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552 FAMILY-CONTROLLED SEDATION WITH MIDAZOLAM IS VERY EFFECTIVE IN CONTROLLING INTRACTABLE PAIN AND SUFFERING IN TERMINALLY ILL PATIENTS
Topic D: TREATMENT APPROACHES (MEDICAL/INTERVENTIONAL) 549 POSTOPERATIVE INTRAVENOUS PATIENT-CONTROLLED ANALGESIA-ADMINSITERED KETAMINE PLUS MORPHINE SPARES MORPHINE USE IN ORTHOPEDIC ONCOLOGICAL PATIENTS S. Chazan, N. Marouani, L. Arbel, J. Bickels, D. Stocki, A. Gorodetzky, A. Nirkin, I. Meller, V. Rudick, Y. Kollender, A.A. Weinbroum ° . CHU Souraski Medical Center, Tel Aviv, Israel Purpose: Pain after surgery for bone and soft tissue tumor is intense, and may require large amounts of analgesics, especially opioids. The concomitant use of ketamine and opioids in patients undergoing general surgery has shown to reduce pain and spare opioids. We compared the effects of standard morphine dose alone vs. subanesthetic dose of ketamine plus 66% of the standard morphine dose via intravenous patient controlled analgesia (IV-PCA) on pain intensity in the orthopedic oncological patients. Methods: Forty patients underwent surgery under standardized general anesthesia. Postoperatively, they received via IV-PCA (lockout time 7 min) randomly, prospectively and double-blindly (n = 20/group) morphine 1.5 mg/bolus (standard dose) or ketamine 5 mg+morphine 1 mg/bolus. Treatment started when the coherent patient subjectively-rated pain as 5/10 on a visual analog scale (VAS), and lasted up to 24 h. Intramuscular rescue diclofenac 75 mg was also available. Results: The mean hourly pain intensity among the ketamine+morphine patients was lower ~50% compared to that in the morphine alone group, as was the morphine consumption. PONV was recorded trice in the only MO group; one of the ketamine+morphine patients reported a momentary unpleasant sensation. Conclusions: The combination of IV-PCA subanesthetic dose of ketamine plus 33% lower dose of morphine reduces pain and spares morphine after surgery for bone and soft tissue tumor than the higher dose of morphine alone. 550 MANAGING CANCER PAIN AND SYMPTOMS OF OUTPATIENTS BY ROTATION TO SUSTAINED-RELEASE HYDROMORPHONE: A PROSPECTIVE CLINICAL TRIAL S. Wirz ° , H.C. Wartenberg, M. Wittamnn, J. Nadstawek. University of Bonn, Clinic for Anesthesiology, Germany Background and Aims: In this prospective clinical trial we examined the technique of opioid rotation to oral sustained-release hydromorphone for controlling pain and symptoms in outpatients with cancer pain. Methods: Before and after rotation, variables of 50 patients were assessed by Numerical Analogue Scales (NRS), or as categorical parameters, and analyzed by descriptive and confirmatory statistics (Poisson regression; paired T-test; Chi2-test). Results: Rotation was successful in 64% of patients experiencing pain (60%), gastrointestinal (32%) and central (26%) symptoms under oral morphine (38%), transdermal fentanyl (22%), tramadol (20%), oxycodone (12%), or sublingual buprenorphine (8%). NRS of pain (4.1 to 3.2; p = 0.015), gastrointestinal symptoms, especially defecation rates (p = 0.04), and incidences of insomnia improved after an increase in morphine-equivalent doses from 108.9 to 137.6 mg/d without modifying concomitant analgesics or co-analgesics. Conclusion: Switching the opioid to oral hydromorphone may be a helpful technique to alleviate pain and several symptoms, but it is still not clear to what extent the underlying mechanisms, such as the technique of rotation itself, better dose adjustment, or using a different opioid have an impact.
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D05 CANCER PAIN – PALLIATIVE CARE 551 SPINAL ANALGESIA IN HOSPICE HOME CARE PATIENTS R. Akhileswaran1 ° , S.N. Yeo2 , B.M.K. Lee3 . 1 Medical Director, HCA Hospice Care, 2 Director, Pain Management Services, Singapore General Hospital, 3 Consultant, Pain Management, Dept. of Anaesthesiology, Tan Tock Seng Hospital, Singapore Invasive Analgesia in patients under hospice home care programmes (HHCP) is not common. This study reviewed patients treated with spinal analgesia for their pain control and problems encountered at home. 13 patients treated with spinal analgesia under the HHCP were studied, 11 of whom were treated from January 2005 to March 2006. 12 patients had advanced malignancies and 1 patient had multiple osteoporotic spinal fractures. 3 patients had predominantly somatic pain and 10 patients had combinations of somatic, visceral and neuropathic pains. 3 patients had epidural analgesia and 10 had intrathecal analgesia. Morphine and Bupivacaine was used in 11 patients. Clonidine was added in 8 patients. Morphine and Marcaine was used for 1 patient and Fentanyl and Bupivacaine for another. VRS or NRS were the pain assessment tools used. Pain was well controlled in 8 patients, partially controlled in 4 and not controlled in 1. Care of the skin, bowel, bladder and nutrition were problems encountered at home for all patients. 4 patients developed infection at the catheter exit site and one of them also had infection at the implant site. 1 patient developed paraplegia and recovered when the catheter was removed. 11 patients had spinal analgesia from 3 to 26 weeks before they died. Spinal analgesia was discontinued after 24 weeks for 1 patient due to infection and continues in another patient 20 weeks after it was started. 12 out of 13 patients under the HHCP had partial to adequate pain relief by spinal analgesia when conventional analgesia failed.
