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Bupivacaine administered intrathecally versus rectally in the management of intractable rectal cancer pain in palliative care.

Zaporowska-Stachowiak I, Kowalski G, Luczak J, Kosicka K, Kotlinska-Lemieszek A, Sopata M, Główka F - Onco Targets Ther (2014)

Bottom Line: Intrathecal bupivacaine (0.5%, 2 mL) caused a drop in blood pressure; other side effects were absent in both cases.Total plasma bupivacaine concentrations following intrathecal and rectal bupivacaine application did not exceed 317.2 ng·mL(-1) and 235.7 ng·mL(-1), respectively.Bupivacaine in boluses administered intrathecally (0.25%, 2 mL) provided effective, safe analgesia in advanced cancer patients.

View Article: PubMed Central - PubMed

Affiliation: Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland ; Palliative Medicine In-patient Unit, University Hospital of Lord's Transfiguration, Poznan University of Medical Sciences, Poznan, Poland.

ABSTRACT

Background: Unacceptable adverse effects, contraindications to and/or ineffectiveness of World Health Organization step III "pain ladder" drugs causes needless suffering among a population of cancer patients. Successful management of severe cancer pain may require invasive treatment. However, a patient's refusal of an invasive procedure necessitates that clinicians consider alternative options.

Objective: Intrathecal bupivacaine delivery as a viable treatment of intractable pain is well documented. There are no data on rectal bupivacaine use in cancer patients or in the treatment of cancer tenesmoid pain. This study aims to demonstrate that bupivacaine administered rectally could be a step in between the current treatment options for intractable cancer pain (conventional/conservative analgesia or invasive procedures), and to evaluate the effect of the mode of administration (intrathecal versus rectal) on the bupivacaine plasma concentration.

Cases: We present two Caucasian, elderly inpatients admitted to hospice due to intractable rectal/tenesmoid pain. The first case is a female with vulvar cancer, and malignant infiltration of the rectum/vagina. Bupivacaine was used intrathecally (0.25-0.5%, 1-2 mL every 6 hours). The second case is a female with ovarian cancer and malignant rectal infiltration. Bupivacaine was adminstered rectally (0.05-0.1%, 100 mL every 4.5-11 hours).

Methods: Total bupivacaine plasma concentrations were determined using the high-performance liquid chromatography-ultraviolet method.

Results: Effective pain control was achieved with intrathecal bupivacaine (0.077-0.154 mg·kg(-1)) and bupivacaine in enema (1.820 mg·kg(-1)). Intrathecal bupivacaine (0.5%, 2 mL) caused a drop in blood pressure; other side effects were absent in both cases. Total plasma bupivacaine concentrations following intrathecal and rectal bupivacaine application did not exceed 317.2 ng·mL(-1) and 235.7 ng·mL(-1), respectively. Bupivacaine elimination was slower after rectal than after intrathecal administration (t½= 5.50 versus 2.02 hours, respectively).

Limitations: This study reports two cases only, and there could be inter-patient variation.

Conclusion: Bupivacaine in boluses administered intrathecally (0.25%, 2 mL) provided effective, safe analgesia in advanced cancer patients. Bupivacaine enema (100 mg·100 mL(-1)) was shown to be a valuable option for control of end-of-life tenesmoid cancer pain.

No MeSH data available.


Related in: MedlinePlus

Bupivacaine administered intrathecally in Case 1.Abbreviations: IV, intravenous; t0.5, elimination half-life; VRS, Verbal Rating Scale; MF, morphine sulphate; Mid, Midazolam; Pp, Propofol.
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f1-ott-7-1541: Bupivacaine administered intrathecally in Case 1.Abbreviations: IV, intravenous; t0.5, elimination half-life; VRS, Verbal Rating Scale; MF, morphine sulphate; Mid, Midazolam; Pp, Propofol.

Mentions: The first bupivacaine intrathecal bolus reduced pain significantly within 2–3 minutes (Figure 1), but caused a drop in BP at nearly the same time. The next boluses contained a half of the first Bupivacaine dose and relieved pain in rest and during nursing excellently. Meanwhile, it had less impact on BP, which remained in the range of 135/84 to 140/70 mmHg for the following 3 hours. Then it declined and remained around 104/60 mmHg (HR around 90 beats per minute) for the next days. SpO2 after the procedures ranged 87%–89%. The onset of maximal analgesia was observed 2–3 minutes after the boluses. The duration of analgesia was 6 hours. Total daily bupivacaine dose was 25 mg. The bupivacaine plasma concentrations ranged from 67.5 to 317.2 ng/mL. The elimination rate constant (Ke) for bupivacaine was 0.344 L/hour. The patient did not want to respond to requests, and no active movements of lower extremities were observed. No ECG changes or other signs of bupivacaine toxicity induced by the drug were detected.


