|Year : 2022 | Volume
| Issue : 1 | Page : 56-58
Continuous intrathecal infusion for refractory pain management in an oncologic patient in intensive care
Alessio Cittadini, Andrea Sica, Daniele Bellantonio, Emanuele Russo, Vanni Agnoletti
Department Major Trauma AUSL Romagna, Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Viale Ghirotti, Cesena, Italy
|Date of Submission||17-Jan-2022|
|Date of Decision||13-Feb-2022|
|Date of Acceptance||09-Mar-2022|
|Date of Web Publication||25-Apr-2022|
Dr. Andrea Sica
Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Viale Ghirotti, 286, Cesena
Source of Support: None, Conflict of Interest: None
Adult patients in the intensive care unit (ICU) often experience pain resulting from acute and chronic illness, as well as from standard positioning and maneuverers in the ICU. In recent years, the need for effective pain control in intensive care has emerged strongly. Partial or ineffective control is associated with multiple complications, such as agitation, delirium, inability to adapt to mechanical ventilation, increased length of stay, and post-traumatic stress disorder. Recent guidelines and studies suggest multimodal strategies for effective pain control, also re-evaluating the use of locoregional anesthesiological techniques. Oncological pain in critically ill patients represents a particular challenge for medical staff, being closely linked to the concept of palliative care. We present a case of refractory pain and agitation in an oncologic patient following an emergency exploratory laparotomy. Through the use of an intrathecal catheter, we provided effective analgesia to control pain and agitation, allowing weaning from mechanical ventilation before, and once the terminal state of the tumor was established, providing palliative care to ensure dignity and satisfaction of the patient.
Keywords: Anesthesia, pain, palliative care
|How to cite this article:|
Cittadini A, Sica A, Bellantonio D, Russo E, Agnoletti V. Continuous intrathecal infusion for refractory pain management in an oncologic patient in intensive care. Indian J Pain 2022;36:56-8
|How to cite this URL:|
Cittadini A, Sica A, Bellantonio D, Russo E, Agnoletti V. Continuous intrathecal infusion for refractory pain management in an oncologic patient in intensive care. Indian J Pain [serial online] 2022 [cited 2022 May 23];36:56-8. Available from: https://www.indianjpain.org/text.asp?2022/36/1/56/343828
| Summary|| |
Pain is a major driver of complications in the intensive care unit (ICU), resulting in worsened patient outcomes. Also due to its multifactorial etiology, in recent years, the need for multimodal treatment has emerged, with particular emphasis on locoregional anesthesia.
Oncological pain in critically ill patient represents a particular challenge for medical staff, being closely linked to the concept of palliative care.
In this report, we describe the use of continuous intrathecal infusion for pain management, reducing intravenous analgesics to achieve weaning from mechanical ventilation, and subsequently ensuring effective palliative sedation.
| Case Report|| |
A 61-year-old man was admitted in our hospital with a pattern of acute abdomen. His comorbidities included atrial fibrillation on anticoagulation therapy and chronic heart failure with reduced ejection fraction (<40%).
An abdominal computed tomography scan revealed free air in the abdomen with intestinal perforation and a pancreatic mass infiltrating the kidney, spleen, and stomach.
The patient underwent an emergency exploratory laparotomy. In agreement with the surgeon and the other physicians, it has been decided to perform a bowel resection and colostomy to remove the perforated part without removing pancreatic cancer, which was deemed inoperable. After surgery, due to hemodynamic instability (septic shock), it has been decided to place an open abdomen dressing (ABThera™) and admit the patient in the ICU.
During the following 3 days, the patient remained under deep analgosedation with propofol, ketamine, and sufentanil before undergoing abdominal closure in the surgical room.
After the procedure, the patient was weaned from mechanical ventilation and extubated. Acetaminophen was administered.
In the following hours, the patient experienced high levels of pain, with NRS scores varying from 7 to 10.
Sufentanil rate of infusion was elevated up to 30 mcg/h, without benefit.
After discussing the case, we decided to place an intrathecal catheter to have a continuous infusion of analgesic drugs.
Hepatic function and coagulation studies were within normal limits (international normalized ratio 1.29, partial thromboplastin time 1.1, and platelets 73 × 103/μL). The patient received subcutaneous heparin (4000 UI twice a day) for venous thromboembolism prophylaxis with a morning dose held on the day of the procedure to ensure >12 h since the previous dose. For additional safety, we performed a rotational thromboelastometry test (ROTEM) to exclude coagulation disorders.
As spinal microcatheters were being unavailable, we used an epidural needle and catheter set (Portex®).
