Lumbar paravertebral blockade as intractable pain management method in palliative care
A 71-year-old woman was referred to the palliative care unit of the Poznan Palium Hospice because of the poor pain control of her L-S (lumbar to sacral) backbone radiating to both legs. Just before the admission to the hospice, her severe pain (of bone and neuropathic origin) was poorly controlled despite having been treated with fentanyl TD 75 μg · hour−1, plus morphine sulfate (MF) subcutaneous (SC) (doses every 4 hours) 40 mg daily, and paracetamol 1,500 mg orally (po) On admission, the pain was assessed as 7–8/10 in rest, while the breakthrough pain equaled 10/10 according to verbal rating scale (VRS) (see Methods section). The physical findings during this hospice examination revealed skin and mucous membrane pallor, mycosis of the mucous membrane in the mouth, decreased muscle tone, and partial paresis of both legs, particularly escalated on the right side. presents clinical characteristics of the patient.\nThe primary site of cancer disease was the right breast. The patient had a mastectomy, followed by chemotherapy. Metastases to the lung led to a right, upper lobectomy with lymphadenotomy, and chemotherapy. Metastases to the bones (vertebral column: Th11–12, L5) and lymph nodes (of aortic arch and paratracheal lymph nodes) were detected and palliative radiotherapy to Th11–12, L5 region was performed. Extraspinal metastases were also detected (to the right and left hip bone shafts, right ilium, and hip joint cavity). Pathological fracture of right femoral neck had impaired pain control. For many years, the patient has been diagnosed with multiple degenerative changes in the Th12-L5 segment, essential hypertension (well controlled with pharmacotherapy), New York Heart Association (NYHA) class II heart failure (relative circulatory efficiency state), chronic kidney disease (CKD; stage 3, estimated glomerular filtration rate [eGFR] = 43 mL/min/1.73 m2), and depression (no written data/documentation available; history taking difficult due to patient’s confused state). The patient declared no drug allergies.\nThe results of laboratory investigations on the patient’s admission and during hospitalization are presented in . As a result of impaired renal function, the regular therapy with MF was switched to fentanyl 750–1,250 μg daily in constant SC infusion. Within 2 days, this improved the patient’s mental state incredibly but had a minor effect on the pain relief, despite repeated MF rescue doses (). Pamidronate was not introduced because of low calcium and high creatinine serum concentrations. Because of poor pain control, EDA was considered. However, the international normalized ratio (INR) value indicated an increased risk of bleeding or hematoma and was a contraindication to the EDA. Next, PVB with bupivacaine solution in boluses was performed with an excellent result. To lower the incidence of nursing procedures (waking up/disturbing/bothering the patient), the drug’s administration was switched into constant paravertebral infusion. The effect on pain was poorer and bupivacaine serum concentrations increased, in comparison to boluses. Thus, after one day, we decided to withdraw bupivacaine for the following 16 hours. Then, LA boluses were reintroduced with an excellent effect ( and ).