Anesth Analg 2004;98:1503-1504
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000114585.53663.2B
LETTERS TO THE EDITOR
Epidural Treatment in Advanced Cancer Patients
Sebastiano Mercadante, MD
Director, Anesthesia and Intensive Care Unit, Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
To the Editor:
I have read with interest the study by Exner et al. (1) on the epidural treatment in an advanced cancer patient unresponsive to systemic treatment. While potential contraindications in practice can be overcome by the compassionate needs, I have some concerns on the initial choice of using the epidural route in the clinical conditions the authors have presented. The choice of positioning an epidural catheter implies the use of large volumes, which commonly also requires frequent pump refilling. This is a risk factor for the development of infection (2). The authors do not explain the system they used (open, subcutaneously tunnelized, port?), and catheter dislocation may depend on this choice. In a previous experience of epidural analgesia, more than 50% of catheters had to be removed and all dislocated catheters were nontunneled; the rate of epidural infections was very high, and some patients required surgery for decompression (3). Epidural route is often complicated by mechanical problems, malfunctioning, pain at injection, and dislocation (4). Patients with advanced cancer are quite frail and repeated procedures are not easy to be accepted for most of them, other than being expensive and requiring hospitalization (5).
Reading about abrupt discontinuation of hydromorphone previously given in doses of 800 mg daily is disturbing. This approach, further worsened by not giving opioid drugs by epidural route, would result in severe withdrawal problems. Moreover, it is not comprehensible why the initial epidural catheter was placed at T7–8 in a patient with pain in dermatomes related to the lumbosacral plexus. High concentrations of bupivacaine were used in the second instance, and I wonder if such doses had any effect on motor function when the catheter was finally placed at L2–3 level. I presume that such high doses were given due to less effects, which could be dependent on the local situation (although inflammation could potentially increase absorption, systemic or leptomeningeal?)
Intrathecal administration requires smaller doses and volumes than epidural administration, presents low mechanical problems, and produces a more defined and clearer dose administration. This is an advantage to patients presumably requiring aggressive treatments, according to their large opioid dose regimen, allowing few pump refills. Although no controlled studies exist, most authors agree that intrathecal treatment offers indisputable advantages over the epidural route, especially in medium long-term periods (4). We agree that terminal sedation for pain is not necessary, but a more rational approach may reduce risks and improve efficacy of an aggressive treatment, such as spinal drug delivery in advanced cancer patients.
References
- 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]
- Di Cicco M, Matovic M, Castellani GT, et al. Time-dependent efficacy of bacterial filters and infection risk in long-term epidural catheterization. Anesthesiology 1995; 82: 765–71.[Web of Science][Medline]
- 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]
- Crul BJ, 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]
- Mercadante S. Problems of long-term spinal opioid treatment in advanced cancer patients. Pain 1999; 79: 1–13.[Web of Science][Medline]
Response
Hans Juha Exner, MD,
Jürgen Peters, MD, and
Matthias Eikermann, MD
Keski Suomen Sairaanhoitopiiri, Anestesiologia ja tehohoito, Jyväskylä, Suomi-Finland
Professor of Anesthesiology and Intensive Care Therapy, Chairman
Oberarzt, Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany
In Response:
We appreciate Dr. Mercandante’s interest in our work (1). We agree that intrathecal route for analgesic drug administration is useful in long-term treatment of intractable pain. However, with regard to our patient with a very short life expectancy, we have reason to doubt Dr. Mercandante’s notion that "most authors agree that intrathecal treatment offers indisputable advantages over epidural route." In fact, this is not what Crul and coworkers stated in their cited study (2). In accordance with the conclusion statement of these authors (2), we agree that "the choice between epidural and subarachnoid administration should be determined primarily by the life expectancy of the patient concerned" (2). In our department, epidural analgesia is the method of first choice in patients with an expected life expectancy of up to 3 months when systemic treatment has failed, either because of inadequate analgesia or because of intolerable side effects.
When using tunnelized epidural systems, which is the standard in our department for long-term pain treatment, leptomeningeal infections are very rare (3). Furthermore, dislocation of the tunnelized epidural catheter, reported with a frequency between zero (2) and 2.3 per 1000 catheter days (3), is also of limited relevance in patients with short life expectancy. Most important, epidural analgesia does not further compromise patients’ quality of life from postdural puncture headache (PPH). This is important, because PPH has been reported after spinal analgesia with a frequency of 33% of patients, even when a microcatheter technique is used (4).
Dr. Mercandante is concerned about the abrupt discontinuation of hydromorphone previously given in doses of 800 mg daily and assumes that this might result in severe withdrawal problems. However, "opioid holiday" is an appropriate therapeutic strategy to reestablish the vanishing effect of opioids in patients with chronic pain who have become exceptionally tolerant to opioids (5). Furthermore, withdrawal symptoms were minimized by neural blockade by thoracic epidural analgesia combined with administration of the  2-adrenoceptor agonist clonidine (5,6).
We placed the initial epidural catheter at the interspace T7–8 because the patient complained about severe pain in the abdominal region, most likely from the cancer infiltrating the peritoneum and the bladder. Obviously, placement of the epidural catheter at T7–8 was appropriate, because this strategy abolished the pain. High concentrations of bupivacaine were required in the second instance when the catheter was finally placed at the L2–3 level. Effects on motor function were not clinically relevant in our patient, as rapid tumor progression in the region of the lumbosacral plexus resulted in a progressive paraparesis.
Thus, epidural analgesia is a rational approach decreasing severe side effects and improving efficacy when systemic treatment fails in patients with short life expectancy.
References
- Exner HJ, Peters J, Eikermann M. Epidural analgesia at the end of life: facing empirical contraindications. Anesth Analg 2003; 97: 1740–2.
- Crul BJ, 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.
- 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.
- Horlocker TT, McGregor DG, Matsushige DK, et al. Neurologic complications of 603 consecutive continuous spinal anesthetics using macrocatheter and microcatheter techniques. Perioperative Outcomes Group. Anesth Analg 1997; 84: 1063–70.[Abstract]
- Breitfeld C, Eikermann M, Kienbaum P, Peters J. Opioid "holiday" following antagonist supported detoxification during general anesthesia improves opioid agonist response in a cancer patient with opioid addiction. Anesthesiology 2003; 98: 571–3.[Web of Science][Medline]
- Kienbaum P, Heuter T, Michel MC, et al. Sympathetic neural activation evoked by mu-receptor blockade in patients addicted to opioids is abolished by intravenous clonidine. Anesthesiology 2002; 96: 346–51.[Medline]
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