Jeon, Y.S., Lee, J.A., Choi, J.W., Kang, E.G., Jung, H.S., Kim, H. K., … Joo, J.D. (2012). Efficacy of epidural analgesia in patients with cancer pain: A retrospective observational study. Yonsei Medical Journal, 53, 649–653.

To evaluate the efficacy and complications of continuous epidural analgesia to improve its efficacy for control of cancer-related pain

Most patients received morphine, bupivacaine, and ketamine via continuous epidural infusion. Dosing was determined by converting the daily total opioid dose to an IV morphine equivalent. The epidural morphine was delivered at 25%–17% of the IV morphine dose. Bupivacaine 12.5–25 mg per day and ketamine 10–20 mg per day were administered at 2 mL/h and varied according to pain location, severity, and type, as well as progression of disease. Additional adjuvant therapies were used and included antiepileptic drugs, antidepressants, anti-inflammatory drugs, and steroids. Pain levels were evaluated at baseline and at two weeks postepidural.

• The study reported on 96 patients.
• Nine patients were 40 years old or younger, 35 patients were 41–59 years old, and 52 patients were 60 years or older.
• Patients had been diagnosed with terminal lung, upper genitourinary, hepatobiliary, pancreatic, rectosigmoidal, urogenital, or other (10.4%) cancers.
• The majority of patients (91.6%) had pain in the chest, abdomen, back, sacral, or lower extremity, and 8.3% had pain in the head, neck, and upper extremity.

The study was conducted at a single site in Korea. The setting type was not specified.

• Patients were at the end-of-life phase of care.
• This study has clinical applicability for elder care and palliative care.

The study design was a retrospective chart analysis.

• Paired sample t-tests were used to evaluate the morphine-equivalent drug dose (MEDD).
• Statistical analysis was performed using SPSS software version 13.0.

The MEDD decreased from 213.4 mg (SD = 221.7 mg) per day to 94.1 mg (SD = 145.0 mg) per day at two weeks follow up. Prior to receiving the epidural, 78.1% of patients reported severe pain; at the two-week follow up, only 19.6% reported severe pain (p < 0.05). Mild catheter complications occurred in 15.6% of patients. Moderate complications occurred in 14.6% of patients, including infection that had to be controlled with antibiotics or removal of the catheter.

Continuous epidural anesthesia is an effective pain control method for patients with cancer at the end of life. However, risk of infection and complications exist because of catheter placement.

• The sample size was small, with fewer than 100 patients.
• A risk of bias exists because of the lack of a control group, blinding, and appropriate attentional control condition.
• The subject withdrawal rate was 10% or greater. The study had an extremely high attrition rate because of patient death (over a two-week span, the sample was reduced from 96 to 56 patients).
• Variations in documentation practices within the medical record were a weakness of this study.
• This was a retrospective study.

For patients seeking more pain control, continuous epidural infusions may be an option for pain relief. The charts reviewed cited inappropriate pain control (78.1%) and intolerable side effects (21.9%) as the reasons for placing the epidural, which are key factors in working to improve comfort in patients with terminal cancer.  Risks of complications include infection, occlusion, catheter removal, risk of respiratory depression, motor block, hypotension, sensory deficits, and gastrointestinal and genitourinary function that must be evaluated while the catheter is in place. In patients with terminal cancer, patient and caregiver education is important.