ĐA LAT, VIET NAM 11/2014

REPORT OF 03 CASES END-STAGE CANCER PAIN

MANAGERMENT WITH LONGTERM EPIDURAL CATHETER

AT CENTRAL TRANSPORT HOSPITAL

ĐO NGOC HIEU, NGUYEN VAN CHUC

CENTRAL TRANSPORT HOSPITAL

Đa Lat, Viet Nam 11/2014

GENERAL

Pain in cancer patients:

• The top concern

• Causes:

• Due to the development of cancer, invasive, predatory

• Related to cancer (muscle spasms, swelling, ulcers)

• Related to cancer treatment (surgical scars, chemical, radiation)

• Other diseases coordination (osteoarthritis, degenerative spine) [1]

• End-stage cancer pain: scary and difficult to manage

• Better pain relief: improve the quaility of life

1. Nguyen Ba Đuc (2003), “Đieu tri đau cho benh nhan ung thu”, Cham soc va đieu tri trieu chung cho benh nhan ung thu, NXB Ha Noi, trang 11-39.

GENERAL

Treatment of cancer pain:

• Mainstream: medicational therapy (analgesics, tranquilizers, anti-depressants, anti-seizure, anti-anxiety)

• Psychological therapy

• Therapy prevents the progression of the disease (surgery, radiation, chemicals, hormones)

• Deaden pain therapy (local anesthesia, neurosurgery)

• Reduced activity therapy (leisure, real estate)

GENERAL

The WHO analgesic ladder

• Using the correct drug, dose, time:

• Inexpensive

• Efficiency of 45% - 100% of the cases (Ferreira (2006) [5])

• With severe pain: morphine mainstream medicine (more side effect)

5. Ferreira SL, Kimura M, Teixeira MJ (2006), “The WHO analgesic ladder for cancer pain control, twenty years of use. How much pain relief does one get from using it?”, Supportive care in cancer, Springer-Verlag, 14 (11): 1086-1093.

GENERAL

Epidural analgesia (EA):

• As No. 4 in The WHO analgesic ladder

• Bringing drugs into the cavity epidural => spinal roots, nodes beside the spine, circulation => effects

• Anesthetic, morphine, clonidine, ..., (pure or mixed)

• Usually applied: acute pain (surgery, trauma)

EA with chronic pain:

• Keep epidural catheter with subcutaneous chamber (port A) (high cost)

• Patients in end-stage cancer : live <3 months; poor

Grisell Vargas-Schaffer MD (2010), I”s the WHO analgesic ladder still valid? Twenty-four years of experience”, Canadian family physician, 56: 514-7.

GENERAL

Report 03 cases of end-stage cancer pain managerment with longterm epidural catheter:

• Not used subcutaneous chamber (port A)

• Inserted a segment catheter subcutaneous and fixed for longterm

• Keep for long time

CASE STUDY 1

Patient: LE VAN B Male 72 years

Add: 198/4/9 Vinh Hung, Hoang Mai, Ha Noi

Disease: Liver cancer in end-stage 2 years of disease evolution, the condition when arrived:

• Cachexia

• Ascites, pain whole abdomen

• Must lie by lateral or high head to breathe

• Difficult to change his positions, must have family support

• 6 ampoule morphine 10 mg are used IM per day

CASE STUDY 1

Process:

• Epidural catheter placement D9-10, lateral

• 6cm long inside cavity

• Just outside the area goes under the skin to the ribs

• Fixed by opsite

• Drugs: morphine ampoule 10mg/1ml

• Dilute to 20ml and injection 4ml (2mg)/times repeatly

• Monitoring in hospital for 1 day

• Augmentin 1,2g / day x 5 days (OR)

CASE STUDY 1

Results:

• VAS <4 after the first dose 10 minutes

• Patients can change posture, sit up

• First day: injected 3 times (6mg)

• The next days, increasing number of injections

• After 1 week: Use about 2 ampuole morphine 10mg/day

• No itching, no vomiting, urinating normally, defecation 3 days 1 times

• Patients died at home after 2 weeks with EA

CASE STUDY 2

Patient: Phạm Thị Th nu 87 years

Disease: Appendix cancer in end-stage, metastases throughout the abdomen

The course of 14 months, was hospitalized in a state:

