experience some weakness. This usually gets better within 48 hours, but on rare occasions may take a month to settle and, very rarely, may be permanent. There will be some change in sensation on the side of the pain. Nineteen out of twenty patients find it no problem, but one in twenty does not like it. There is little that can be done about it. You may experience a headache for the first 48 hours. There is a theoretical risk of loss of bladder control, but this has not been seen in practice (Jackson et al 1999). Preparation It is important that medications are continued up to the time of the procedure. You can have a light diet and drink freely; you do not need to fast. You will be asked to sign a consent form after a full explanation has been given, with an opportunity to ask questions. You will need to wear a theatre gown. Procedure The nerves carrying pain from one side of the body cross to the other side once they enter the spinal cord and travel to the brain in a bundle called the lateral spinothalamic tract. If this bundle of nerves is divided in the neck, pain sensation from the opposite side of the body can be blocked. You will lie on your back under an X-ray camera. A needle will be inserted into a vein in your hand or forearm and a saline drip set up. Pain killers can be given to make you comfortable. Using local anaesthetic a needle will be inserted into the side of your neck, below and behind the ear, on the opposite side to the pain. X-rays are used to guide the needle. Gentle electrical stimulation is then used and, by asking what you report what you feel, we can check the position of the needle tip. The needle tip is then heated to destroy the nerves carrying pain. After the procedure Your blood pressure will be measured for 4 hours. If well, you may sit up and drink immediately. Normal diet after 4 hours. An overnight admission is required. Occasional patients may need longer. You should remain on bed rest overnight, mobilising with assistance next morning. The saline drip will continue overnight and removed when you go home the following day. Morphine-type painkillers are usually decreased by 30-50%, then readjusted to need. Your anaesthetist will supervise the reduction of your morphine and liase with your GP if necessary. Write here: v2 May 2011 Page 7 of 11 Printed on 25/11/11

8 Alternative treatments Higher doses of your painkillers can be tried. Painkllers can be delivered by pump as a continuous infusion either subcutaneously (under the skin) or into the spine through an epidural or spinal catheter. Intrathecal neurolysis may be used when a cordotomy is not possible. In this procedure, phenol or alcohol is injected into the spinal canal to numb the pain nerves as they enter the spinal cord. Reference Jackson M.B et al (1999) Percutaneous cervical cordotomy for the control of pain in patients with pleural mesothelioma Thorax, 54: Authors Dr JHL Antrobus, Consultant in Anaesthesia and Pain Management. Debbie Mundy, Lead Clinical Nurse Specialist, Pain Service. For further information, contact: The Pain Service Warwick Hospital Lakin Road, Warwick CV34 5BW Tel: ext 4738 Website: Publication date: December 2008 Revised: April 2011 Review date: April 2014 PALS We offer a Patient Advice Liaison Service (PALS). This is a confidential service for patients and their families to help with any questions or concerns about local health services. You can contact the service by the direct telephone line on or using the phone links which are available in both hospitals or calling in at the office located in the main entrance at Warwick Hospital. As a key provider of acute healthcare and as an employer, the Trust has a statutory obligation to promote and respect equality and human rights. This is set out in various pieces of legislation including: Race Relations (Amendment) Act 2000, Disability Discrimination Act (2005), Sex Discrimination Act (1975) and the Age Discrimination Act (2006) Our information for patients can also be made available in other languages, Braille, audio tape, disc or in large print. Write here: v2 May 2011 Page 8 of 11 Printed on 25/11/11

9 13. Appendix B Monitoring Form Title of Document Date 25 th May 2011 Percutaneous Cervical Cordotomy Guidance on Referral Criteria. SWH CQC regulations relating to this document (if any) NHSLA Standard related to this document (if any) Does the document fulfil the criterion of NHSLA? (please circle as appropriate) YES No N/A If not, why not: 1. How will the document be monitored? (please circle as appropriate and type in the methodology) 2. What is the process for reviewing results of monitoring? 3. Who is responsible for conducting the monitoring? Audit KPI Review Other, please specify; Methodology: Periodic review with feedback from users. Comments from end users received in the course of routine clinical communication. Group / Committee Individual Name / Title (also include position of individuals): 1. Dr JHL Antrobus, Consultant Anaesthetist 2. AGM Surgical Directorate 4. How often will COMPLIANCE with the document be monitored? (please circle as appropriate) Monthly 6 Monthly Yearly Comments: Other, please specify; 3 Years Write here: v2 May 2011 Page 9 of 11 Printed on 25/11/11

10 14. Appendix C Plan for Dissemination of Trust Documents Title of Trust Document Date finalised 6th July 2011 Percutaneous Cervical Cordotomy Guidance on Referral Criteria. SWH Ratifying Committee i.e. which group gave final approval of the document? Dissemination lead (Print name and contact details) Previous Document already being used? If, yes in what format and where? What action will be used to retrieve out-of-date copies of the document: Receiver (area / ward / unit) Surgical Audit and Operational Governance Group Anita Phazey, Anaesthetic Department Coordinator Ext Anita.phazey@swft.nhs.uk Electronic format, on old Trust internet page now removed. N/A old document was not uploaded to new website Dissemination Process Process Responsible Timeline Format (paper or electronic) Trust internet page Upload A. Phazey 31 July 11 Electronic Date completed Anaesthetic document store File Record of Dissemination of Procedural Documents Date of approval of the document 15 th June 2011 Date the document is due review June 2014 Write here: v2 May 2011 Page 10 of 11 Printed on 25/11/11

11 15. Appendix D Approving Documents Checklist Title of Trust Document: Author: Ratifying Committee / Group Date of Submission May 2011 Percutaneous Cervical Cordotomy Guidance on Referral Criteria. SWH Dr JHL Antrobus, Consultant Anaesthetist Surgical Audit and Operational Governance Group Item 1 Has the Development and Control and Trust Documents Procedure and it s associated documents been consulted during the development of this document? 2 Has the appropriate template been used? 3 Has the South Warwickshire General Hospital NHS Trust Style Guide been used to develop this document (refer to Appendix E of Development and Control of Trust Documents Procedure if unsure)? 4 Have the appropriate committees / groups / individuals been consulted 4a Complete (YES / NO) as to the appropriateness of the content of this document? Please list these committees / groups / individuals: This is an update of the style of the document to include the new Foundation Trust Logo. No further consultation necessary. 5 Has the first half of the Plan for Dissemination of Trust Documents form been completed? 6 Has an Equality Impact Assessment been undertaken? (This needs to be carried out before approval can be granted). 7 Has the Trust document been sent to the approving body? 8 Has the Monitoring Compliance of Trust Documents Form been completed? Author (sign off) I declare that the information above is a true and accurate record Name Position Signature Dr JHL Antrobus Consultant Anaesthetist Appropriate Manager for Subject (sign off) I declare that I have overseen the development of this Trust document and believe all appropriate matters have been addressed Name Position Signature Mr R Jackson AMD Surgical Division Write here: v2 May 2011 Page 11 of 11 Printed on 25/11/11