Advancing Anesthesiology as END OF LIFE specialists?

Anesth Analg 2005;100:183-188

The Evolving and Important Role of Anesthesiology in Palliative Care
Perry G. Fine, MD

Department of Anesthesiology, Pain Management Center, University of Utah, Salt Lake City, Utah

Address correspondence and reprint requests to Perry G. Fine, MD, Department of Anesthesiology, Pain Management Center, Ste. 200, 615 Arapeen Dr., University of Utah, Salt Lake City, UT 84109. Address e-mail to [email protected].

A small but clinically significant proportion of dying patients experience severe physically or psychologically distressing symptoms that are refractory to the usual first-line therapies. Anesthesiologists, currently poorly represented in the rapidly evolving specialties of hospice and palliative medicine, are uniquely qualified to contribute to the comprehensive care of patients who are in this category. Anesthesiologists' interpersonal capabilities in the management of patients and families under duress, their knowledge and comfort level with the application of potent analgesic and consciousness-altering pharmacology, and their titrating and monitoring skills would add a valuable dimension to palliative care teams. This article summarizes the state of the art and means by which anesthesiologists might contribute to improvements in the important end-of-life outcome of safe and comfortable dying.

IMPLICATIONS: Safe and comfortable dying at the end of a progressive, life-limiting illness are key outcome measures in end-of-life care and are high priorities voiced by patients and their families. Anesthesiologists have unique skills that could greatly improve these critically important outcomes.

FROM ASA syllabus

Palliative Care in Geriatric Anesthesia

Palliative medicine is a recent addition to the list of medical subspecialties. In late 1987, the Royal College of Physicians of London recognized palliative medicine as a specialty within general internal medicine.1 Palliative care arose out of the change from acute to chronic causes of death. Currently the emphasis of health care is on improving the quality of life. Palliative care has received increasingattention in the United States as the debate over euthanasia and AIDS have become political "hot button" issues.

It is now well established that a primary cause for a chronically ill patient to consider euthanasia involves the lack of adequate pain control, especially if the patient is already suffering from a terminal disease process. As the current generation ages, there will likely be an increase in the numbers of people dying from cancer. There is an anticipated 20 percent increase in men and a 12 percent increase in women dying from cancer between 1980 and the turn of the century. A study by Cartwright found that 84 percent of surviving relatives reported that cancer patients suffered pain in the last year of life.2

The World Health Organization (WHO) has also realized the efficacy of palliative care. In 1990, a WHO expert committee on cancer pain relief and palliative care suggested that 30-50 percent of cancer patients are experiencing pain or being treated for it. In an effort to advance the cause, the WHO provides this definition of palliative care:3

* Affirms life and regards dying as a normal process
* Neither hastens nor postpones death
* Provides relief from pain and other distressing symptoms
* Integrates the psychological and spiritual aspects of patient care
* Offers a support system to help the family cope during the patientâs illness and in their own bereavement.

In short, palliative medicine is the active total care of patients whose disease is not responsive to curative treatment. This requires a multidisciplinary approach to treat symptoms, control pain and address the psychological, social and spiritual needs of the patient. Palliative care can be provided with less expense and can provide more satisfaction to the patients and their families.4

The anesthesiologist, especially the anesthesiologist trained in pain management, should be a member of the multidisciplinary palliative care team. Given the fact that the primary complaint of terminal patients is pain, the anesthesiologist should be central in the palliative medicine model. There is no other medical/surgical specialty that can provide the medical and procedural expertise allowing a patient to remain functional until they die.

Cancer pain may be somatic or visceral due to tumor invasion. Terminal patients may also present with neuropathic, sympathetically mediated and centrally mediated pain either due to their end-stage disease or the treatment of the diseases. The anesthesiologist is uniquely trained to differentiate and treat these differing pain entities.

