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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 rectally in Case 2.Abbreviations: IV, intravenous; t0.5, elimination half-life; VRS, Verbal Rating Scale; Sp, Spasmalgon; amp, ampule; Mid, Midazolam; MF, morphine sulphate.
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f2-ott-7-1541: Bupivacaine administered rectally in Case 2.Abbreviations: IV, intravenous; t0.5, elimination half-life; VRS, Verbal Rating Scale; Sp, Spasmalgon; amp, ampule; Mid, Midazolam; MF, morphine sulphate.

Mentions: The first bupivacaine dose reduced pain by 25% at rest and by 20% during movements within 12–15 minutes following dosage (maximal analgesia) (Figure 2). That is why the next bupivacaine dose was doubled. It improved pain control satisfactorily within 10 minutes (Figure 2). The duration of analgesia was 4.5 hours for the first enema and 11 hours for the second one. Bupivacaine plasma concentrations remained within the range of 46.5–235.7 ng/mL following both boluses. Total daily bupivacaine dose equaled 150 mg. Ke for bupivacaine was 0.125 L/hour. After the first and the second bupivacaine doses, no side effects, complications, or additional ECG changes were noticed. BP and HR remained within the range of 131/73 to 166/106 mmHg and 79–113 beats per minute, respectively. SpO2 ranged from 88%–92% after the procedures. The patient was able to sit and walk (no motor block/paralysis was observed).


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 rectally in Case 2.Abbreviations: IV, intravenous; t0.5, elimination half-life; VRS, Verbal Rating Scale; Sp, Spasmalgon; amp, ampule; Mid, Midazolam; MF, morphine sulphate.
© Copyright Policy
Related In: Results  -  Collection

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

f2-ott-7-1541: Bupivacaine administered rectally in Case 2.Abbreviations: IV, intravenous; t0.5, elimination half-life; VRS, Verbal Rating Scale; Sp, Spasmalgon; amp, ampule; Mid, Midazolam; MF, morphine sulphate.
Mentions: The first bupivacaine dose reduced pain by 25% at rest and by 20% during movements within 12–15 minutes following dosage (maximal analgesia) (Figure 2). That is why the next bupivacaine dose was doubled. It improved pain control satisfactorily within 10 minutes (Figure 2). The duration of analgesia was 4.5 hours for the first enema and 11 hours for the second one. Bupivacaine plasma concentrations remained within the range of 46.5–235.7 ng/mL following both boluses. Total daily bupivacaine dose equaled 150 mg. Ke for bupivacaine was 0.125 L/hour. After the first and the second bupivacaine doses, no side effects, complications, or additional ECG changes were noticed. BP and HR remained within the range of 131/73 to 166/106 mmHg and 79–113 beats per minute, respectively. SpO2 ranged from 88%–92% after the procedures. The patient was able to sit and walk (no motor block/paralysis was observed).

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