Seminars in Surgical Oncology 6:173-176 (1990)
lntraspinal Narcotics for Treatment of Cancer Pain TIMOTHY R. LUBENOW, MD, AND ANTHONY D. IVANKOVICH, MD From the Department of Anesthesiology, Rush-Presbyterian-St.Luke‘s Medical Center, Chicago, Illinois
Inadequate pain relief remains a problem for many patients with cancer. Narcotic administration by the epidural or subarachnoid route is a relatively recent innovation and is indicated when pain is poorly controlled with high doses of systemic narcotics, or when patients experience limiting narcotic side effects. When given by the epidural or intrathecal route, narcotics have a longer duration of action and a lower dose is effective. These techniques involve personnel trained in catheter insertion and maintenance. Epidural and intrathecal administration of narcotics is an alternative when oral narcotics are ineffective. In this report the term “intraspinal” refers to epidural and/or subarachnoid placement of catheters and drugs.
KEYWORDS:epidural narcotics, intrathecal narcotics, subarachnoid administration INTRODUCTION For physicians treating cancer patients, control of pain poses a great challenge. Sixty to 90% of patients with far advanced or terminal cancer suffer from moderate to severe pain. As many as 25% of cancer patients throughout the world die without relief from severe pain [ 1,2]. The discovery of opiate receptors in the spinal cord has brought a new route of administration of drugs for relief of severe cancer pain to the forefront. Subarachnoid or epidural narcotics provide excellent analgesia; therefore, these techniques have been growing in popularity. Epidural or subarachnoid administration is indicated for patients with cancer pain who are poorly controlled with high doses of systemic narcotics, or who experience limiting narcotic side effects such as sedation, hallucinations, and/or dissociative reactions. The advantages of epidural and subarachnoid over systemic narcotic administration are a longer duration of analgesia and lower effective dose. In a non-tolerant patient, the duration of analgesia can be 15 h or longer when the narcotic is given as an epidural bolus. The dose of morphine is also much lower-usually 2040% of the systemic dose if given epidurally, and 10% of the epidural dose if subarachnoid. Segmental analgesia with fewer side effects is achieved by selectively activating spinal opiate receptors at the dorsal horn of the spinal cord. For 0 1990 Wiley-Liss, Lnc.
these reasons, subarachnoid or epidural narcotic administration is preferable for many cancer patients with moderate to severe pain.
PHYSIOLOGY Epidural or subarachnoid narcotics produce a selective nocioceptive block by binding to opiate receptors in the substantia gelatinosa region of the spinal cord. This binding specificity spares sympathetic and motor fibers allowing narcotics to provide analgesia without a concommitant sympathetic or motor block. This contrasts to local anesthetics which have their effect at the mixed spinal nerve and do produce sympathetic and motor block as well as sensory loss (see Fig. 1). Drug delivery via the subarachnoid or epidural route is technically more difficult and requires skilled personnel for its administration. The potential complications are rare, but serious. Infections leading to meningitis, arachnoiditis, or abscess formation have been reported. These infections are generally encountered only with long-term use and are usually seen in immunocompromised patients such as those with bone marrow suppression or Address reprint requests to Timothy R. Lubenow, M.D., Department of Anesthesiology, Rush-Presbyterian-St. Luke’s Medical Center, Jelke 739, 1753 West Congress Parkway, Chicago, IL 60612.
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a portable computer. The advantage of this system over an epidural placement with a percutaneous catheter is that the system is totally subcutaneous, which minimizes the risk of infection and may be somewhat more esthetically pleasing for the patient. The disadvantage is that the reservoir needs to be refilled every 2-3 weeks, depending upon the dose being used by the patient. A second disadvantage relates to the cost of this unit. This cost may be considered prohibitively high for a patient with a relatively limited life expectancy.
