Toshimichi Nakaho

The oral-to-intravenous equianalgesic ratio of morphine based on plasma concentrations of morphine and metabolites in advanced cancer patients receiving chronic morphine treatment.

To provide additional pharmacokinetic evidence for the oral-to-parenteral relative potency ratio of 1:2 to 1:3 for chronic morphine use in a palliative care setting, we determined the plasma concentrations of morphine and its major metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G), in hospitalized advanced cancer patients maintained on long-term oral or intravenous morphine. There were significant linear correlations between daily doses of morphine and plasma concentrations (molar base) of morphine, M3G and M6G for both routes of administration. The oral-to-intravenous relative ratios of the regression coefficients were 2.9 for morphine and 1.8 for morphine» / M6G. The morphine kinetic variables were not significantly influenced by any hepato-renal biochemical markers. These results support the commonly used oral-to-intravenous relative potency ratio of 1:2 to 1:3 in patients with cancer pain receiving chronic morphine treatment.

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

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.

Silent gastric perforation in a pancreatic cancer patient treated with neurolytic celiac plexus block

nal pain. Mid-epigastric pain radiating through the back was his first symptom in the diagnosis of cancer in the pancreatic tail, which had been made 6 months previously. At the time of the diagnosis, an advanced stage of malignancy was highly suspected by multiple examinations including radiographic imaging and serological tumor markers. The patient did not choose to have surgical resection of the tumor, and antineoplasmic therapy consisted of gemcitabine chemotherapy, which had no remarkable effect on the tumor progression. His pain intensity progressively increased during the treatment period in spite of opioid therapy. On appearance at our division, his general condition remained relatively good without abnormal findings from either routine blood examination or tests of coagulation function, except for anemia (hemoglobin 11g·dl 1) and hyperglycemia (blood glucose 318 mg·dl 1). The latest computed tomography revealed a relatively normal anatomy of the retrocrural space of the diaphragm at the 12th thoracic (Th12)–second lumbar (L2) vertebral levels. Although oral morphine at doses increased to 90mg·day 1 accompanied by 150 mg·day 1 of oral diclofenac sodium at our division had failed to relieve his pain, uncontrollable nausea and dizziness prevented a further increase of the morphine dose. Continuous epidural block with 1% lidocaine at the Th5–12 dermatome levels, to which the majority of the splanchnic nerves refer, reduced his pain significantly. We informed him of NCPB as a possible treatment option for his pain. After the patient had given full consent to receive the treatment, NCPB was performed 5h after termination of the epidural injection of local anesthetics. Using a single-needle transintervertebral disc approach [4,5] (Fig. 1), the celiac neurolysis was completed with 20ml of 99.5% alcohol after confirming optimal pain relief with a diagnostic injection of 20ml of 2% lidocaine. The patient obtained significant pain relief with no immediate problems. His daily dose of morphine sulfate was reduced to 20mg with no rescue doses required upon discharge from the

Power spectral analysis of the electroencephalogram during induced total spinal block.

AbstractPurpose. To evaluate the effects of total spinal block (TSB) on brain function, TSB-induced changes in cortical electrical activities were analyzed using power spectral analysis of an electroencephalogram (EEG). Methods. Six patients suffering from chronic pain who were undergoing TSB therapy were studied. TSB was established with intrathecal 1% lidocaine (0.3 ml·kg−1) injected through the C1–2 lateral intervertebral space. Mechanical ventilation was continued via a laryngeal mask until the recovery of respiration. The EEG recording was started before TSB induction and continued until 10 min after extubation. The following processed EEG parameters were monitored: spectral edge frequency-90% (SEF90), spectral median frequency (SMF), and relative power in the frequency bands of δ, θ, α, β, and the δ ratio [(α + β)/δ]. Results. TSB induced an unconscious state more than 40 min in all patients. During TSB, 12–13 Hz in SEF90 and 6–7 Hz in SMF were observed. These values are consistent with the previously reported prearousal threshold from general anesthesia. The other EEG descriptors did not change during the TSB-induced unconscious state. Conclusion. The dissociation of cortical electrical activities and the clinical coma-like condition may be characteristic of the TSB-induced unconscious state.