Providing medical management for pain to include non-narcotic analgesics, narcotics (with all their modes of administration), anticonvulsants, local anesthetics, steroids and sympathetic nervous system antagonists may not be the sole purview of anesthesiologists; members of other specialties may be well trained in all of these medical regimens. On the other hand, many medical specialists may not feel comfortable using narcotics in the doses sometimes required to ease the pain of the terminal patient.

After defining the pain syndromes of the palliative care patient, there are procedural skills the anesthesiologist possesses that aid in pain control, including epidural and/or intrathecal administration of narcotics via implantable pumps, chemical neurolysis of nerve roots and sympathetic ganglia, cryoanalgesia, radiofrequency ablation, TENS units and dorsal column stimulators. Many of these interventions provide long term, patient-controlled analgesia, thereby allowing the patient to continue to function and perform their activities of daily living.

There is little research that specifically addresses the utility of the anesthesiologist in palliative care. Future work in this area will be vital in expanding the role of the anesthesiologist as a perioperative physician.

Adding a short case report abstract! Epidural done in Germany for end of life management.

Anesth Analg 2003;97:1740-1742
© 2003 International Anesthesia Research Society

Epidural Analgesia at End of Life: Facing Empirical Contraindications
Hans Juha Exner, MD, Jürgen Peters, MD, and Matthias Eikermann, MD

In a patient with unbearable cancer pain at the end of life, long-lasting analgesia without impairment of consciousness could only be achieved with an epidural infusion of local anesthetics combined with opioids and clonidine. Despite leptomeningeal infection during prolonged treatment, epidural analgesia at the lumbar level provided analgesia using very large doses of local anesthetics combined with clonidine and morphine. Thus, terminal sedation was avoided, allowing the patient’s end-of-life planning of an "aware" death surrounded by her family. It may be useful to reconsider institutional pain management standards when unbearable pain occurs in patients with limited life expectancy.

IMPLICATIONS: We report a patient with severe visceral and neurogenic pain from metastatic carcinoma of the colon resistant to multimodal oral analgesic therapy. Although there were empirical contraindications, epidural analgesia was successful, allowing the patient’s end-of-life planning of an "aware" death surrounded by the family.

Progress and Needs in Pediatric Palliative Care Pain Management
Sophie M. Colleau, PhD, and Arthur G. Lipman, PharmD

Pain management is essential for good palliative care, and palliative care is one of the most rapidly growing fields for pain clinicians worldwide. Pain treatment is a priority in palliative care because it often is not possible to address psychosocial, spiritual, and other physical problems until pain is properly controlled.

For a variety of cultural, regulatory, and scientific reasons, progress in pediatric pain management has come about relatively late. The science and practice of pediatric pain management have grown in recent years, however, and we now have a body of knowledge the clinical pain community can—and must—use more effectively. This need is especially acute in palliative care because 80% of children with advanced cancer experience pain.

Cancer Pain Release, the publication of the World Health Organization (WHO) Pain and Palliative Care Communications Program, draws attention to pediatric pain in a special double issue (Volume 16, Nos. 2 & 3, 2003), "Achieving Pain Control in Pediatric Palliative Care." The issue begins with a stark telling of "the facts."

Recent evidence shows 25% of children with cancer die of their disease or its complications. When a child is dying, there is also evidence that

- Terminal symptoms and pain are not adequately relieved.
- There are not enough specialists trained in symptom control.
- Palliative care can improve the experience for the pediatric patient and parents, but many do not commonly have access to palliative care services.
- Palliative care specialists are not adequately trained in pediatrics.
- Parents want to give their children every available treatment to extend their lives.
- Parents want their children to be comfortable and pain-free.
- New models to deliver pediatric palliative care are needed, incorporating pain and symptom control in routine pediatric oncology.

This special Cancer Pain Release issue highlights a few examples of these new models, and will be useful to all who care for—or about—pediatric pain patients with advanced disease.