Epidural Catheter Insertion
Fig. 1. Sites of action of local anesthetics.
severe malnutrition. Tunneling the epidural catheter subcutaneously to exit near the anterior abdominal wall minimizes the risk of infection and allows for long-term use. In addition, the exit site is easily accessible to the patient for needed dressing changes. Long-term continuous infusion via portable or implanted pump is preferred over bolus administration for several reasons. Continuous infusion generally minimizes the dose required compared to intermittent bolus administration. It provides a steady cerebrospinal fluid concentration of narcotic. Continuous infusion also prevents catheter occlusion or obstruction, and eases the pain of injection in patients with spinal or epidural metastases. For the active patient with slowly progressive disease, use of a fully implantable continuous infusion pump system (InfusaidB or Metronic@)may be preferable [3].
INSERTION TECHNIQUES Subarachnoid Insertion The placement of a fully implanted pump connected to a subarachnoid catheter is generally done by a neurosurgeon. The technique involves placing a small gauge catheter into the subarachnoid space through a small incision in the dorsal midline. Local anesthesia is supplemented by monitored anesthesia care. Once the catheter is advanced into the subarachnoid space and cerebrospinal fluid is aspirated, the other end of the catheter is tunneled around to the anterior abdominal wall where a small pocket is made for implantation of the pump infusion reservoir. The catheter is then connected to the pump, which is inserted into the pocket. The skin incisions are closed. The pump can then be filled percutaneously. It can also be programmed to adjust the rate of infusion via
The epidural route of administration involves use of two pieces: a) an epidural catheter segment and b) a white silicone catheter equipped with a subcutaneous Dacron cuff and external Luer-Lok connector. These two segments are spliced together with a short metal connector. The epidural segment is shorter and is usually attached to the metal connector at the proximal end near the spinous process. This catheter comes as a prepackaged unit (DuPen Long-Term Epidural Catheter, C.R. Bard, Inc., Cranston, RI) [4].Epidural catheter insertion is usually done by an anesthesiologist. The patient is placed in the lateral decubitus position, although insertion may be done with the patient in the prone position. The patient is prepared with Betadine and draped in a sterile fashion including the lower lumbar spine, flank, and abdomen up to the midline. A small incision is made in the dorsal midline under local anesthesia. A 17 gauge Touhy epidural needle is inserted; the epidural space is identified with the usual loss of resistance technique. Once the needle tip is positioned in the epidural space, radiocontrast medium is instilled to confirm placement. Following needle placement, an 18 gauge catheter is threaded into the epidural space. The opposite end is then connected to a white silicone catheter. The silicone catheter exits the flank with the use of a tunneling instrument. This silicone tubing is then connected to a portable infusion pump which can be programmed by the physician for continuous infusion.
INFUSION DEVICES The clinician can chose from many available models of infusion devices. The most effective utilization of epidural narcotic infusions for the ambulatory patient is achieved with a portable pump; however, not all small portable pumps have the sophisticated timing or programming device to deliver a bolus, followed by a preset lock-out time to prevent overdosing by the patient. Important features in addition to portability and programming capability are the ability to deliver a continuous infusion plus intermittent self-dosing and the ease of use of the device by the patient. An excellent review of the currently available patient-controlled analgesia (PCA)
Intraspinal Narcotics for Cancer Pain
pumps has been presented by Barkas and Duafala [5]. The electronically operated PCA devices do not vary greatly in cost (average $4,000). We have had experience with two models. One is a small (11 oz.) battery-powered (9 V) portable device recently introduced by Bard Medical Systems Division (Murray Hills, NJ). It is fully computerized (Fig. 2). This device can be programmed either for an intermittent bolus, a continuous infusion, or a continuous infusion with intermittent bolus. It has ample storage capacity (100 or 250 ml) and disposable plastic containers, has fail-safe features, and the drug compartment is tamperproof. Special microbore infusion tubing is available for epidural or subarachnoid narcotic administration. The second model, the Pharmacia CADD-PCA@ (Pharmacia Deltec Inc., St. Paul, MN) is a small, light (15 oz) portable, programmable device, which may allow increased patient mobility because of its compact size (Fig. 3). It is battery-operated (9 V), can be obtained with a 50 or 100 ml reservoir, or a remote reservoir adapter for connection to a bag of intravenous fluid. Once programmed, the pump delivers incremental doses of analgesic drugs on demand with a lock-out interval from 5 to 999 min. The pump can also continuously infuse drugs at a rate of 0-20 ml/h.
