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ĐA LAT, VIET NAM 
11/2014
REPORT OF 03 CASES END-STAGE CANCER PAIN 
MANAGERMENT WITH LONGTERM EPIDURAL CATHETER 
AT CENTRAL TRANSPORT HOSPITAL 
ĐO NGOC HIEU, NGUYEN VAN CHUC 
CENTRAL TRANSPORT HOSPITAL 
Đa Lat, Viet Nam 11/2014
GENERAL 
Pain in cancer patients: 
• The top concern 
• Causes: 
• Due to the development of cancer, invasive, predatory 
• Related to cancer (muscle spasms, swelling, ulcers) 
• Related to cancer treatment (surgical scars, chemical, 
radiation) 
• Other diseases coordination (osteoarthritis, degenerative 
spine) [1] 
• End-stage cancer pain: scary and difficult to manage 
• Better pain relief: improve the quaility of life 
1. Nguyen Ba Đuc (2003), “Đieu tri đau cho benh nhan ung thu”, Cham soc va đieu tri trieu chung cho benh nhan ung thu, NXB Ha Noi, 
trang 11-39.
GENERAL 
Treatment of cancer pain: 
• Mainstream: medicational therapy (analgesics, 
tranquilizers, anti-depressants, anti-seizure, anti-anxiety) 
• Psychological therapy 
• Therapy prevents the progression of the disease (surgery, 
radiation, chemicals, hormones) 
• Deaden pain therapy (local anesthesia, neurosurgery) 
• Reduced activity therapy (leisure, real estate)
GENERAL 
The WHO analgesic ladder 
• Using the correct drug, dose, time: 
• Inexpensive 
• Efficiency of 45% - 100% of the cases (Ferreira (2006) [5]) 
• With severe pain: morphine mainstream medicine (more side effect) 
5. Ferreira SL, Kimura M, Teixeira MJ (2006), “The WHO analgesic ladder for cancer pain control, twenty years of use. How much pain relief 
does one get from using it?”, Supportive care in cancer, Springer-Verlag, 14 (11): 1086-1093.
GENERAL 
Epidural analgesia (EA): 
• As No. 4 in The WHO analgesic ladder 
• Bringing drugs into the cavity epidural => spinal roots, 
nodes beside the spine, circulation => effects 
• Anesthetic, morphine, clonidine, ..., (pure or mixed) 
• Usually applied: acute pain (surgery, trauma) 
EA with chronic pain: 
• Keep epidural catheter with subcutaneous chamber (port 
A) (high cost) 
• Patients in end-stage cancer : live <3 months; poor 
Grisell Vargas-Schaffer MD (2010), I”s the WHO analgesic ladder still valid? Twenty-four years of experience”, Canadian family physician, 
56: 514-7.
GENERAL 
Report 03 cases of end-stage cancer pain managerment 
with longterm epidural catheter: 
• Not used subcutaneous chamber (port A) 
• Inserted a segment catheter subcutaneous and fixed for 
longterm 
• Keep for long time
CASE STUDY 1 
Patient: LE VAN B Male 72 years 
Add: 198/4/9 Vinh Hung, Hoang Mai, Ha Noi 
Disease: Liver cancer in end-stage 
2 years of disease evolution, the condition when arrived: 
• Cachexia 
• Ascites, pain whole abdomen 
• Must lie by lateral or high head to breathe 
• Difficult to change his positions, must have family support 
• 6 ampoule morphine 10 mg are used IM per day
CASE STUDY 1 
Process: 
• Epidural catheter placement D9-10, lateral 
• 6cm long inside cavity 
• Just outside the area goes under the skin to the ribs 
• Fixed by opsite 
• Drugs: morphine ampoule 10mg/1ml 
• Dilute to 20ml and injection 4ml (2mg)/times repeatly 
• Monitoring in hospital for 1 day 
• Augmentin 1,2g / day x 5 days (OR)
CASE STUDY 1 
Results: 
• VAS <4 after the first dose 10 minutes 
• Patients can change posture, sit up 
• First day: injected 3 times (6mg) 
• The next days, increasing number of injections 
• After 1 week: Use about 2 ampuole morphine 10mg/day 
• No itching, no vomiting, urinating normally, defecation 3 
days 1 times 
• Patients died at home after 2 weeks with EA
CASE STUDY 2 
Patient: Phạm Thị Th nu 87 years 
Disease: Appendix cancer in end-stage, metastases 
throughout the abdomen 
The course of 14 months, was hospitalized in a state: 
• Cachexia 
• Ascites, pain whole abdomen 
• WHO analgesic ladder: still more pain 
• 4-6 ampoule morphine 10mg subcutaneous injection/day
CASE STUDY 2 
Procedure: 
• Placement of catheter: D10-11, lateral 
• 5cm long inside cavity 
• Inserted catheter subcutaneous to the lumbar 
• Fixed by opsite and bandage 
• PCEA, background=0, bolus 3ml/time, lock 
out 30ph (Using Coopdech Balloonjector- 
Japan) 
• Drugs: solution morphine 0.1 mg / ml (Adjust 
according to the demands of patients) 
• Hospitalized for 2 weeks, drink augmentin 
1,2g / day x 5 days 
• Changed Balloonjector every 2-3 weeks Coopdech Baloonjecter (Nhật Bản)
CASE STUDY 2 
Results: 
• Patients almost no pain (VAS <4) 
• Reduce the amount of morphine consumption, the first day of 
use 2-10mg / day, the following day, the total amount of 
morphine gradually increased. 