The body of knowledge on controlling pain in children safely and effectively is impressive, but too seldom translated into clinical practice. An interview with Patricia McGrath, PhD, director of the Chronic Pain Program at the Hospital for Sick Children, professor of anesthesia at the University of Toronto, and current APS treasurer, describes some of this underused knowledge. Dr. McGrath concluded her interview by saying, "In no particular order, increased education of health professionals, better information for families, cooperation of health professionals with parents and children, documentation of pain, establishment of explicit treatment protocols, and routine institutionalization of protocols—all these factors can improve pain control for children in the palliative care setting."

The issue proves wrong several important myths and misconceptions about pediatric pain control; truths are presented to replace false beliefs. Examples of such truths are that infants can feel pain; opioids should not be reserved only as a last resort; health professionals often can effectively assess children's pain; and simple nondrug therapies can be effective in pediatric pain control.

Brief descriptions of the use of NSAIDs, opioids, and local anesthetics in children are provided with citations of key references on these topics.

Some clinical "pearls" include:

Children metabolize drugs faster than adults because their liver mass is larger per kilogram of body weight.

Because drugs clear more rapidly in children than in adults, more frequent drug dosing is required. For example, a sustained-release morphine dosage form that is appropriate for twice-daily dosing in adults may require three-times-daily dosing in children.

Common pediatric drug dosing errors include milligram-microgram conversions, decimal point errors, confusion between daily dose and fractional dose, and dilution errors.

The Pediatric Pain Profile is described as a tool for understanding pain in children who cannot speak. Online resources on pediatric pain, a course for pediatric oncology nurses, a manual for patient/family education, and U.S. and U.K. guidelines on pediatric palliative care provision are described. This Cancer Pain Release issue includes many useful and timely resources, including tools to improve clinical competency in pediatric pain management, resources to develop pediatric palliative care services, new books and journals about pain in children with cancer, and recent evidence about pain measurement, the relief of surgical pain, and palliative care for newborns.

Use of intensive care at the end of life in the United States: An epidemiologic study.

FEATURE ARTICLES
Critical Care Medicine. 32(3):638-643, March 2004.
Angus, Derek C. MB, ChB, MPH, FCCM; Barnato, Amber E. MD, MPH, MS; Linde-Zwirble, Walter T.; Weissfeld, Lisa A. PhD; Watson, R. Scott MD, MPH; Rickert, Tim BA; Rubenfeld, Gordon D. MD, MSc; on behalf of the Robert Wood Johnson Foundation ICU End-of-Life Peer Group

Abstract:
Objective: Despite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is unknown. We sought to describe the use of ICU care at the end of life in the United States using hospital discharge data from 1999 for six states and the National Death Index.

Design: Retrospective analysis of administrative data to calculate age-specific rates of hospitalization with and without ICU use at the end of life, to generate national estimates of end-of-life hospital and ICU use, and to characterize age-specific case mix of ICU decedents.

Setting: All nonfederal hospitals in the states of Florida, Massachusetts, New Jersey, New York, Virginia, and Washington.

Patients: All inpatients in nonfederal hospitals in the six states in 1999.

Intervention: None.

Measurements and Main Results: We found that there were 552,157 deaths in the six states in 1999, of which 38.3% occurred in hospital and 22.4% occurred after ICU admission. Using these data to project nationwide estimates, 540,000 people die after ICU admission each year. The age-specific rate of ICU use at the end of life was highest for infants (43%), ranged from 18% to 26% among older children and adults, and fell to 14% for those >85 yrs. Average length of stay and costs were 12.9 days and $24,541 for terminal ICU hospitalizations and 8.9 days and $8,548 for non-ICU terminal hospitalizations.

Conclusions: One in five Americans die using ICU services. The doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for dying patients in other settings.


(C) 2004 Lippincott Williams & Wilkins, Inc.

dhb said:

that is a shocking statistic! how much truth is there in this projection?

Click to expand...

yeap. i agree. have to use EBM to analyze the data.