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Fig. 3. The Pharmacia CADD-PCA@,portable, programmable, battery-operated device for ambulatory use.
make them ideal for use as a continuous epidural infusion. It may be preferable to use lipophilic narcotics such as fentanyl rather than the more hydrophilic narcotics such as morphine because of a decreased incidence of side Drug Choices effects [9]. Since fentanyl is extremely lipophilic (ocThe therapeutic differences between narcotics relate to tanol partition coefficient 813), it partitions itself more their durations of action following a single bolus and into the lipid spinal cord and less in the aqueous ceretheir propensity to produce side effects. Generally, pain brospinal fluid. Morphine, a hydrophilic agent (octanol relief is longest with morphine, intermediate with me- partition coefficient 1.4) will partition itself more within peridine or methadone, and shortest with fentanyl and the cerebrospinal fluid and relatively less in the cord [6]. sufentanil [6,7]. Once within the cerebrospinal fluid, it ascends rostrally The relatively long duration of action of morphine to the brainstem causing the side effects of pruritus, nauallows it to be utilized effectively as an intermittent bolus sea, and respiratory depression. given every 12 h. Morphine can also be used as a continuous epidural infusion and has been associated with Initiation fewer side effects when administered in this fashion [8]. Physicians should place the subarachnoid or epidural The shorter duration of action of fentanyl and sufentanil device while the patient is in the hospital in order to begin the infusion under close observation. The dose should be titrated for optimal analgesia. The use of an infusion pump with intermittent bolus capabilities has the advantage of allowing the patient to give additional medication for the periods when pain tends to be greater. Once the desired infusion rate has been achieved, the patient should be observed for another 24 h prior to discharge. During this period, the nurse who will supervise the patient after discharge should visit the patient and familiarize herself with the infusion system.
Fig. 2. The portable, computerized Bard device for patientcontrolled analgesia.
NURSES’ RESPONSIBILITIES Nurses should be familiar with the concept of intraspinal narcotic analgesia and should educate the patient
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about the delivery system. Nurses should assess the patient’s response to the intraspinal infusion, particularly noting if a patient requires an amount of narcotic greater than that prescribed initially. If pain relief is inadequate, the nurse should contact the physician for directions on narcotic dose titration. In addition, nurses should closely observe the patient for the side effects associated with narcotic administration and be ready to intervene if necessary. Respiratory depression and the development of tolerance are the two most significant side effects. Other side effects of narcotics which may be seen are pruritus, nausea, and sedation. Nurses must ensure that the infusion device is functioning properly. They must be thoroughly familiar with it so any malfunction can be promptly recognized.
SPECIAL CONSIDERATIONS The development of drug tolerance is a problem in achieving adequate analgesia, especially in patients who are in long-term therapy. Patients must be evaluated on an individual basis and should have their dosage adjusted as needed. One method of overcoming tolerance is to institute intermittent or continuous infusion of local anesthetics for several days, thereby allowing the opiate receptors to regain sensitivity to their ligands. Another method is the infusion of a combination of narcotic with dilute concentrations of local anesthetics.
THE RUSH EXPERIENCE Intrathecal catheters with implanted infusion reservoirs have been placed in 55 patients over the past 7 years. The average life span after implantation was 7.4 months with a range of 1 month to 6Y2 years. The usual daily dose of intrathecal morphine was 10-20 mg. The daily dose ranges from 0.2 mg to 100 mg/day. None of these patients suffered infectious complications related to the placement of the system. Nineteen patients have had percutaneous epidural
catheters placed during the past 4 years. These patients usually had a shorter life span. The longest survival was 4 months after placement. The usual effective dose was 2-4 mg per hour of morphine. If this failed to give good relief, fentanyl was often utilized in combination with bupivacaine 0.1%. In severe cases higher concentrations of bupivacaine ( 0 . 2 4 5 % ) were used, but only in bedridden patients.
