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LETTER TO THE EDITOR

Epidural Analgesia in Advanced Cancer Patients

Klinik für Anästhesiologie und Intensivmedizin, matthias.eikermann{at}uni-essen.de (Eikermann) Professor of Anesthesiology and Intensive Care Therapy, Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany (Peters)

In Response:

We are grateful to Linklater and Macaulay for strengthening our suggestion that epidural analgesia is a rational approach in patients with short life expectancy when systemic treatment of chronic pain has failed (1). The authors demonstrated in 65 patients near their end of life a short-term but major reduction of mean pain intensity. Unfortunately, however, no information is provided on patients’ pain intensity after termination of the (30 h?) epidural infusion.

Furthermore, we have some additional comments on the authors’ practice:

First, the authors did not specify their criteria for epidural catheter placement. Epidural analgesia, we believe, should only be considered for treatment of chronic pain when systemic treatment had failed, in patients with a short life expectancy (3 mo), since leptomeningeal and spinal cord infection is a frequent complication and is associated with a high morbidity and mortality (2).

Second, the authors applied for epidural analgesia only a single standard drug regimen to all patients (i.e., "bupivacaine 0.5% 9 mL, clonidine 150 µg, and diamorphine over 30 h"). In contrast, we strongly recommend individual dosing of local anesthetics so as to balance analgesic effects with side effects of epidural analgesia such as motor blockade or CNS and/or cardiac toxicity. This is of particular importance when epidural analgesia is applied for chronic pain therapy, since inter- and intraindividual variability of plasma bupivacaine concentrations with continuous infusion is very high (3). Moreover, since cancer pain is characterized by variable pain states (4), dosing should be adjusted during follow-up visits.

Third, the authors did not use a tunnelized epidural system. However, when using tunnelized epidural systems, which is standard in our department for long-term pain treatment, dislocation rates of epidural catheters are definitely lower than the 32.3% observed by Linklater and Macaulay. In fact, disclocation has a frequency of approximately 2 per 1000 catheter days when tunnelized systems are used (2).

Epidural analgesia is a viable method for providing persistent reduction of unbearable cancer pain without impairment of consciousness. However, sufficient patient selection and individualized treatment are required to achieve persistent beneficial effects on patients’ quality of life.

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. Sillevis Smitt P, Tsafka A, van de Zande FT, et al. Outcome and complications of epidural analgesia in patients with chronic cancer pain. Cancer 1998;83:2015–22.[Web of Science][Medline]
3. Du Pen SL, Kharasch ED, Williams A, et al. Chronic epidural bupivacaine-opioid infusion in intractable cancer pain. Pain 1992;49:293–300.[Medline]
4. Caraceni A, Weinstein SM. Classification of cancer pain syndromes. Oncology 2001;15:1627–40.[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 Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Eikermann, M. Articles by Peters, J. Search for Related Content PubMed Articles by Eikermann, M. Articles by Peters, J.