• No signs of respiratory distress, vomiting or rashes. 
• Catheter retention time: 35 days (catheter dislodging the 
patient to sleep). 
• The patient survived 02 weeks after catheter slipped NMC
CASE STUDY 2 
Patient: Nguyen Thi D Female 67 years 
Disease: Bililary cancer in end-stage 
• Diagnosed 3 months 
• Releaf pain by 4-6 ampoule morphine 10mg/day (IM) 
Procedure: 
• Epidural catheter placement D8-9, lateral, 
• NMC 5cm deep cavity 
• Just outside the area goes under the skin to the ribs 
• Fixed by stitching and paste opsi
CASE STUDY 3 
Tiến hành: 
• PCEA, background=0, bolus 3ml/time, lock out 30ph (Using 
Coopdech Balloonjector-Japan) 
• Drugs: bupivacaine 0.1% + morphine 0.1 mg/ml + adre 1/200000 
(Adjust the amount of morphine increased according to the 
demands of patients) 
• Hospitalized for 5 days, taking augmentin 1,2g/day x 7 days 
• Changed Balloonjector every 2-3 weeks
CASE STUDY 3 
Rerults: 
• Reduced pain (VAS <4) 
• Patients can walk normally, care herself 
• No respiratory depression, no hypotension 
• No nausea, vomiting, no constipation, urinary retention 
• Keep catheter for 45 days (patient deaths)
DISCUSS 
• Comparison of 3 patients
DISCUSS 
• Prescribe to EA: 
• Treatment according to the WHO ladder does not reach the 
desired effect 
• Patients and families to explain and understand the 
methods 
• There are no contraindications (note coagulation function) 
• Technical implementation: 
• Select the appropriate needle placement (use anesthetic 
when necessary coordination) 
• Catheter under the block skin 
• Fixed by sewing and opsite
DISCUSS 
• Medicines and how to use: 
• Morphine is the most effective option 
• Coordinate anesthetic, adre to increase time relieve pain and 
reduce dose 
• Analgesic efficacy:
DISCUSS 
• NMC on catheter length: 
• Patients with end-stage K, survival prognosis of less than 3 
months? => Save NMC catheter until death 
Bong Ha Heo, Tae Hee Pyeon, et al (2014), “Epidural infusion of morphine and levobupivacaine through a subcutaneous port for cancer pain management” 
Ruppen W, Derry S, et al (2007), “Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis”, 
BMC Palliative Care, 6:3. 
Yeon Soo Jeon, Jung Ah Lee, et al (2012), “Efficacy of epidural analgesia in patients with cancer pain: A retrospective observational study”
DISCUSS 
• Undesirable effects: 
• No infections: shallow in skin or deep in epidural cavity 
• Ruppen (2007): 
• Deep infection: 1 in 35 patients with catheter 74 days to save 
• 1 in 500 deaths related to infection 
• Other side effects include: nausea, rashes, urinary retention, 
constipation related total morphine use 
• Bong Ha Heo (2014): 17.2% nausea-vomiting, urinary retention 
6.9% 
Ruppen W, Derry S, et al (2007), “Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis”, 
BMC Palliative Care, 6:3. 
Bong Ha Heo, Tae Hee Pyeon, et al (2014), “Epidural infusion of morphine and levobupivacaine through a subcutaneous port for cancer pain management”
CONCLUSION 
• Keep epidural catheter analgesia for patients with end-stage 
cancer 
• Initially bring effective 
• Inexpensive 
• No severe complications 
• Fewer side effects.