Bupivacaine administered intrathecally versus rectally in the management of intractable rectal cancer pain in palliative care.

Zaporowska-Stachowiak I, Kowalski G, Luczak J, Kosicka K, Kotlinska-Lemieszek A, Sopata M, Główka F - Onco Targets Ther (2014)

Bupivacaine administered intrathecally in Case 1.Abbreviations: IV, intravenous; t0.5, elimination half-life; VRS, Verbal Rating Scale; MF, morphine sulphate; Mid, Midazolam; Pp, Propofol.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4199793&req=5

f1-ott-7-1541: Bupivacaine administered intrathecally in Case 1.Abbreviations: IV, intravenous; t0.5, elimination half-life; VRS, Verbal Rating Scale; MF, morphine sulphate; Mid, Midazolam; Pp, Propofol.
Mentions: The first bupivacaine intrathecal bolus reduced pain significantly within 2–3 minutes (Figure 1), but caused a drop in BP at nearly the same time. The next boluses contained a half of the first Bupivacaine dose and relieved pain in rest and during nursing excellently. Meanwhile, it had less impact on BP, which remained in the range of 135/84 to 140/70 mmHg for the following 3 hours. Then it declined and remained around 104/60 mmHg (HR around 90 beats per minute) for the next days. SpO2 after the procedures ranged 87%–89%. The onset of maximal analgesia was observed 2–3 minutes after the boluses. The duration of analgesia was 6 hours. Total daily bupivacaine dose was 25 mg. The bupivacaine plasma concentrations ranged from 67.5 to 317.2 ng/mL. The elimination rate constant (Ke) for bupivacaine was 0.344 L/hour. The patient did not want to respond to requests, and no active movements of lower extremities were observed. No ECG changes or other signs of bupivacaine toxicity induced by the drug were detected.

Bottom Line: Intrathecal bupivacaine (0.5%, 2 mL) caused a drop in blood pressure; other side effects were absent in both cases.Total plasma bupivacaine concentrations following intrathecal and rectal bupivacaine application did not exceed 317.2 ng·mL(-1) and 235.7 ng·mL(-1), respectively.Bupivacaine in boluses administered intrathecally (0.25%, 2 mL) provided effective, safe analgesia in advanced cancer patients.

View Article: PubMed Central - PubMed

Affiliation: Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland ; Palliative Medicine In-patient Unit, University Hospital of Lord's Transfiguration, Poznan University of Medical Sciences, Poznan, Poland.

ABSTRACT

Background: Unacceptable adverse effects, contraindications to and/or ineffectiveness of World Health Organization step III "pain ladder" drugs causes needless suffering among a population of cancer patients. Successful management of severe cancer pain may require invasive treatment. However, a patient's refusal of an invasive procedure necessitates that clinicians consider alternative options.

Objective: Intrathecal bupivacaine delivery as a viable treatment of intractable pain is well documented. There are no data on rectal bupivacaine use in cancer patients or in the treatment of cancer tenesmoid pain. This study aims to demonstrate that bupivacaine administered rectally could be a step in between the current treatment options for intractable cancer pain (conventional/conservative analgesia or invasive procedures), and to evaluate the effect of the mode of administration (intrathecal versus rectal) on the bupivacaine plasma concentration.

Cases: We present two Caucasian, elderly inpatients admitted to hospice due to intractable rectal/tenesmoid pain. The first case is a female with vulvar cancer, and malignant infiltration of the rectum/vagina. Bupivacaine was used intrathecally (0.25-0.5%, 1-2 mL every 6 hours). The second case is a female with ovarian cancer and malignant rectal infiltration. Bupivacaine was adminstered rectally (0.05-0.1%, 100 mL every 4.5-11 hours).

Methods: Total bupivacaine plasma concentrations were determined using the high-performance liquid chromatography-ultraviolet method.

Results: Effective pain control was achieved with intrathecal bupivacaine (0.077-0.154 mg·kg(-1)) and bupivacaine in enema (1.820 mg·kg(-1)). Intrathecal bupivacaine (0.5%, 2 mL) caused a drop in blood pressure; other side effects were absent in both cases. Total plasma bupivacaine concentrations following intrathecal and rectal bupivacaine application did not exceed 317.2 ng·mL(-1) and 235.7 ng·mL(-1), respectively. Bupivacaine elimination was slower after rectal than after intrathecal administration (t½= 5.50 versus 2.02 hours, respectively).

Limitations: This study reports two cases only, and there could be inter-patient variation.

Conclusion: Bupivacaine in boluses administered intrathecally (0.25%, 2 mL) provided effective, safe analgesia in advanced cancer patients. Bupivacaine enema (100 mg·100 mL(-1)) was shown to be a valuable option for control of end-of-life tenesmoid cancer pain.

No MeSH data available.


Related in: MedlinePlus