Perry G. Fine, MD

Background and indications

This article will discuss the use of ketamine in subanesthetic doses to treat pain that is refractory to conventional pharmacological modalities. Fortunately, adherence to validated pain management guidelines can reliably provide good to excellent pain control in most cases. Nevertheless, there remains a small percentage of patients with far advanced disease who experience severe pain despite rapid upward titration of opioid analgesics, anti-inflammatories, or other pain modulating drugs (e.g., tricyclic antidepressants or anticonvulsants for neuropathic pain).2 Or, pain relief may only be realized at the cost of drug-related adverse effects that are intolerable. Patients with far-advanced cancer can experience terminal "crescendo" pain as they near death, a time when the provision of specialized interventional techniques is not desirable. Even when specialized techniques are plausible and offered in the home setting (e.g., epidural or intrathecal catheter placement for delivery of local anesthetics, opioids, or clonidine) without having to transport or transfer the patient, families often express a desire (as do patients, when able to communicate) to avoid any procedure perceived to be "invasive" during this terminal phase of disease as long as there is another way to alleviate symptoms. This might equally apply to palliative radiation therapy and other potentially highly effective interventional pain-relieving procedures, such as neurolytic celiac plexus block, where "opportunity costs" exceed perceived benefits. These circumstances have led to the use of low-dose ketamine in palliative care settings where opioid-refractory pain or opioid-mediated adverse effects prevent satisfactory pain relief.

Case example

A 58-year-old man with a pancoast tumor was admitted to hospice when he was no longer viewed as a candidate for active antitumor therapy. He had recently undergone radiation therapy to no avail, in an effort to reduce brachial plexopathy symptoms, including escalating pain. He was cachectic, bed-bound, and it was anticipated that he would die within days to weeks at most. His chest and upper extremity pain were rated as "9-10" on a 10-point scale, only made barely tolerable with rapidly escalating doses of hydromorphone and gabapentin. Over the days preceding hospice admission, his family stated that he was becoming disoriented and increasingly agitated. During initial hospice evaluation it was noted that he was exhibiting intermittent myoclonic jerks. He was restless and unable to be positioned for personal cares without exhibiting behaviors suggestive of pain and distress. He had a written advance directive stating that he did not want any invasive procedures or lifesustaining interventions when his cancer was determined to be "incurable," except for whatever was necessary to assure pain relief and comfort. A subcutaneous infusion device was placed and he was given a bolus of 7.5 mg ketamine (approximately 0.1 mg/kg) and his opioid and gabapentin doses were decreased by 50 percent. He appeared to be much more comfortable over the next 30-45 minutes, with the ability to be bathed and turned. Acontinuous infusion of ketamine was begun via the subcutaneous route at a rate of 15 mg/hr after a rebolus dose of 7.5 mg. Over the subsequent 24 hours, he became more alert, less restless, myoclonic jerks discontinued, and he appeared calm, able to converse with his family and other caregivers intermittently. He only desired small sips of water and ice chips, and he died several days later.

In summary, ketamine can be a highly effective adjunct for the control of pain that is otherwise refractory to conventional pharmacological approaches. Risks are low, efficacy is high, and the application of this intervention is relatively inexpensive, rapidly learned, and yields gratifying results.

Link to full article: http://www.aahpm.org/pdf/spring03.pdf

Controlled Sedation for Refractory Symptoms in Dying Patients.

Mercadante S, Intravaia G, Villari P, Ferrera P, David F, Casuccio A.

J Pain Symptom Manage. 2008 Nov 26.

Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit (S.M., G.I., P.V., P.F., F.D.), La Maddalena Cancer Center; Department of Anesthesiology, Intensive Care and Emergency and Department of Palliative Medicine (S.M.) and Department of Clinical Neuroscience (A.C.), University of Palermo, Palermo, Italy.

Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. A prospective cohort study was performed on a consecutive sample of dying patients admitted to an acute pain relief and palliative care unit within a cancer center. Indications for sedation, opioid and midazolam doses, level of delirium and sedation, nutrition, hydration, rattle, inability to cough and swallow, pharyngeal aspiration, duration of sedation and survival, and use of anticholinergics or other drugs were recorded. Family members were interviewed. Forty-two of 77 dying patients were sedated, and had a longer survival than those who were not sedated (P=0.003). Prevalent indications for sedation were dyspnea and/or delirium. Twelve patients began with an intermediate sedation, and 38 patients started with definitive sedation. The median sedation duration was 22 hours. Opioid doses did not change during sedation. Agitated delirium significantly decreased with increasing doses of midazolam, whereas the capacity to communicate concomitantly decreased. Interviewed relatives were actively involved in the process of end-of-life care, and the decision to sedate, and the efficacy of sedation, were considered appropriate by almost all relatives. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.

Agitated delirium significantly decreased with increasing doses of midazolam, whereas the capacity to communicate concomitantly decreased.

Is there a way to conserve the capacity to communicate? Novel regional and pain techniques? Any input or thoughts?

Intrathecal Ziconotide Combination Therapy for the Management of Refractory Cancer Pain in Patients at the End of Life: A Case Series
Stearns L MD 1, Wallace M MD 2
The Center for Pain and Supportive Care Scottsdale AZ 1,
UCSD Medical Center La Jolla CA 2

Introduction
Cancer-related pain is often progressive and can remain intractable with conventional treatment. To address this issue, a panel of experts convened in 2003 and developed recommendations for the use of intrathecal (IT) drugs for cancer pain (1). More aggressive treatment with IT drugs (eg, morphine, hydromorphone, bupivacaine) was recommended for patients at the end of life (life expectancy ≤1 year) than for patients with longer life expectancies. Because ziconotide was under review by the US Food and Drug Administration at the time of the panel meeting, it was not included in the algorithm. However, IT ziconotide was approved for monotherapy use in the management of severe chronic pain in 2004. Although ziconotide monotherapy has been shown to be effective in patients with cancer (2), ziconotide combination therapy has not been investigated in cancer patients at the end of life. Three cases are presented to demonstrate the use of combination IT ziconotide therapy in this population.

Case Reports
Patient 1 was a 70-year-old woman with squamous cell carcinoma and severe abdominal pain secondary to retroperitoneal metastasis. Intercostal nerve blocks, systemic opioids, and IT fentanyl (100-360 mcg/d) alone and in combination with IT bupivacaine (up to 9.6 mg/d) provided insufficient analgesia. Ziconotide (2.4 mcg/d) was added to IT fentanyl and bupivacaine, resulting in a 60% reduction in pain intensity until her death from cardiopulmonary arrest due to cancer progression. No adverse events (AEs) were reported. Patient 2 was a 74 year-old man with severe chest wall pain secondary to metastatic mesothelioma. Systemic analgesics did not adequately control his pain, and IT hydromorphone (0.5 mg/d) therapy was initiated. The patient experienced nausea, which resolved after his treatment was changed to IT fentanyl (100 mcg/d). Intrathecal fentanyl failed to provide lasting analgesia, and ziconotide (2.4 mcg/d) was added. The combination of ziconotide (up to 7.2 mcg/d) and fentanyl (up to 300 mcg/d) resulted in a 50% reduction in pain intensity, without AEs, until the patient's death from cardiopulmonary arrest due to cancer progression. Patient 3 is a 30-year-old man with leiomyosarcoma and severe lumbosacral pain secondary to metastasis to the spine. An IT trial was performed after systemic analgesics failed to provide adequate relief. Intrathecal fentanyl (100 mcg/d) and ziconotide (2.4 mcg/d) delivered via an external pump produced marked analgesia within 24 hours, and a permanent pump was implanted 1 week later. Continuous IT infusion with fentanyl (375 mcg/d), ziconotide (7.2 mcg/d), and bupivacaine (4.6 mg/d) has resulted in a 50% reduction in pain intensity, without AEs, since pump implantation.

Discussion
Cancer patients at the end of life may require more complex polyanalgesia than do patients with longer life expectancies (1). In this case series, combination IT regimens that included ziconotide were tolerated and were associated with substantial reductions in pain. Intrathecal ziconotide combination therapy can be a viable treatment option for patients with refractory cancer pain at the end of life.