TTHHAANNKKSS YYOOUU SSOO MMUUCCHH !! 
DA LAT, VIET NAM, 
11/2014

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Do ngoc hieu ta

  • 1. ĐA LAT, VIET NAM 11/2014
  • 2. REPORT OF 03 CASES END-STAGE CANCER PAIN MANAGERMENT WITH LONGTERM EPIDURAL CATHETER AT CENTRAL TRANSPORT HOSPITAL ĐO NGOC HIEU, NGUYEN VAN CHUC CENTRAL TRANSPORT HOSPITAL Đa Lat, Viet Nam 11/2014
  • 3. GENERAL Pain in cancer patients: • The top concern • Causes: • Due to the development of cancer, invasive, predatory • Related to cancer (muscle spasms, swelling, ulcers) • Related to cancer treatment (surgical scars, chemical, radiation) • Other diseases coordination (osteoarthritis, degenerative spine) [1] • End-stage cancer pain: scary and difficult to manage • Better pain relief: improve the quaility of life 1. Nguyen Ba Đuc (2003), “Đieu tri đau cho benh nhan ung thu”, Cham soc va đieu tri trieu chung cho benh nhan ung thu, NXB Ha Noi, trang 11-39.
  • 4. GENERAL Treatment of cancer pain: • Mainstream: medicational therapy (analgesics, tranquilizers, anti-depressants, anti-seizure, anti-anxiety) • Psychological therapy • Therapy prevents the progression of the disease (surgery, radiation, chemicals, hormones) • Deaden pain therapy (local anesthesia, neurosurgery) • Reduced activity therapy (leisure, real estate)
  • 5. GENERAL The WHO analgesic ladder • Using the correct drug, dose, time: • Inexpensive • Efficiency of 45% - 100% of the cases (Ferreira (2006) [5]) • With severe pain: morphine mainstream medicine (more side effect) 5. Ferreira SL, Kimura M, Teixeira MJ (2006), “The WHO analgesic ladder for cancer pain control, twenty years of use. How much pain relief does one get from using it?”, Supportive care in cancer, Springer-Verlag, 14 (11): 1086-1093.
  • 6. GENERAL Epidural analgesia (EA): • As No. 4 in The WHO analgesic ladder • Bringing drugs into the cavity epidural => spinal roots, nodes beside the spine, circulation => effects • Anesthetic, morphine, clonidine, ..., (pure or mixed) • Usually applied: acute pain (surgery, trauma) EA with chronic pain: • Keep epidural catheter with subcutaneous chamber (port A) (high cost) • Patients in end-stage cancer : live <3 months; poor Grisell Vargas-Schaffer MD (2010), I”s the WHO analgesic ladder still valid? Twenty-four years of experience”, Canadian family physician, 56: 514-7.
  • 7. GENERAL Report 03 cases of end-stage cancer pain managerment with longterm epidural catheter: • Not used subcutaneous chamber (port A) • Inserted a segment catheter subcutaneous and fixed for longterm • Keep for long time
  • 8. CASE STUDY 1 Patient: LE VAN B Male 72 years Add: 198/4/9 Vinh Hung, Hoang Mai, Ha Noi Disease: Liver cancer in end-stage 2 years of disease evolution, the condition when arrived: • Cachexia • Ascites, pain whole abdomen • Must lie by lateral or high head to breathe • Difficult to change his positions, must have family support • 6 ampoule morphine 10 mg are used IM per day
  • 9. CASE STUDY 1 Process: • Epidural catheter placement D9-10, lateral • 6cm long inside cavity • Just outside the area goes under the skin to the ribs • Fixed by opsite • Drugs: morphine ampoule 10mg/1ml • Dilute to 20ml and injection 4ml (2mg)/times repeatly • Monitoring in hospital for 1 day • Augmentin 1,2g / day x 5 days (OR)
  • 10. CASE STUDY 1 Results: • VAS <4 after the first dose 10 minutes • Patients can change posture, sit up • First day: injected 3 times (6mg) • The next days, increasing number of injections • After 1 week: Use about 2 ampuole morphine 10mg/day • No itching, no vomiting, urinating normally, defecation 3 days 1 times • Patients died at home after 2 weeks with EA
  • 11. CASE STUDY 2 Patient: Phạm Thị Th nu 87 years Disease: Appendix cancer in end-stage, metastases throughout the abdomen The course of 14 months, was hospitalized in a state: • Cachexia • Ascites, pain whole abdomen • WHO analgesic ladder: still more pain • 4-6 ampoule morphine 10mg subcutaneous injection/day
