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LETTER TO THE EDITOR

Epidural Analgesia in Advanced Cancer Patients

Specialist Registrar, med198{at}abdn.ac.uk (Linklater) Research and Development Nurse, Roxburghe House, Department of Palliative Medicine, NHS Grampian, Aberdeen, Scotland, UK (Macaulay)

To the Editor:

We were interested to read the case report by Exner et al. (1) and the subsequent correspondence of Mercadante (2). We agree with Exner et al. in their conclusion that epidural analgesia can be a useful treatment option for such patients and present prospectively gathered data on 65 patients who have had epidurals in our unit over the last 5 years.

We have previously described a pragmatic approach for epidural insertion and management in a specialist palliative care unit (3). The epidural is inserted at the patient’s bedside and the externalized nontunneled catheter is attached to a Graseby MS26 syringe driver. We use a low-volume continuous infusion mix (bupivacaine 0.5% 9 mL, clonidine 150 µg, and diamorphine over 30 h).

Over the past 5 years, we have inserted epidurals in 65 patients (93 lines) giving 2018 catheter days. The average patient is 64 years old. The mean time the first epidural line is inserted before patient death is 74 days (median, 40 days), illustrating that these patients have advanced disease.

Data regarding pain, opioid-related side effects, and simple functional ability were prospectively gathered before insertion and at 7 days postinsertion.

There were significant improvements in opioid-related side effects (drowsiness, confusion, hallucinations, and constipation). The mean patient-rated overall pain score improved from 6.36 to 3.97 as measured on a 11-point Lickert scale (P < 0.01). A significant reduction in pain interfering with walking and sitting, but most dramatically pain while lying in bed, was also demonstrated.

Serious adverse events were infrequent. Superficial infections were seen in 10/93 lines (10.8%), deep infections 2/93 (2.1%), and paraesthesia 4/93 (4.3%). The most common reasons for removal were line migration/dislocation out of the epidural space 30/93 (32.3%) and patient death from the underlying malignancy 21/93 (22.5%). The mean line life expectancy is 22.9 days (range, 1–227 days).

We have demonstrated the benefits of the short-term use of this simple method of epidural analgesia in patients with advanced cancer and difficult-to-control pain. Our serious complication rates compare favorably with those described in other series (4,5). We would agree that for longer term pain control an alternative method is required, for example a completely implanted intrathecal infusion device (2,4).

References

1. Exner HJ, Peters J, Eikermann M. Epidural analgesia at the end of life: facing empirical contraindications. Anesth Analg 2003;97:1740–2.[Abstract/Free Full Text]
2. Mercadante S. Epidural treatment in advanced cancer patients. Anesth Analg 2004;98:1499–505.[Free Full Text]
3. Lee MA, Leng MEF, Tiernan EJJ, Chambers WA. A simple method of using epidural analgesia in palliative medicine. Pall Med 2001;15:347–9.
4. Crul BJP, Delhaas EM. Technical complications during long-term subarachnoid or epidural administration of morphine in terminally ill cancer patients: a review of 140 cases. Reg Anesth 1991;16:209–13.[Medline]
5. Smitt PS, Tsafka A, Teng-van de Zande T, et al. Outcome and complications of epidural analgesia in patients with chronic cancer pain. Cancer 1998;83:2015–22.[Web of Science][Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Linklater, G. T. Articles by Macaulay, L. Search for Related Content PubMed PubMed Citation Articles by Linklater, G. T. Articles by Macaulay, L.