Lumbar paravertebral blockade as intractable pain management method in palliative care

Iwona Zaporowska-Stachowiak,^1,2 Aleksandra Kotlinska-Lemieszek,³ Grzegorz Kowalski,³ Katarzyna Kosicka,⁴ Karolina Hoffmann,⁵ Franciszek Główka,⁴ Jacek Łuczak<sup>2

1</sup>Department of Pharmacology, ²Palliative Medicine In-patient Unit, University Hospital of Lord’s Transfiguration, ³Department of Palliative Care, ⁴Department of Physical Pharmacy and Pharmacokinetics, ⁵Department of Internal Medicine, Metabolic Disorders and Arterial Hypertension, Poznan University of Medical Sciences, Poznan, Poland

Abstract: Optimal symptoms control in advanced cancer disease, with refractory to conventional pain treatment, needs an interventional procedure. This paper presents coadministration of local anesthetic (LA) via paravertebral blockade (PVB) as the alternative to an unsuccessful subcutaneous fentanyl pain control in a 71-year old cancer patient with pathological fracture of femoral neck, bone metastases, and contraindications to morphine. Bupivacaine in continuous infusion (0.25%, 5 mL · hour^-1) or in boluses (10 mL of 0.125%–0.5% solution), used for lumbar PVB, resulted in pain relief, decreased demand for opioids, and led to better social interactions. The factors contributing to an increased risk of systemic toxicity from LA in the patient were: renal impairment; heart failure; hypoalbuminemia; hypocalcemia; and a complex therapy with possible drug–drug interactions. These factors were taken into consideration during treatment. Bupivacaine’s side effects were absent. Coadministered drugs could mask LA’s toxicity. Elevated plasma α1-acid glycoprotein levels were a protective factor. To evaluate the benefit-risk ratio of the PVB treatment in boluses and in constant infusion, bupivacaine serum levels were determined and the drug plasma half-lives were calculated. Bupivacaine’s elimination was slower when administered in constant infusion than in boluses (t_½ = 7.80 hours versus 2.64 hours). Total drug serum concentrations remained within the safe ranges during the whole treatment course (22.9–927.4 ng · mL^-1). In the case presented, lumbar PVB with bupivacaine in boluses (≤137.5 mg · 24 hours^-1) was an easy to perform, safe, effective method for pain control. Bupivacaine in continuous infusion (≤150 mg · 12 hours^-1) had an acceptable risk-benefits ratio, but was ineffective.

Keywords: bone metastases, bupivacaine, intractable pain, opioid ineffectiveness