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Long-term Continuous Cervical Paravertebral Block for Treatment of Neuropathic Pain due to End Stage Pancoast Tumor
Donnelly M1, Elliott E2, Radson E3, Cumpstone T4, Boezaart A5
University of Florida1, University of Florida2, University of Florida3, University of Florida4, University of Florida5

Background: The continuous cervical paravertebral block (CCPVB) has been used to provide intra- and postoperative analgesia to the arm and shoulder by blocking the roots of the brachial plexus (1). Nerve catheters have been used to provide extended pain relief to patients suffering from metastatic cancer (2). This case report illustrates the use of a CCPVB to provide analgesia to a patient with a supraclavicular tumor infiltrating the brachial plexus during her last month of life.

Case Report: The patient was a 53-year-old female with metastatic adenocarcinoma of the lung who suffered from poorly controlled neuropathic pain in her shoulder and arm related to a lesion infiltrating the brachial plexus in the right supraclavicular region. Her pain had been treated with pregabalin, duloxetine HCL, and high-dose opioids with little pain relief and unacceptable somnolence. The patient also suffered from pain in her face related to swelling caused by extensive right upper extremity deep venous thrombosis. The primary adenocarcinoma was in the left lung for which a pneumonectomy had been done previously. She was ineligible for further treatment of her cancer, and her opioid requirements were increasing. Extensive discussions were held with the family and patient about the risks and benefits of placing a CCPVB in the setting of the patient's previous pneumonectomy on the contralateral side, and therapeutic anticoagulation. A decision was made to proceed with the nerve block and to withhold heparin 2 hours prior to the block. A CCPVB was placed using the loss of resistance technique. The CCPVB was placed this way because the patient could not be sedated for the procedure because of respiratory insufficiency, nerve stimulation could cause severe pain, and the patient could not hold still to enable the use of ultrasound. A bolus of 20 mL of 0.25% ropivacaine was injected slowly; assessing ventilatory function after each 5 mL increment. The patient's respiratory status remained stable, and an infusion of 3mL/hr with no bolus function was initiated. This was increased to 7ml/hr with 7ml patient-controlled boluses every 30 minutes. The patient achieved satisfactory pain relief in her arm, but still required minimal narcotics for her facial and chest pain. She was discharged from the hospital with the CCPVB in situ and followed daily by Hospice and weekly by the Acute Pain Team. The catheter was replaced 2 weeks later due to catheter disconnection, and was left in for a total of 40 days. The catheter was removed due to subcutaneous tumor infiltration and infection at the catheter site. The patient died shortly thereafter.

Conclusion: Long-term CCPVB placed with the loss of resistance to air technique provided an excellent alternative to opioids for this patient with terminal Pancoast tumor and severe neuropathic pain in an ambulatory Hospice setting.

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from 2007

The Anterior Ultrasound-Guided Superior Hypogastric Plexus Neurolysis in Pelvic Cancer Pain
Mishra S1, Mishra D2, Gupta D3, Bhatnagar S4, Thulkar S5
IRCH, All India Institute of Medical Sciences1, IRCH, AIIMS2, IRCH, AIIMS3, IRCH, AIIMS4, IRCH, AIIMS5

Introduction:
The hypogastric plexus block is classically given by posterior approach; recent literature shows a few reports on CT-guided anterior approach for patients who have difficult access to hypogastric plexus by posterior approach. We are presenting a report of two cases that were successfully given ultrasound guided superior hypogastric plexus block.

Materials and Methods:
After setting local cutaneous and subcutaneous anaesthesia, a 15-cm-long 22 G-Chiba-needle was introduced into the hypogastrium. The point of the needle was--ultrasonographically guided--inserted into the retroperitoneal tissue between the two common iliac arteries just anterior to body of L5 lumbar vertebra. For the enforcement of a diagnostic block after careful aspiration, 10 ml of bupivacaine 0.5% was injected. For the enforcement of a neurolytic superior hypogastric plexus block 10 ml ethanol 50% in bupivacaine 0.25% was administered next day. The assistance of on-call radiologist with portable ultrasound equipment was utilized as difficult anatomic considerations were expected in hypogastrium from anterior approach.

