Local Anesthetics for Breakthrough Pain in Patients Receiving Intrathecal Treatment for Cancer Pain Management

Abstract

To the Editor: Neuraxial administration of drugs is often used to optimize the treatment in patients no longer responsive to systemic analgesics (1). Despite optimal analgesia, patients may suffer from fluctuations in pain intensity (breakthrough pain) (2). This condition is challenging for physician, as no specific indications have been provided for patients receiving a continuous spinal drug combination. We report three cases of patients selected for intrathecal therapy, implanted with a port-system and an external pump, and presenting breakthrough episodes treated by the use of local anesthetics as needed. The first patient, a 57-year-old male, with colon cancer was admitted for abdominal pain due to extensive visceral involvement. The second patient was a 40-year-old female, admitted for unbearable pain due to pelvic relapse of colon cancer, presenting multiple metastases (spleen, pancreas, left colon, presacral area, left ischiorectal fossa, bladder, left ala ilii, abdominal wall, ureter, lung, and liver). She complained of abdominal-pelvic pain with irradiation to the left leg, with a mixed component, visceral, neuropathic, and somatic. The third patient, a 76-year-old male with lung cancer, was admitted for vertebral, chest wall, and shoulder pain, irradiated to the left arm, which increased in intensity on movement due to chest wall involvement. An intrathecal catheter was introduced at the level of corresponding segmental area and connected with a subcutaneous port placed in the anterior thoracic wall, after tunneling the catheter subcutaneously. The proper position of the catheter tip was checked by contrast medium injection. These patients received an intrathecal mixture containing morphine and levobupivacaine, in doses of 25–80 mg and 6–40 mg, respectively, with a mean infusion rate of levobupivacaine of 37 mg/day (about 1.5 mg/h), allowing an acceptable basal pain relief (<4 on a numerical scale of 0–10). Episodes of breakthrough pain, unresponsive to large doses of systemic opioids, were relieved by intrathecal boluses of about 1.25 mg (0.5 mL of levobupivacaine), by a three-way stopcock placed in the external system, close to the port. This means that the dose required to treat breakthrough events was approximately the hourly dose. No infection signs or important hemodynamic changes were observed, despite the repeated boluses. Of interest, the treatment was subsequently maintained at home by properly instructed relatives, without reporting complications for a survival time of 10, 45, 32 days, respectively. This is the first report on the use of local anesthetics as an intrathecal bolus for treating breakthrough pain in cancer patients receiving a spinal analgesic treatment. This treatment should be reserved to very selected population, providing the best methods to prevent the risk of infection due to the high rate of manipulations. Sebastiano Mercadante, MD Patrizia Ferrera, MD Patrizia Villari, MD Anesthesia and Intensive Care Unit; Pain Relief and Palliative Care Unit; La Maddalena Cancer Center; Palermo, Italy; [email protected] Edoardo Arcuri, MD Intensive Care and Pain Therapy Unit; National Cancer Institute Regina Elena; Rome, Italy