SUMMARY Adequate pain relief is an integral part of the overall therapy of patients with cancer pain. Methods for pain amelioration or control are necessary if quality of life is to be improved in the large segment of patients who are not cured of their cancer. The use of intraspinal narcotics is one tool in this armamentarium.
REFERENCES 1. Foley K: Treatment of pain in the patient with cancer. Cancer J Clinicians 36(4): 194-215, 1986. 2. Foley K: Cancer pain syndromes. J Pain Symptom Management 2(2):S13, 1987. 3. Penn RD, Paice JA, Gottschalk W, Ivankovich AD: Cancer pain relief using chronic morphine infusions: Early experience with a programmable implanted drug pump. J Neurosurg 61:302-306, 1984. 4. DuPen SL, Peterson DG, Bogosian AC, Ramsey DH, et al: A new permanent exteriorized epidural catheter for narcotic self-administration to control cancer pain. Cancer 59:98&993, 1987. 5 . Barkas G, Duafala ME: Advances in cancer pain management: A review of patient-controlled analgesia. J Pain Symptom Management 3:150-160, 1988. 6. Cousins MJ, Mather LE: Intrathecal and epidural administration of opioids. Anesthesiology 61:27&310, 1984. 7. Rose11 PMJ, Van den Brock W, Boer FC, F’rakash 0: Epidural sufentanil for intra- and postoperative analgesia in thoracic surgery: A comparative study with intravenous sufentanil. ACTA Anaesth S c a d 32:192-98, 1988. 8. El-Baz N , Faber LP, Jensik RJ: Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: A new technique. Anesth Analg 63:757-764, 1984. 9. Fischer R, Lubenow TR, Liceaga A, et al: Comparison of continuous epidural infusion of fentanyl-bupivacaine and morphinebupivacaine in management of postoperative pain. Anesth Analg 67:559-63, 1988.
lntraspinal Narcotics for Treatment of Cancer Pain TIMOTHY R. LUBENOW, MD, AND ANTHONY D. IVANKOVICH, MD From the Department of Anesthesiology, Rush-Presbyterian-St.Luke‘s Medical Center, Chicago, Illinois
Inadequate pain relief remains a problem for many patients with cancer. Narcotic administration by the epidural or subarachnoid route is a relatively recent innovation and is indicated when pain is poorly controlled with high doses of systemic narcotics, or when patients experience limiting narcotic side effects. When given by the epidural or intrathecal route, narcotics have a longer duration of action and a lower dose is effective. These techniques involve personnel trained in catheter insertion and maintenance. Epidural and intrathecal administration of narcotics is an alternative when oral narcotics are ineffective. In this report the term “intraspinal” refers to epidural and/or subarachnoid placement of catheters and drugs.
KEYWORDS:epidural narcotics, intrathecal narcotics, subarachnoid administration INTRODUCTION For physicians treating cancer patients, control of pain poses a great challenge. Sixty to 90% of patients with far advanced or terminal cancer suffer from moderate to severe pain. As many as 25% of cancer patients throughout the world die without relief from severe pain [ 1,2]. The discovery of opiate receptors in the spinal cord has brought a new route of administration of drugs for relief of severe cancer pain to the forefront. Subarachnoid or epidural narcotics provide excellent analgesia; therefore, these techniques have been growing in popularity. Epidural or subarachnoid administration is indicated for patients with cancer pain who are poorly controlled with high doses of systemic narcotics, or who experience limiting narcotic side effects such as sedation, hallucinations, and/or dissociative reactions. The advantages of epidural and subarachnoid over systemic narcotic administration are a longer duration of analgesia and lower effective dose. In a non-tolerant patient, the duration of analgesia can be 15 h or longer when the narcotic is given as an epidural bolus. The dose of morphine is also much lower-usually 2040% of the systemic dose if given epidurally, and 10% of the epidural dose if subarachnoid. Segmental analgesia with fewer side effects is achieved by selectively activating spinal opiate receptors at the dorsal horn of the spinal cord. For 0 1990 Wiley-Liss, Lnc.
these reasons, subarachnoid or epidural narcotic administration is preferable for many cancer patients with moderate to severe pain.
