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Regional anesthesia for an upper extremity amputation for palliative care in a patient with end-stage osteosarcoma complicated by a large anterior mediastinal mass.

Hakim M, Burrier C, Bhalla T, Raman VT, Martin DP, Dairo O, Mayerson JL, Tobias JD - J Pain Res (2015)

Bottom Line: Tumor progression during end-of-life care can lead to significant pain, which at times may be refractory to routine analgesic techniques.The anesthetic management was complicated by the presence of a large mediastinal mass, limited pulmonary reserve, and severe chronic pain with a high preoperative opioid requirement.The perioperative applications of regional anesthesia in palliative and home hospice care are discussed.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.

ABSTRACT
Tumor progression during end-of-life care can lead to significant pain, which at times may be refractory to routine analgesic techniques. Although regional anesthesia is commonly used for postoperative pain care, there is limited experience with its use during home hospice care. We present a 24-year-old male with end-stage metastatic osteosarcoma who required anesthetic care for a right-sided above-the-elbow amputation. The anesthetic management was complicated by the presence of a large mediastinal mass, limited pulmonary reserve, and severe chronic pain with a high preoperative opioid requirement. Intraoperative anesthesia and postoperative pain management were provided by regional anesthesia using an interscalene catheter. He was discharged home with the interscalene catheter in place with a continuous local anesthetic infusion that allowed weaning of his chronic opioid medications and the provision of effective pain control. The perioperative applications of regional anesthesia in palliative and home hospice care are discussed.

No MeSH data available.


Related in: MedlinePlus

Preoperative photograph showing tumor progression and involvement of the area of previous amputation.
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f1-jpr-8-641: Preoperative photograph showing tumor progression and involvement of the area of previous amputation.

Mentions: Institutional Review Board approval is not required at Nationwide Children’s Hospital (Columbus, OH, USA) for the presentation of single case report. The patient was a 24-year-old, 79 kg male who presented for a palliative right-sided, above-the-elbow amputation for recurrent osteosarcoma of the right arm with intractable pain. His medical history was significant for osteosarcoma of the right distal radius with metastatic disease to the lungs, status after two cycles of palliative chemotherapy that included methotrexate, doxorubicin, and cisplatin. He previously had undergone a right below-the-elbow amputation. At the time of presentation, he had electively discontinued his palliative chemotherapy. He presented with local progression of the tumor into the humerus and axilla as well as progression of the lung metastases with severe pain in the affected extremity. The right arm mass measured 15 cm ×14 cm ×18 cm (Figure 1). He was being followed by the palliative care service and requested surgical options for treatment of his pain. Computed tomography demonstrated an 8.1 cm ×6.8 cm ×6.4 cm anterior mediastinal mass at the level of the transverse aortic arch with severely narrowed left innominate vein with dilated collateral vessels and displaced left pulmonary artery (Figure 2). He also had a left inferior posterior pulmonary mass, multiple pulmonary nodules, and a left lower lobe infiltrate. Current home medications included self-prescribed high-dose vitamin C. The current pain medication schedule had escalated to include hydromorphone 4 mg orally (PO) every 3 hours as needed, methadone 10 mg PO every 6 hours, morphine 15 mg PO every 3 hours as needed, and gabapentin 300 mg PO four times per day. Although the patient was generally noncompliant with opioid medications and not taking them as prescribed, his daily oral morphine equivalents were equal to 568 mg. He had no known drug or environmental allergies.


Regional anesthesia for an upper extremity amputation for palliative care in a patient with end-stage osteosarcoma complicated by a large anterior mediastinal mass.

Hakim M, Burrier C, Bhalla T, Raman VT, Martin DP, Dairo O, Mayerson JL, Tobias JD - J Pain Res (2015)

Preoperative photograph showing tumor progression and involvement of the area of previous amputation.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4590571&req=5

f1-jpr-8-641: Preoperative photograph showing tumor progression and involvement of the area of previous amputation.
Mentions: Institutional Review Board approval is not required at Nationwide Children’s Hospital (Columbus, OH, USA) for the presentation of single case report. The patient was a 24-year-old, 79 kg male who presented for a palliative right-sided, above-the-elbow amputation for recurrent osteosarcoma of the right arm with intractable pain. His medical history was significant for osteosarcoma of the right distal radius with metastatic disease to the lungs, status after two cycles of palliative chemotherapy that included methotrexate, doxorubicin, and cisplatin. He previously had undergone a right below-the-elbow amputation. At the time of presentation, he had electively discontinued his palliative chemotherapy. He presented with local progression of the tumor into the humerus and axilla as well as progression of the lung metastases with severe pain in the affected extremity. The right arm mass measured 15 cm ×14 cm ×18 cm (Figure 1). He was being followed by the palliative care service and requested surgical options for treatment of his pain. Computed tomography demonstrated an 8.1 cm ×6.8 cm ×6.4 cm anterior mediastinal mass at the level of the transverse aortic arch with severely narrowed left innominate vein with dilated collateral vessels and displaced left pulmonary artery (Figure 2). He also had a left inferior posterior pulmonary mass, multiple pulmonary nodules, and a left lower lobe infiltrate. Current home medications included self-prescribed high-dose vitamin C. The current pain medication schedule had escalated to include hydromorphone 4 mg orally (PO) every 3 hours as needed, methadone 10 mg PO every 6 hours, morphine 15 mg PO every 3 hours as needed, and gabapentin 300 mg PO four times per day. Although the patient was generally noncompliant with opioid medications and not taking them as prescribed, his daily oral morphine equivalents were equal to 568 mg. He had no known drug or environmental allergies.

Bottom Line: Tumor progression during end-of-life care can lead to significant pain, which at times may be refractory to routine analgesic techniques.The anesthetic management was complicated by the presence of a large mediastinal mass, limited pulmonary reserve, and severe chronic pain with a high preoperative opioid requirement.The perioperative applications of regional anesthesia in palliative and home hospice care are discussed.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.

ABSTRACT
Tumor progression during end-of-life care can lead to significant pain, which at times may be refractory to routine analgesic techniques. Although regional anesthesia is commonly used for postoperative pain care, there is limited experience with its use during home hospice care. We present a 24-year-old male with end-stage metastatic osteosarcoma who required anesthetic care for a right-sided above-the-elbow amputation. The anesthetic management was complicated by the presence of a large mediastinal mass, limited pulmonary reserve, and severe chronic pain with a high preoperative opioid requirement. Intraoperative anesthesia and postoperative pain management were provided by regional anesthesia using an interscalene catheter. He was discharged home with the interscalene catheter in place with a continuous local anesthetic infusion that allowed weaning of his chronic opioid medications and the provision of effective pain control. The perioperative applications of regional anesthesia in palliative and home hospice care are discussed.

No MeSH data available.


Related in: MedlinePlus