552 FAMILY-CONTROLLED SEDATION WITH MIDAZOLAM IS VERY EFFECTIVE IN CONTROLLING INTRACTABLE PAIN AND SUFFERING IN TERMINALLY ILL PATIENTS E.S. Panteli, D. Aretha ° , M. Karanikolas. Anaesthesiology and Critical Care, University hospital of Patras, Rion, Achaia, Greece Background: Relief of end-of-life pain and suffering is the most important goal in palliative care. Use of family-controlled midazolam sedation for intractable end-of-life symptom relief has been reported, but not fully evaluated. Methods: We prospectively established a family-controlled sedation protocol for terminal cancer patients with severe pain/distress. Inclusion criteria were pain and suffering resistant to standard interventions, patient/family consent, presence of a competent adult at bedside and life expectancy shorter than a week. Five patients (2 men, 3 women, 24 to 73 years old) enrolled. Life expectancy was short in all cases (PPI > 9). Midazolam was administered intravenously by a programmable electronic pump controlled by family members. Midazolam was started at 0.3 mg bolus, 20 minutes lockout (no basal) and adjusted to optimize symptom control. Sedation was assessed on a 4-point scale: 1) agitated, 2) awake, 3) arousable 4) unarousable. Family satisfaction was measured on a 4-point scale: 1) good, 2) fair, 3) poor, 4) unacceptable. Results: Midazolam consumption was 10 to 34 mg/day. There was no respiratory depression. Death occurred one to three days after sedation started, and family satisfaction was high in all cases. Sedation was rated as 2 or 3 (on the 4-point scale) at most times. Discussion: In our experience family-controlled sedation with midazolam is very effective in controlling refractory pain and suffering in terminal cancer. Further investigation is needed to determine the optimal timing, route and dosage of sedation and confirm the safety and efficacy of the method.
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D05 CANCER PAIN – PALLIATIVE CARE 551 SPINAL ANALGESIA IN HOSPICE HOME CARE PATIENTS R. Akhileswaran1 ° , S.N. Yeo2 , B.M.K. Lee3 . 1 Medical Director, HCA Hospice Care, 2 Director, Pain Management Services, Singapore General Hospital, 3 Consultant, Pain Management, Dept. of Anaesthesiology, Tan Tock Seng Hospital, Singapore Invasive Analgesia in patients under hospice home care programmes (HHCP) is not common. This study reviewed patients treated with spinal analgesia for their pain control and problems encountered at home. 13 patients treated with spinal analgesia under the HHCP were studied, 11 of whom were treated from January 2005 to March 2006. 12 patients had advanced malignancies and 1 patient had multiple osteoporotic spinal fractures. 3 patients had predominantly somatic pain and 10 patients had combinations of somatic, visceral and neuropathic pains. 3 patients had epidural analgesia and 10 had intrathecal analgesia. Morphine and Bupivacaine was used in 11 patients. Clonidine was added in 8 patients. Morphine and Marcaine was used for 1 patient and Fentanyl and Bupivacaine for another. VRS or NRS were the pain assessment tools used. Pain was well controlled in 8 patients, partially controlled in 4 and not controlled in 1. Care of the skin, bowel, bladder and nutrition were problems encountered at home for all patients. 4 patients developed infection at the catheter exit site and one of them also had infection at the implant site. 1 patient developed paraplegia and recovered when the catheter was removed. 11 patients had spinal analgesia from 3 to 26 weeks before they died. Spinal analgesia was discontinued after 24 weeks for 1 patient due to infection and continues in another patient 20 weeks after it was started. 12 out of 13 patients under the HHCP had partial to adequate pain relief by spinal analgesia when conventional analgesia failed.
552 FAMILY-CONTROLLED SEDATION WITH MIDAZOLAM IS VERY EFFECTIVE IN CONTROLLING INTRACTABLE PAIN AND SUFFERING IN TERMINALLY ILL PATIENTS E.S. Panteli, D. Aretha ° , M. Karanikolas. Anaesthesiology and Critical Care, University hospital of Patras, Rion, Achaia, Greece Background: Relief of end-of-life pain and suffering is the most important goal in palliative care. Use of family-controlled midazolam sedation for intractable end-of-life symptom relief has been reported, but not fully evaluated. Methods: We prospectively established a family-controlled sedation protocol for terminal cancer patients with severe pain/distress. Inclusion criteria were pain and suffering resistant to standard interventions, patient/family consent, presence of a competent adult at bedside and life expectancy shorter than a week. Five patients (2 men, 3 women, 24 to 73 years old) enrolled. Life expectancy was short in all cases (PPI > 9). Midazolam was administered intravenously by a programmable electronic pump controlled by family members. Midazolam was started at 0.3 mg bolus, 20 minutes lockout (no basal) and adjusted to optimize symptom control. Sedation was assessed on a 4-point scale: 1) agitated, 2) awake, 3) arousable 4) unarousable. Family satisfaction was measured on a 4-point scale: 1) good, 2) fair, 3) poor, 4) unacceptable. Results: Midazolam consumption was 10 to 34 mg/day. There was no respiratory depression. Death occurred one to three days after sedation started, and family satisfaction was high in all cases. Sedation was rated as 2 or 3 (on the 4-point scale) at most times. Discussion: In our experience family-controlled sedation with midazolam is very effective in controlling refractory pain and suffering in terminal cancer. Further investigation is needed to determine the optimal timing, route and dosage of sedation and confirm the safety and efficacy of the method.