PHYSIOLOGY Epidural or subarachnoid narcotics produce a selective nocioceptive block by binding to opiate receptors in the substantia gelatinosa region of the spinal cord. This binding specificity spares sympathetic and motor fibers allowing narcotics to provide analgesia without a concommitant sympathetic or motor block. This contrasts to local anesthetics which have their effect at the mixed spinal nerve and do produce sympathetic and motor block as well as sensory loss (see Fig. 1). Drug delivery via the subarachnoid or epidural route is technically more difficult and requires skilled personnel for its administration. The potential complications are rare, but serious. Infections leading to meningitis, arachnoiditis, or abscess formation have been reported. These infections are generally encountered only with long-term use and are usually seen in immunocompromised patients such as those with bone marrow suppression or Address reprint requests to Timothy R. Lubenow, M.D., Department of Anesthesiology, Rush-Presbyterian-St. Luke’s Medical Center, Jelke 739, 1753 West Congress Parkway, Chicago, IL 60612.
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a portable computer. The advantage of this system over an epidural placement with a percutaneous catheter is that the system is totally subcutaneous, which minimizes the risk of infection and may be somewhat more esthetically pleasing for the patient. The disadvantage is that the reservoir needs to be refilled every 2-3 weeks, depending upon the dose being used by the patient. A second disadvantage relates to the cost of this unit. This cost may be considered prohibitively high for a patient with a relatively limited life expectancy.
Epidural Catheter Insertion
Fig. 1. Sites of action of local anesthetics.
severe malnutrition. Tunneling the epidural catheter subcutaneously to exit near the anterior abdominal wall minimizes the risk of infection and allows for long-term use. In addition, the exit site is easily accessible to the patient for needed dressing changes. Long-term continuous infusion via portable or implanted pump is preferred over bolus administration for several reasons. Continuous infusion generally minimizes the dose required compared to intermittent bolus administration. It provides a steady cerebrospinal fluid concentration of narcotic. Continuous infusion also prevents catheter occlusion or obstruction, and eases the pain of injection in patients with spinal or epidural metastases. For the active patient with slowly progressive disease, use of a fully implantable continuous infusion pump system (InfusaidB or Metronic@)may be preferable [3].
INSERTION TECHNIQUES Subarachnoid Insertion The placement of a fully implanted pump connected to a subarachnoid catheter is generally done by a neurosurgeon. The technique involves placing a small gauge catheter into the subarachnoid space through a small incision in the dorsal midline. Local anesthesia is supplemented by monitored anesthesia care. Once the catheter is advanced into the subarachnoid space and cerebrospinal fluid is aspirated, the other end of the catheter is tunneled around to the anterior abdominal wall where a small pocket is made for implantation of the pump infusion reservoir. The catheter is then connected to the pump, which is inserted into the pocket. The skin incisions are closed. The pump can then be filled percutaneously. It can also be programmed to adjust the rate of infusion via
The epidural route of administration involves use of two pieces: a) an epidural catheter segment and b) a white silicone catheter equipped with a subcutaneous Dacron cuff and external Luer-Lok connector. These two segments are spliced together with a short metal connector. The epidural segment is shorter and is usually attached to the metal connector at the proximal end near the spinous process. This catheter comes as a prepackaged unit (DuPen Long-Term Epidural Catheter, C.R. Bard, Inc., Cranston, RI) [4].Epidural catheter insertion is usually done by an anesthesiologist. The patient is placed in the lateral decubitus position, although insertion may be done with the patient in the prone position. The patient is prepared with Betadine and draped in a sterile fashion including the lower lumbar spine, flank, and abdomen up to the midline. A small incision is made in the dorsal midline under local anesthesia. A 17 gauge Touhy epidural needle is inserted; the epidural space is identified with the usual loss of resistance technique. Once the needle tip is positioned in the epidural space, radiocontrast medium is instilled to confirm placement. Following needle placement, an 18 gauge catheter is threaded into the epidural space. The opposite end is then connected to a white silicone catheter. The silicone catheter exits the flank with the use of a tunneling instrument. This silicone tubing is then connected to a portable infusion pump which can be programmed by the physician for continuous infusion.