Results:
The first case was a 57-year-old patient suffering from pelvic pain. She was a diagnosed case of carcinoma cervix and had undergone transabdominal hysterectomy with post-operative curative radiotherapy. She had residual local and pelvic disease. The second case was a 60-year-old female suffering from chronic pain of the pelvic and anal region. She was a diagnosed case of malignant melanoma anal canal with rectal, vaginal and levator ani involvement, and multiple liver and lung metastasis. No curative intervention was possible at this stage of disease. Both patients presented at the pain clinic for the first time with VAS 100 and were planned for neurolytic block as the first line management. The visual analog scale scores 24 hours after the block were 0 and 30 respectively. No visceral injury and other complications were reported in the patients. The patients were discharged after four days of admission in palliative care unit on non-steroidal anti inflammatory drugs as on required basis.

Discussion:
The anterior ultrasound-guided superior hypogastric plexus neurolysis technique is simple to perform, and it avoids the radiation exposure involved with computed tomography-guided approach.
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Bedside Ultrasound-Guided Celiac Plexus Block Can Be An Effective Pain Control Technique In Advanced Upper Abdominal Cancer Pain
Authors: Bhatnagar S1, Bhatnagar S2, Mishra S3, Gupta D4, Thulkar S5
IRCH, All India Institute of Medical Sciences1, IRCH, AIIMS2, IRCH, AIIMS3, IRCH, AIIMS4, IRCH, AIIMS5

Introduction:
The coeliac plexus block is an approved method for the relief of upper abdominal cancer pain. Classically the fluoroscopic guided posterior approach to the coeliac plexus block has been employed; little attention has been given to the alternative approaches. Other approaches that have been described are: ultrasound guided or CT-guided anterior approach and endoscopic ultrasound (EUS) guided approach. We describe here our experience and discretion to use ultrasound guided anterior approach.

Materials and Methods:
Our palliative care unit (PCU) caters to pain and symptom management in advanced cancer patients. Six patients admitted in PCU were given bedside celiac plexus block with the ultrasonic-guided anterior approach. The assistance of on-call radiologist with portable ultrasound equipment was utilized as these pain interventions were new for our PCU and difficult anatomic considerations were expected in patients of advanced carcinoma gall bladder. The ultrasound-guided anterior approach was preferred over CT-guided approach to avoid radiation exposure; and EUS guided approach was not available bedside and more uncomfortable to the terminally sick patient. EUS guided celiac block would have been more comfortable if employed at the time of diagnostic endoscopy. After setting local cutaneous and subcutaneous anaesthesia, a 15-cm-long 22 G-Chiba-needle was introduced into the epigastrium. The point of the needle was--ultrasonographically guided--inserted into the pre-aortic area near the discharge of the truncus coeliacus. For the enforcement of a diagnostic coeliac plexus block after careful aspiration, 10 ml of bupivacaine 0.25% was injected bilaterally. The spread of the solution was evaluated by ultrasound. For the enforcement of a neurolytic coeliac plexus block 10 ml ethanol 50% in bupivacaine 0.25% was administered bilaterally.

Results:
These six patients (four males and two females) with median age 40 years presented with severe pain on varying dosages of morphine. Four patients were diagnosed cases of carcinoma gall bladder and two patients were diagnosed case of carcinoma pancreas.On admission median pain score (VAS) was 90; range being 80-100. After neurolysis median VAS was 20; range being 0-30. Patients were discharged on decreased daily morphine requirements. No patient complained transitory diarrhea or orthostatic hypotension as an appropriate infusion of fluids before enforcement of the block was given to all the patients.

