Control of severe pain in children with terminal malignancy,☆☆,,★★

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Abstract

Objective: To identify the characteristics of the subset of children with malignancy in whom massive opioid infusions are needed during the terminal phase. Design: Retrospective review of the records of the 199 patients who died of malignancy after treatment at Children's Hospital, Boston, from March 1989 to July 1993, identifying characteristics of patients who required massive opioid infusions (operationally defined as infusion of >3 mg/kg per hour of morphine dose equivalent) during the terminal phase. Results: Twelve patients (6%) required massive opioid infusions, and eight of these patients required extraordinary measures (epidural or subarachnoid infusion and/or sedation) to achieve adequate analgesia. The duration of epidural or subarachnoid infusions in three patients ranged from 3 to 9 days, and minimal complications occurred. The duration of sedation ranged from 1 to 15 days. Maximal intravenous opioid dosing ranged from 3.8 to 518 mg/kg per hour of morphine equivalent. The maximal infusion rate (exceeding all previous published reports) occurred in an infant with an isolated metastasis in the periaqueductal gray matter, a brain-stem site linked to mediating analgesia and defense reactions. The need for massive opioid dosing in 11 of 12 patients was associated with tumor spread to the spinal nerve roots, nerve plexus, large peripheral nerve, or spinal cord compression. Conclusions: Standard dosing of opioids adequately treats most cancer pain in children; however, a significant group requires more extensive management. These problems occur more commonly among patients with solid tumors metastatic to spine and major nerves. (J PEDIATR 1995;126:653-7)

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METHODS

The study protocol was approved by the clinical investigation committee at the Dana-Farber Cancer Institute and Children's Hospital, Boston. A retrospective chart analysis was made of the inpatient and outpatient records of the Dana-Farber Cancer Institute and Children's Hospital, Boston, and the hospice agency records (if appropriate) of the 199 patients who died of malignancy after treatment at Children's Hospital, Boston, from March 1989 to July 1993. During this time the WHO algorithm2 was

Patient characteristics

The 199 patients ranged in age at the time of death from 5 months to 20 1/2 years. Forty-four percent had leukemia-lymphoma, 33% solid tumors, and 23% central nervous system tumors. Of the 199 patients, 12 (6%: 7 female, 5 male) required massive opioid infusion. An additional six patients, not described here, received relatively low-dose opioid infusions (<3 mg/kg per hour of intravenous morphine dose equivalent) but required epidural or spinal infusions, or celiac plexus blockade, primarily

DISCUSSION

The WHO recommendations for the management of cancer pain are effective for the majority of children. We have identified a small group of children requiring massive opioid dosing with or without extraordinary measures to achieve adequate analgesia during the terminal phase of their illness. Solid tumors were overrepresented in the group requiring massive opioid infusions, and the most significant predictor of massive opioid need was tumor spread involving spinal nerve roots, major plexus, or

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From the Pain Treatment Service, Division of Hematology/Oncology, and Departments of Anesthesia, Medicine, and Pathology, Children's Hospital, Boston; the Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston; and the Departments of Anesthesia, Pediatrics, and Pathology, Harvard Medical School, Boston, Massachusetts

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Supported by grants from the Department of Oncology, Children's Hospital, Sydney, New South Wales, Australia, and the Department of Anesthesia, Children's Hospital, Boston, Massachusetts (Dr. Collins), and by the Anesthesia Patient Safety Foundation, Christopher Coakley Memorial Fund, and Mayday Fund (Dr. Berde).

Reprint requests: Charles B. Berde MD, PhD, Director, Pain Treatment Service, Farley 306, Children's Hospital, 300 Longwood Ave., Boston, MA 02115.

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0022-3476/95/$3.00 + 0 9/25/61755

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