Edmonton injector: Use in Córdoba, Argentina

372 /armal of Pain and SymplomMan-t

Vol. 12 No. 6 Ikmnbm I !%

Cliniaal Note

Edmonton Injector: Use in Grdoba, Argentina Maria Pruvost, MD, Oscar E. De la Colina. MD, and Nidia Alejandra Monastemlo. MD Pain and P&live M&&e Se&m (M.P), Anrrthrsia Sprv~rr(M.P, O.D.C., N.A.M.). Hmpikzl San Rqw, cdrriobn,Aqmlinn

Fourteenpatier& with advanred rancor receivedinknniltenl subcutaneousinjection of motphine using an Edmonfon Inj&or (EI). Twelvepatients used the s+m at home. The minimal doseo/morphine urns 15 mg ew~y 4 hr and the maximal dosr was 90 mg every 4 hx There were htm complicatiotrs:abscessand bleeding. In developing cowltics, the safdy, low cod, and vmalilily of he Edmonton Injtclor offm an imporlnnl aknaliw in terminally ill palienis. This deviceis an ideal %jec~ion pump” fm usein &wloping counWics,where castsare mosslimportant in nwhing tre&nex! decisions.o U.S. Cancer Pain Relief Committee, 1996. J Pain Symptom Manage 1996;12:?72-375. Edntmkm Injex~m(EI), subcukznevussouls, c5ncerpain, cost nduclion

Most cancer patients require opioids for wn.. ‘.‘L and most of those who die U. &e disease require alternative ways of opioi 1 adminisuation: 4.4 The subcutaneous (SC) route is commonly used, currently accepted as safe,‘-%’ anti currently provides the possibility of patienttontrolled analgesia (PCA) or famity management. There are a great Mriety of devices for drug delivery’ in advanced cancer patients, but most are not suitable to develop ing counvies because of health care system limitations. The Edmonton Injector (El)!‘,‘” was designed with some characteristics (no engine, simplicity, low cost of device, and disposable) that might make it appropriate for use in developing countries (Figure I).” The Adams n$nint rqwsts lo: Maria Pruvost. MD. Lais de Azpcitia 1655.5009 Cord&a, Argentina. Acqded Jor@blicatim~February 26. 1996. 0 U.S. Caccr Pain Relief Committee. 1996 P~btis!.ed ty Fkvier, New York. NC-WYork

aim of this brief report is to describe our prelim:?ary experience with the first patients who received analgesic treatmeut using this device.

Mt?thOdS In a retrospective study, we reviewed the charts of 14 consecutive cancer patients in which the EI was applied for intermittent sub cutaneous administration of morphine for pain relief. The EI wds used whenever SC administration was warranted.‘” The types of indications included (1) nausea and vomiting, (2) bowel obstruction, (3) dysphagia, (4) confusion, (5) high od dose required, (6) desire for home treatment, and (7) cost reduction. Patient characteristics, primary tumor, gender, and age are summarized in Table I. The reasons for the change from oral administration to SC are specified in Table 2. The subcutaneous needle site was changed every 7 days if it remaiued asymptomatic. The needle cite oe85-3924/.~/$15.00 PII So&35m?4(%)oomS4

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Fig. 1. Edmonton

19%

The Edmontml

T&l Patient-

67 47 58 53 57 42 51 55 41 42 5s 55 49 40

373

Injector.

varied among thL, chest, the upper abdominal wall, or the deltoid. In outpatients, it was impossible to inspect the site daily, and followup was made by telephone, homecare nurse. or during clinic visits. A solution of powder of morphine chlorhydtate in saline solution was used. It was specially prepared at our hospital pharmacy and was packed in a previously sterilized *%nsfusion bag. There was no availability of IO0 mL

Age

h+?ctm

bags, bacteria) filcels, or laminar flux for preparing solutions using traditional sterilization. The concentration of the solution was 15 mg/mL and 30 mg/mL. Coa calculations were made for oral and injection solutions, hours of work of the pharmacist, butterfly needles, bags, sterilization. and the COSLof the El itself.

Results are summarized in Table 3. The reasons for SC infusion were dysphagia (three cases), vomiting (two cases), bowel obstruction (one case), and poor pain control despite high oral doses in the rest of patients. Of the I4 patients, I2 used the El at home. Three were inpatients at the time the El was used, and IWO patients remained in the hospital T&k 2

-

for subnamcous hljeetim

WPW Vomiting Bowel obswction Poor pin conuol despite oral high dose

3 2 I 9

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374

TobIt 3

Resuits in 14 colpeeutive cancer Patiots Initial dose-

Final dose

Day using El

(mg)

(mg)

22 54 I 14 2 78 5 5 5

15 !iz 45 So 15 15 15 !iz

:z

2 60 5

E.5

90 45

E 45

60 30 60

z

J-w a, home

w inpatient

Camplicationa

Dircontinwzd for

22 E.5 SO

54 I

2 30 15 15

2 68 5 5 5 15 ‘El 60 5 2: ?O

14

death. Number of days of treatment ranged from 1 to 78 (mean, 25.14 + 24.92). The minimal morphine dose was 15 mg every 4 hr and maximal dose was 90 mg every 4 hr. The mean dose was 33.5 mg every 4 hr. No systemic toxicity was observed. Local tolerance was good. One patient developed sub cutaneous nodes that became abscessed, and one had subcutaneous bleeding at the subclavicular site. One oatient rejected the El after 5 days of treatment. The reasons for treatment suspension are dcsrrihrd ;o T,-ble 3. The main reason was death. Three patients were from Cordoba city: one 20 km away, another 50 km, and another 300 km. This last patient received the El through a relative and written instructions to a local doctor. No problem was reported, and the patient died under treatment at day 5. The patient’s family returned the El and the unused morphine to us. The cost of preparing the solutions is described in Table 4. The cost of the El is $120 (U.S.). Nurse cost was not calculated because the majority of patients were at home. until