INFUSION DEVICES The clinician can chose from many available models of infusion devices. The most effective utilization of epidural narcotic infusions for the ambulatory patient is achieved with a portable pump; however, not all small portable pumps have the sophisticated timing or programming device to deliver a bolus, followed by a preset lock-out time to prevent overdosing by the patient. Important features in addition to portability and programming capability are the ability to deliver a continuous infusion plus intermittent self-dosing and the ease of use of the device by the patient. An excellent review of the currently available patient-controlled analgesia (PCA)
Intraspinal Narcotics for Cancer Pain
pumps has been presented by Barkas and Duafala [5]. The electronically operated PCA devices do not vary greatly in cost (average $4,000). We have had experience with two models. One is a small (11 oz.) battery-powered (9 V) portable device recently introduced by Bard Medical Systems Division (Murray Hills, NJ). It is fully computerized (Fig. 2). This device can be programmed either for an intermittent bolus, a continuous infusion, or a continuous infusion with intermittent bolus. It has ample storage capacity (100 or 250 ml) and disposable plastic containers, has fail-safe features, and the drug compartment is tamperproof. Special microbore infusion tubing is available for epidural or subarachnoid narcotic administration. The second model, the Pharmacia CADD-PCA@ (Pharmacia Deltec Inc., St. Paul, MN) is a small, light (15 oz) portable, programmable device, which may allow increased patient mobility because of its compact size (Fig. 3). It is battery-operated (9 V), can be obtained with a 50 or 100 ml reservoir, or a remote reservoir adapter for connection to a bag of intravenous fluid. Once programmed, the pump delivers incremental doses of analgesic drugs on demand with a lock-out interval from 5 to 999 min. The pump can also continuously infuse drugs at a rate of 0-20 ml/h.
175
Fig. 3. The Pharmacia CADD-PCA@,portable, programmable, battery-operated device for ambulatory use.
make them ideal for use as a continuous epidural infusion. It may be preferable to use lipophilic narcotics such as fentanyl rather than the more hydrophilic narcotics such as morphine because of a decreased incidence of side Drug Choices effects [9]. Since fentanyl is extremely lipophilic (ocThe therapeutic differences between narcotics relate to tanol partition coefficient 813), it partitions itself more their durations of action following a single bolus and into the lipid spinal cord and less in the aqueous ceretheir propensity to produce side effects. Generally, pain brospinal fluid. Morphine, a hydrophilic agent (octanol relief is longest with morphine, intermediate with me- partition coefficient 1.4) will partition itself more within peridine or methadone, and shortest with fentanyl and the cerebrospinal fluid and relatively less in the cord [6]. sufentanil [6,7]. Once within the cerebrospinal fluid, it ascends rostrally The relatively long duration of action of morphine to the brainstem causing the side effects of pruritus, nauallows it to be utilized effectively as an intermittent bolus sea, and respiratory depression. given every 12 h. Morphine can also be used as a continuous epidural infusion and has been associated with Initiation fewer side effects when administered in this fashion [8]. Physicians should place the subarachnoid or epidural The shorter duration of action of fentanyl and sufentanil device while the patient is in the hospital in order to begin the infusion under close observation. The dose should be titrated for optimal analgesia. The use of an infusion pump with intermittent bolus capabilities has the advantage of allowing the patient to give additional medication for the periods when pain tends to be greater. Once the desired infusion rate has been achieved, the patient should be observed for another 24 h prior to discharge. During this period, the nurse who will supervise the patient after discharge should visit the patient and familiarize herself with the infusion system.
