Three modalities for control of cancer pain: efficacy and safety

We have studied 60 patients suffering from intractable upper abdominal cancer pain. They were classified into 3 equal groups. Group I [oral morphine]: patients were given oral sustained-release morphine tablets [MST] every 12 hours with short-acting morphine tablets as required for breakthrough pain. The dose was adjusted every week to achieve pain relief without maximal recommended dose. Group II [neurolytic celiac plexus block]: patients were scheduled for neurolytic celiac plexus block, under X-ray screening, using alcohol 100%. Oral MST was given as a supplement if there was any residual pain after the block. Group III [epidural morphine]: patients were scheduled for epidural morphine injection via an epidural catheter, 0.03 - 0.05 mg/kg every 4-6 hours as required. No oral MST supplementation was given. The success of each treatment was evaluated by comparing pre-treatment [baseline] and post-treatment [for 12 weeks] scores: pain intensity using visual analogue scale and functional status using Karnofsky performance scale. Opioid consumption per day and side effects of each treatment were recorded. Our results showed that all modalities produced adequate pain relief. There was gradual and significant [p<0.05] increase in the oral morphine dose from the first to last week [from 48 to 227 mg/day] with gradual deterioration in the patient's functional status. Drug-related side effects were nausea, vomiting and constipation. Neurolytic celiac plexus block was associated with a reduction in analgesic drug administration, drug related side effects and insignificant improvement of the functional status of the patients during the first 2 weeks. Complications related to the block were transient diarrhea and hypotension without any neurological complications. With epidural morphine, all patients had adequate pain relief from 11 mg morphine/day, but the daily epidural morphine requirement showed a three fold increase at the 12[th] week [p<0.05]. The functional status of the patients was significantly [p<0.05] high during the first 2 weeks. Pruritus was the main subjective complaint, in addition to the technical complications, such as dislodgment or occlusion of the epidural catheter, or infection. Respiratory depression was not detected in any of our patients. We conclude that no single modality is capable of providing complete relief of intractable upper abdominal cancer pain. Combination therapy should be the rule rather than the exception as each one offers its own advantages and disadvantages

Comparison between intravenous pethidine and / or clonidine in management of postextradural shivering

This study detected the efficacy of intravenous pethidine and / or clonidine to suppress post-extradural shivering in patients had lower abdominal surgery. 60 healthy patients ASA I or II who developed shivering after extradural block, were allocated randomly into 4 groups [each of 15 patients]. Group I [saline group] : patients in this group received 5 ml normal saline intravenously; group II [pethidine group]: patients in this group received i.v. pethidine in a dose of 0.3 mg/kg diluted with normal saline to a total volume 5 ml.; group III [clonidine group]: patients in this group received clonidine 30 micro g diluted in normal saline to a total volume of 5 ml, this bolus had been repeated every 6 min. if the initial therapy produced no improvement, up to maximum dose 90 micro.g.; group IV [pethidine and clonidine group] : patients in this group received i.v. pethidine and clonidine in the same previous doses and volumes. In all this patients we measured HR, mean ABP and Respiratory rate, before treatment and every 5 minutes after, up to 30 minutes. Atrial blood samples were taken before and after treatment of shivering to measure PaO[2] SaO[2],PaCO[2], HCO[3] and pH. From the present study, we found that non of the patients stopped shivering in saline group and shivering inhibited in all patients 7 min after pethidine in a dose of [0.3 mg/kg] with success rate 100%. In clonidine group, shivering was inhibited in 12 patients 6 min after treatment using [30 micro g] clonidine and the other 3 patients need the 2[nd] dose clonidine to stop shivering after 15 min., thus, the success rate was 100%. In combination group, shivering had stopped within 6 min. in 100% of the patients and they all received only one dose of clonidine [30 micro g]. There was an improvement of the respiratory rate metabolic acidosis, and no haemodynamic adverse effects of the administered doses. PaCO[2] was below normal, while PaO[2] was below normal before treatment and insignificantly improved after treatment although there was an increase in oxygen consumption during shivering and did not return to its basal line after treatment indicating that shivering patients need oxygen during and after treatment of shivering

Control of heparin anticoagulation during cardiopulmonary bypass experience with a small initial dose

Forty adult patients of both sex undergoing cardiac surgical procedures requiring cardiopulmonary bypass were included in the present study. Patients were classified into two equal groups [each of 20 patients], group I were given the usual initial dose of heparin 400 IU/Kg while group II were given an initial dose of heparin 200 IU/Kg. Additional doses of heparin 50 IU/Kg added to attain ACT just above 400 sec in both groups to study this small initial dose for safe anticoagulation during CPB. It is found that the total heaparin dose before cannulation, the mean ACT values, the total heparin during surgery and the protamine dose for reversal were significantly lower in group II than in group I. So, starting with an initial heparin dose of 200 IU/Kg, adding small incremental doses to attain ACT just above 400 sec and proper ACT monitoring is a safe technique for heparin anticoagulation during CPB avoiding heparin overdosager