  • 12. CASE STUDY 2 Procedure: • Placement of catheter: D10-11, lateral • 5cm long inside cavity • Inserted catheter subcutaneous to the lumbar • Fixed by opsite and bandage • PCEA, background=0, bolus 3ml/time, lock out 30ph (Using Coopdech Balloonjector- Japan) • Drugs: solution morphine 0.1 mg / ml (Adjust according to the demands of patients) • Hospitalized for 2 weeks, drink augmentin 1,2g / day x 5 days • Changed Balloonjector every 2-3 weeks Coopdech Baloonjecter (Nhật Bản)
  • 13. CASE STUDY 2 Results: • Patients almost no pain (VAS <4) • Reduce the amount of morphine consumption, the first day of use 2-10mg / day, the following day, the total amount of morphine gradually increased. • No signs of respiratory distress, vomiting or rashes. • Catheter retention time: 35 days (catheter dislodging the patient to sleep). • The patient survived 02 weeks after catheter slipped NMC
  • 14. CASE STUDY 2 Patient: Nguyen Thi D Female 67 years Disease: Bililary cancer in end-stage • Diagnosed 3 months • Releaf pain by 4-6 ampoule morphine 10mg/day (IM) Procedure: • Epidural catheter placement D8-9, lateral, • NMC 5cm deep cavity • Just outside the area goes under the skin to the ribs • Fixed by stitching and paste opsi
  • 15. CASE STUDY 3 Tiến hành: • PCEA, background=0, bolus 3ml/time, lock out 30ph (Using Coopdech Balloonjector-Japan) • Drugs: bupivacaine 0.1% + morphine 0.1 mg/ml + adre 1/200000 (Adjust the amount of morphine increased according to the demands of patients) • Hospitalized for 5 days, taking augmentin 1,2g/day x 7 days • Changed Balloonjector every 2-3 weeks
  • 16. CASE STUDY 3 Rerults: • Reduced pain (VAS <4) • Patients can walk normally, care herself • No respiratory depression, no hypotension • No nausea, vomiting, no constipation, urinary retention • Keep catheter for 45 days (patient deaths)
  • 17. DISCUSS • Comparison of 3 patients
  • 18. DISCUSS • Prescribe to EA: • Treatment according to the WHO ladder does not reach the desired effect • Patients and families to explain and understand the methods • There are no contraindications (note coagulation function) • Technical implementation: • Select the appropriate needle placement (use anesthetic when necessary coordination) • Catheter under the block skin • Fixed by sewing and opsite
  • 19. DISCUSS • Medicines and how to use: • Morphine is the most effective option • Coordinate anesthetic, adre to increase time relieve pain and reduce dose • Analgesic efficacy:
  • 20. DISCUSS • NMC on catheter length: • Patients with end-stage K, survival prognosis of less than 3 months? => Save NMC catheter until death Bong Ha Heo, Tae Hee Pyeon, et al (2014), “Epidural infusion of morphine and levobupivacaine through a subcutaneous port for cancer pain management” Ruppen W, Derry S, et al (2007), “Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis”, BMC Palliative Care, 6:3. Yeon Soo Jeon, Jung Ah Lee, et al (2012), “Efficacy of epidural analgesia in patients with cancer pain: A retrospective observational study”
  • 21. DISCUSS • Undesirable effects: • No infections: shallow in skin or deep in epidural cavity • Ruppen (2007): • Deep infection: 1 in 35 patients with catheter 74 days to save • 1 in 500 deaths related to infection • Other side effects include: nausea, rashes, urinary retention, constipation related total morphine use • Bong Ha Heo (2014): 17.2% nausea-vomiting, urinary retention 6.9% Ruppen W, Derry S, et al (2007), “Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis”, BMC Palliative Care, 6:3. Bong Ha Heo, Tae Hee Pyeon, et al (2014), “Epidural infusion of morphine and levobupivacaine through a subcutaneous port for cancer pain management”
  • 22. CONCLUSION • Keep epidural catheter analgesia for patients with end-stage cancer • Initially bring effective • Inexpensive • No severe complications • Fewer side effects.
  • 23. TTHHAANNKKSS YYOOUU SSOO MMUUCCHH !! DA LAT, VIET NAM, 11/2014