• Cachexia

• Ascites, pain whole abdomen

• WHO analgesic ladder: still more pain

• 4-6 ampoule morphine 10mg subcutaneous injection/day

CASE STUDY 2

Procedure:

• Placement of catheter: D10-11, lateral

• 5cm long inside cavity

• Inserted catheter subcutaneous to the lumbar

• Fixed by opsite and bandage

• PCEA, background=0, bolus 3ml/time, lock out 30ph (Using Coopdech Balloonjector-Japan)

• Drugs: solution morphine 0.1 mg / ml (Adjust according to the demands of patients)

• Hospitalized for 2 weeks, drink augmentin 1,2g / day x 5 days

• Changed Balloonjector every 2-3 weeksCoopdech Baloonjecter (Nhật Bản)

CASE STUDY 2

Results:

• Patients almost no pain (VAS <4)

• Reduce the amount of morphine consumption, the first day of use 2-10mg / day, the following day, the total amount of morphine gradually increased.

• No signs of respiratory distress, vomiting or rashes.

• Catheter retention time: 35 days (catheter dislodging the patient to sleep).

• The patient survived 02 weeks after catheter slipped NMC

CASE STUDY 2

Patient: Nguyen Thi D Female 67 yearsDisease: Bililary cancer in end-stage

• Diagnosed 3 months

• Releaf pain by 4-6 ampoule morphine 10mg/day (IM)

Procedure:• Epidural catheter placement D8-9, lateral,

• NMC 5cm deep cavity

• Just outside the area goes under the skin to the ribs

• Fixed by stitching and paste opsi

CASE STUDY 3

Tiến hành:

• PCEA, background=0, bolus 3ml/time, lock out 30ph (Using Coopdech Balloonjector-Japan)

• Drugs: bupivacaine 0.1% + morphine 0.1 mg/ml + adre 1/200000(Adjust the amount of morphine increased according to the demands of patients)

• Hospitalized for 5 days, taking augmentin 1,2g/day x 7 days

• Changed Balloonjector every 2-3 weeks

CASE STUDY 3

Rerults:

• Reduced pain (VAS <4)

• Patients can walk normally, care herself

• No respiratory depression, no hypotension

• No nausea, vomiting, no constipation, urinary retention

• Keep catheter for 45 days (patient deaths)

DISCUSS

• Comparison of 3 patients

DISCUSS

• Prescribe to EA:

• Treatment according to the WHO ladder does not reach the desired effect

• Patients and families to explain and understand the methods

• There are no contraindications (note coagulation function)

• Technical implementation:

• Select the appropriate needle placement (use anesthetic when necessary coordination)

• Catheter under the block skin

• Fixed by sewing and opsite

DISCUSS

• Medicines and how to use:• Morphine is the most effective option

• Coordinate anesthetic, adre to increase time relieve pain and reduce dose

• Analgesic efficacy:

DISCUSS

• NMC on catheter length:

• Patients with end-stage K, survival prognosis of less than 3 months? => Save NMC catheter until death

Bong Ha Heo, Tae Hee Pyeon, et al (2014), “Epidural infusion of morphine and levobupivacaine through a subcutaneous port for cancer pain management”Ruppen W, Derry S, et al (2007), “Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis”, BMC Palliative Care, 6:3.Yeon Soo Jeon, Jung Ah Lee, et al (2012), “Efficacy of epidural analgesia in patients with cancer pain: A retrospective observational study”

DISCUSS

• Undesirable effects:• No infections: shallow in skin or deep in epidural cavity

• Ruppen (2007):• Deep infection: 1 in 35 patients with catheter 74 days to save

• 1 in 500 deaths related to infection

• Other side effects include: nausea, rashes, urinary retention, constipation related total morphine use

• Bong Ha Heo (2014): 17.2% nausea-vomiting, urinary retention 6.9%

Ruppen W, Derry S, et al (2007), “Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis”, BMC Palliative Care, 6:3.Bong Ha Heo, Tae Hee Pyeon, et al (2014), “Epidural infusion of morphine and levobupivacaine through a subcutaneous port for cancer pain management”

CONCLUSION

• Keep epidural catheter analgesia for patients with end-stage cancer

• Initially bring effective

• Inexpensive

• No severe complications

• Fewer side effects.

THANKS YOU SO MUCH !THANKS YOU SO MUCH !

DA LAT, VIET NAM, 11/2014