In lateral position under full aseptic precaution, the 18-gauge Tuohy needle was introduced in L1–L2 with the paramedian approach. After the epidural loss of resistance, the stylet was reinserted, and the needle advanced in small increments with intermittent stylet removal to check for cerebrospinal fluid flow (CSF), which is usually brisk through a large needle. Once the fluid was obtained, the stylet was reinserted to prevent unnecessary loss of CSF and then immediately replaced by the catheter, which was finally secured by subcutaneous tunneling.
After the placement, we started a continuous infusion of ropivacaine 0.2% and morphine 0.004%, with great benefit. Extemporaneous boluses were administered as necessary.
During the following days, the patient experienced lower levels of pain, with NRS scores between 0 and 3.
Sufentanil endovenous infusion was gradually suspended.
Continuous infusion of morphine has been pursued as palliative care at 2 mg/h after 6 days from catheter placement.
The patient died 7 days after catheter placement with a Richmond Agitation–Sedation Scale-1.
| Discussion|| |
Pain is a major driver of complications in the ICU, triggering agitation and delirium, hindering weaning from mechanical ventilation, and prolonging the hospital stay.
In our case, effective pain control was difficult to achieve because of the peculiar characteristics of end-stage oncologic pain.
The simultaneous presence of multiple mechanisms underlying the clinical manifestation of neoplastic syndrome makes it difficult to discriminate the individual components closely related to the effects of neoplasia and the components related to treatments.
Epidural and intrathecal techniques are well established for minimizing refractory cancer pain, frequently using a combination of opioids and local anesthetics.
The choice of intrathecal versus epidural route has been motivated by the fact that the latter has a limited range of action to a few dermatomes, while hydrophilic agents such as morphine have a prolonged half-life in CSF and a delayed onset of the analgesic effect, mainly because of the rostral migration with the drugs. Intrathecal morphine administration produced more satisfactory pain relief with lower doses and fewer side effects than epidural administration.
Intrathecal low concentrations of local anesthetics minimally interfere with autonomic and motor control, without significant hemodynamic impact and without affecting motility.
Continuous infusion of local anesthetic and intrathecal opioids allowed rapid optimization of pain control, reducing intravenous sedation and allowing respiratory weaning.
Following the end-of-life diagnosis, we had the need to adopt palliative care.
Palliative care does not mean futility, but it is worth remembering how the etymology derives from the Latin word pallium, meaning “cloak,” “protection.”
The World Health Organization defines palliative care as 'an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.
Multiple societies representing critical care professionals have published practice recommendations and/or guidelines related to important aspects of ICU palliative care, and these are evidence-based and extensively referenced.
Palliative treatment should therefore not be understood as an alternative to intensive care but as comprehensive care of the critically ill patient that involves the control of pain and other symptoms.
Intrathecal drug delivery systems for many years have been well established to improve cancer pain management.,,,,,
We, therefore, consider our case to be of clinical interest for several reasons.
The incremental opioid infusion was completely ineffective. As well as offering no pain relief, it exposed the patient to various complications such as vomiting and pneumonia ab ingestis. Respiratory weaning should be understood consensually with a view to avoiding inappropriate treatment, i.e., mechanical ventilation would have caused stress and discomfort to the patient. Despite the poor prognosis, the patient's overall state of health was unacceptable and required further strategies.
In the present case, therapeutic options, even in the context of multimodal strategies, were limited.
New interventional techniques emerged in recent years to provide pain relief to patients with cancer-related pain of difficult management or intractable nature; however, they could not be adopted in our context: sympathetic blocks are complex and invasive, and their efficacy depends on the individual anatomical distribution, which was distorted with the local progression of the tumor, while the use of peripheral blocks was limited by the large body surface area involved in painful stimulation.
According to the saying “old but still gold,” the continuous intrathecal infusion was therefore the option that best met the patient's needs for treatment of “mixed pain,” the manifestation of neuropathic and nociceptive mechanisms operating simultaneously.
Continuous spinal analgesia with standard epidural catheters is feasible and successful, with a relatively simple learning curve and with the additional obvious advantages of being able to be used in conditions of limited resources. The reported technique also safeguards against the risk of excessive CSF leakage.
Although the safety and outcome data presented in several studies support a more widespread acceptance, the use in ICUs is still limited due to the fear of side effects on hemodynamics or bleeding (spinal hematoma).
Catheter placement met the safety standards of international guidelines, with additional assurance of coagulation control by ROTEM, while the reduced concentration of ropivacaine and intrathecal morphine was a guarantee of low hemodynamic impact.
Continuous intrathecal infusion allows the treatment of refractory pain of multiple and complex etiologies such as in the critical patient (postsurgical, procedural, and oncological pain) as part of a multimodal strategy and, in the context of palliative care, offers the terminal patients' appropriate support to control suffering respecting their dignity, as “old but also new gold.”
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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