Discussion:
The bedside ultrasound guided anterior approach of the neurolytic coeliac plexus block is a fast, safe and cost-effective method, which can be employed as first line intervention in the palliative care units for good quality of life in the advanced stages of upper abdominal cancer.

Treatment Efficacy of Neural Blockade in Specialized Palliative Care Services in Japan: A Multicenter Audit Survey

Journal of Pain and Symptom Management
Volume 36, Issue 5, November 2008, Pages 461-467

Yo Tei MDa, Tatsuya Morita MDb, , , Toshimichi Nakaho MDc, Chizuko Takigawa MDd, Akiko Higuchi MDe, Akihiko Suga MDf, Tsukasa Tajima MDg, Masayuki Ikenaga MDh, Hitomi Higuchi MDi, Naohito Shimoyama MD, PhDj and Mayumi Fujimoto MDk

aSeirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu
bDepartment of Palliative and Supportive Care, Palliative Care Team and Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu
cDepartment of Palliative Medicine, Tohoku University Hospital, Miyagi
dDepartment of Palliative Medicine, Keiyukai Sapporo Hospital, Sapporo
eDivision of Anesthesiology and Palliative Care Unit, Toyama Prefectural Central Hospital, Toyama
fDepartment of Palliative Medicine, Shizuoka General Hospital, Shizuoka
gDepartment of Palliative Medicine, Miyagi Cancer Center, Miyagi
hHospice, Yodogawa Christian Hospital, Osaka
iPalliative Care Center, Showa University Hospital, Tokyo
jDepartment of Palliative Medicine, National Cancer Center Hospital, Tokyo
kDepartment of Anesthesiology, Hiroshima Prefectural Hospital, Hiroshima, Japan


Abstract
More than 85% of cancer-related pain is pharmacologically controllable, but some patients require interventional treatments. Although audit assessment of these interventions is of importance to clarify the types of patients likely to receive benefits, there have been no multicenter studies in Japan. The primary aims of this study were (1) to clarify the frequency of neural blockade in certified palliative care units and palliative care teams, (2) determine the efficacy of interventions, and (3) explore the predictors of successful or unsuccessful intervention. All patients who received neural blockade were consecutively recruited from seven certified palliative care units and five hospital palliative care teams in Japan. Primary responsible physicians reported pain intensity on the Support Team Assessment Schedule, performance status, communication levels on the Communication Capacity Scale, presence or absence of delirium, opioid consumption, and adverse effects before and one week after the procedure on the basis of retrospective chart review. A total of 162 interventions in 136 patients were obtained, comprising 3.8% of all patients receiving specialized palliative care services during the study period. Common procedures were epidural nerve block with local anesthetic and/or opioids (n = 84), neurolytic sympathetic plexus block (n = 24), and intrathecal nerve block with phenol (n = 21). There were significant differences in the frequency of neural blockade between palliative care units and palliative care teams (3.1% vs. 4.6%, respectively, P = 0.018), and between institutions whose leading physicians are anesthesiologists or have other specialties (4.8% vs. 1.5%, respectively, P < 0.001). Pain intensity measured on the Support Team Assessment Schedule (2.9 ± 0.8 to 1.7 ± 0.9, P < 0.001), performance status (2.7 ± 1.0 to 2.4 ± 1.0, P < 0.001), and opioid consumption (248 ± 348 to 186 ± 288 mg morphine equivalent/day, P < 0.001) were significantly improved after interventions. There was a tendency toward improvement in the communication level measured on the Communication Capacity Scale. There was no significant improvement in the prevalence of delirium, but six patients (32%) recovered from delirium after interventions. Adverse effects occurred in 9.2%, but all were predictable or transient. No fatal complications were reported. Pain intensity was significantly more improved in patients who survived 28 days or longer than others (P = 0.002). There were no significant correlations of changes in pain intensity with the performance status or previous opioid consumption. In conclusion, neural blockade was performed in 3.8% of cancer patients who received specialized palliative care services in Japan. Neural blockade could contribute to the improvement of pain intensity, performance service status, and opioid consumption without unpredictable serious side effects.