A high percentage of patients with advanced cancer require a change in the opioid administration route. This change is required for different reasons: need for high dose, confusion that does not permit on1 dosing, tumor localization (that is, head and neck cancer or

IO

?I

esophageal cancer), bowel obstruction, nausea, and others. Between November 1992 and November 1993, 180 cancer patients were admitted to our Service for pain relief. Just 59 (32.7%) of these 180 patieuls were treated with strong opioids (third step of World Health Organiaation’s scheme) at the first consultation, despite the description by most of unbearable pain. Fourteen of them required parenteral opioids. This is an aberage of 7.7%, usually the proportion of patients who require a change from oral sdministration. This statistic reveals that cancer pain control is still a problem in our country because of severe undertreatment. The possibility of having a system that permits self-administration or family administtation of morphine without excessive cost and tith easy handling is essential in developing countries. such as Argentina. It could be said that the El is the ideal injection pump in Tobe 4

cosl of PreParing Solutions Oral solution

Injection solution

morphine I g = $3.00

morphine chlorhydrata

half an hour of pharmacist’s work = $1.85 sterilization cost = $1.00

onelfl=ss.oo our of pharmac w’s work = fS.90

daily cost for 540 mg/day. $3.00 (U.S.)

sterili7ation cost = Il.00 bag coot = $1.00 butterfly rxtdle = $1&O daily coJt for 180 mg/day, $0.90 (U.S.)

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TheEdmonlonInjrcloT

developing countries. We used it far from Cardoba, using written instructions to a local doctor. One of the most important aspects for us is cost. The mean daily SC dose of So mg every 4 hr is equivalent to 90 mg orally every 4 hr. Oral solution costs about @/day, but SC solution is still cheaper, about 80.90/day, not including the El cost ($120 in our count--v). The main cost difference is in the price of morphine ampules. \Ve have two commercial formulations of morphine, IO mg and 20 mg per ampule. and the cost is around $4 pet ampule. If we need three ampules of IO mg every 4 hr. we would need 400 ampules for 20 days of treatment. This would equal $1600 in 20 days, or $t30 for a day of treatment. By making the SC solution at the hospital pharmacy, we spent $18.90 for 20 days of treatment, around $l/day. The Hospital invested $600 dollars to buy five El’s and recovered the investment with one patient who used SC morphine rather than the same amount of morphine in ampules. Patient comfort was greatly increased. One patient even worked selling newspapers while using the El. Two patients, one with colon cancer and the other with rectal cancer, rejected the El because they were reluctant to wear another bag. One needed a neurolytic block for poor control of pain in the perineal region. Another patient did not like the El and rejected it on day 5. Some of our patients appeared LO improve in cognition as compared to patients receiving high oral doses. The reason for this is uncleat and must be confirmed in other studies. One possibility would be that the systemic administration resulted in less production of active metabolites of morphine. In conclusion, we believe that the use of the El must be included as a possible approach to cancer pain treatment in developing countries. All that is needed for access is a sterilized morphine solution. In countries. like our own. in which the cost of infusion pumps is prohibi-

tive, the EI constituux

375

an alternative

for the

majority of patients.

The authors wanlc, like to acknowledge the pharmacy staff at rhc Hospital San Roque, and Dr. Eduardo Bruxa and Roberta Allen for their help with th.: manuscript.

1. Foley R The Ire .‘mmt of cancer pain. J Med 1985.31384-95.

S Engl

2. Ripamonti C. Bruera E. Rectal, bural. aud sub lingual narcotics for the management of cancer pain.J Palliat Care 1991;7:%&35. 3. Bruera E, Brenncis C, Mac Donald Rh’. Continuous SC infusion of narcotics for the treatment of cancer pain: an update. Cancer Treat Rep 1987; 7 I :953-9x 4. Coyle N, Mauskop A. Maggard J. Foley IL... Continuous subcutaneous infusions of opiales in cancer patients with pain. Oncol Nun Forum 1986: 1.3:53-57. 5. Ventafridda V. Spoldi E, Canceni A, Tambutini M, De Conno F. The importance of continuous sub cutaneous mcqhine administration for cancer pain control. Pain Clin 1986:1:47-55. 6. Brenneis C. Michaud M. Bruea E. et al. Local toxicity during the subcutaneous infusion of narcotics: a Prospective study. Cancer Sun 1987;lO: 172-176. 7. Twycross R. The management of Pain in cancer: a guide to drugs and dosages. Prim Care Cancer 1988;May. 8. Brueta E. Brenncis C. Perry B, Mac Donald RN. Continuous subcutaneous administration of narcotics for the treatment of cdncer pain (a guide to C.S.C.I.).Cross Cancer Institute. University of Alberrs. Canada. 9. Brueta E, Mac Milian R, Hanson J, Mac Donald RN. The Edmonton Injector. a simple device for parientcontrotted subcutaneous analgesia. Pain 1991;44:167-169. 10. Bruera E. Ambulatory infusion devices in the continuing care of patients wifh advanced diseases. J Pain Symptom Manage 1991:5:287-296. 11. Wenk R. lnyector Instrucciones

de Edmonton.

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