Fig. 2. The portable, computerized Bard device for patientcontrolled analgesia.
NURSES’ RESPONSIBILITIES Nurses should be familiar with the concept of intraspinal narcotic analgesia and should educate the patient
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Lubenow and Ivankovich
about the delivery system. Nurses should assess the patient’s response to the intraspinal infusion, particularly noting if a patient requires an amount of narcotic greater than that prescribed initially. If pain relief is inadequate, the nurse should contact the physician for directions on narcotic dose titration. In addition, nurses should closely observe the patient for the side effects associated with narcotic administration and be ready to intervene if necessary. Respiratory depression and the development of tolerance are the two most significant side effects. Other side effects of narcotics which may be seen are pruritus, nausea, and sedation. Nurses must ensure that the infusion device is functioning properly. They must be thoroughly familiar with it so any malfunction can be promptly recognized.
SPECIAL CONSIDERATIONS The development of drug tolerance is a problem in achieving adequate analgesia, especially in patients who are in long-term therapy. Patients must be evaluated on an individual basis and should have their dosage adjusted as needed. One method of overcoming tolerance is to institute intermittent or continuous infusion of local anesthetics for several days, thereby allowing the opiate receptors to regain sensitivity to their ligands. Another method is the infusion of a combination of narcotic with dilute concentrations of local anesthetics.
THE RUSH EXPERIENCE Intrathecal catheters with implanted infusion reservoirs have been placed in 55 patients over the past 7 years. The average life span after implantation was 7.4 months with a range of 1 month to 6Y2 years. The usual daily dose of intrathecal morphine was 10-20 mg. The daily dose ranges from 0.2 mg to 100 mg/day. None of these patients suffered infectious complications related to the placement of the system. Nineteen patients have had percutaneous epidural
catheters placed during the past 4 years. These patients usually had a shorter life span. The longest survival was 4 months after placement. The usual effective dose was 2-4 mg per hour of morphine. If this failed to give good relief, fentanyl was often utilized in combination with bupivacaine 0.1%. In severe cases higher concentrations of bupivacaine ( 0 . 2 4 5 % ) were used, but only in bedridden patients.
SUMMARY Adequate pain relief is an integral part of the overall therapy of patients with cancer pain. Methods for pain amelioration or control are necessary if quality of life is to be improved in the large segment of patients who are not cured of their cancer. The use of intraspinal narcotics is one tool in this armamentarium.
REFERENCES 1. Foley K: Treatment of pain in the patient with cancer. Cancer J Clinicians 36(4): 194-215, 1986. 2. Foley K: Cancer pain syndromes. J Pain Symptom Management 2(2):S13, 1987. 3. Penn RD, Paice JA, Gottschalk W, Ivankovich AD: Cancer pain relief using chronic morphine infusions: Early experience with a programmable implanted drug pump. J Neurosurg 61:302-306, 1984. 4. DuPen SL, Peterson DG, Bogosian AC, Ramsey DH, et al: A new permanent exteriorized epidural catheter for narcotic self-administration to control cancer pain. Cancer 59:98&993, 1987. 5 . Barkas G, Duafala ME: Advances in cancer pain management: A review of patient-controlled analgesia. J Pain Symptom Management 3:150-160, 1988. 6. Cousins MJ, Mather LE: Intrathecal and epidural administration of opioids. Anesthesiology 61:27&310, 1984. 7. Rose11 PMJ, Van den Brock W, Boer FC, F’rakash 0: Epidural sufentanil for intra- and postoperative analgesia in thoracic surgery: A comparative study with intravenous sufentanil. ACTA Anaesth S c a d 32:192-98, 1988. 8. El-Baz N , Faber LP, Jensik RJ: Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: A new technique. Anesth Analg 63:757-764, 1984. 9. Fischer R, Lubenow TR, Liceaga A, et al: Comparison of continuous epidural infusion of fentanyl-bupivacaine and morphinebupivacaine in management of postoperative pain. Anesth Analg 67:559-63, 1988.
