91 side effects after more than 2500 single retention was not noted. 1 patient reported a injections. Urinary which disappeared when the under the inj...

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91 side effects after more than 2500 single retention was not noted. 1 patient reported a injections. Urinary which disappeared when the under the injection, burning pain epidural catheter was changed. 2 patients vomited. There were no withdrawal signs. Epidural morphine seems to be an ideal method for treatment of pain from terminal cancer. Even outpatient use of this method is possible. An effective antiseptic, such as povidone iodine, for cover of the puncture site and as a bath additive, is essential for the long term use of epidural morphine. We have



the Editor


SIR,-Epidural opiates

may be of benefit in



pain. 1-3 However, there have been no long-term studies of opiates given via indwelling epidural catheter. We have treated 40 patients with terminal carcinoma. Pain was induced by bone metastases or primary invasion of cancer. The main site of pain extended from the sacral to the thoracic dermatomes. A peridural catheter was inserted and sutured (37 lumbar and 3 thoracic puncture sites). The puncture site was covered by povidone iodine. 2-5 mg morphine hydrochloride in 10-15 ml saline solution was injected. Further injections were given as indicated by subjective estimates of pain. On average the peridural catheter was in place for 23±5 days (range 1-118 days). No spinal infections were noted. In 2 cases the catheter was changed because of infection at the puncture site. 9’3±3-00 mg morphine per day were necessary to obtain a satisfactory analgesia, the mean single dose being 4 -1 ±2 - 0 mg. There was no need for other analgesics. The analgesic effect of each dose lasted for 12±3 h (range 1-93 h). No tolerance to morphine developed in the first 25-day treatment period (figure): the average dosage

Constancy of peridural morphine dose. Doses shown in


exceeded 10 mg per day. After this period there was an increasing need for epidural morphine in some cases, in accordance with the continuing infiltration of cancer in the terminal stage. Yet, even with a dosage of 4 x 20 mg morphine peridurally in the last never

three weeks of a 118-day treatment period, there were no clinical signs of respiratory depression or sedation. 12 cases were treated as outpatients. The procedure for these patients was a weekly check, in our clinic, of the puncture site, morphine dosage, and degree of analgesia. At home the patients were treated by their family physicians. Povidone iodine proved useful as an unguent for the puncture site or as a bath additive for the prevention of local infection.4 Although the consumption of analgesics could not be compared before and after epidural morphine, one case demonstrates the decreasing amount of analgesics needed. A patient with bronchial cancer and bone metastases received, on average, 600 mg pethidine each day over a period of 3 weeks before epidural morphine. With epidural injections, just 15 mg morphine was sufficient to obtain an even better degree of analgesia. This dosage was continued over a period of 4 weeks until death. 1. Behar

M, Magora F, Olshwang D, Davidson JT Epidural morphine in treatment of 1979;i: 527. 2. Magora F, Olshwang D, Eimerl D, Shorr J, Katzenelson R, Cotev S, Davidson JT. Observations on extradural morphine analgesia in various pain conditions. Br J Anaesth 1980, 52: 247. 3 Zenz M, Piepenbrock S, Otten B, Otten G Epidurale Morphininjektion zur Schmerzbekämpfung Fortschr Med 1980; 9: 306. 4. Dietzel W Infektionsprophylaxe in der Intensiv-therapie durch Patientenwaschungen mit PVP-Jod. Prakt Anasth 1977, 12: 318 pain Lancet

not seen severe

Institute for Anaesthesiology Medizinische Hochschule Hannover, D 3000 Hannover 51, West Germany


Institute for Anaesthesiology, Klinikum Steglitz, Berlin


Women’s Clinic, Medizinische Hochschule Hannover



SIR,-One problem with the medical treatment of cancer is the patient who vomits with each injection almost as a conditioned reflex. Vomiting may begin before chemotherapy is given and continue for several hours afterwards. Once such a pattern is established conventional antiemetics, even combined with phenothiazines, have little impact unless sedation is so heavy as to make cardiovascular or respiratory depression a worry. We have found 4-5 mg i.v. lorazepam given just before chemotherapy combined with standard, centrally acting antiemetics to be a safe and useful way of improving toleration of chemotherapy. Seven patients were studied for at least three courses of multiple drug chemotherapy given 3-4 weeks apart. Regimens included actinomycin D, doxorubicin, cyclophosphamide, and DTIC (decarbazine) for malignancies including breast cancer, melanoma, and soft tissue sarcomas. All the patients had distressing vomiting associated with each dose of chemotherapy, and this had not been relieved by centrally

acting antiemetics, including intramuscular phenothiazines. Severe vomiting for several hours after chemotherapy regularly disturbed sleep on the night after the injection, and four patients had anticipatory vomiting. All patients were under 50 and they were relatively well between injections. They regarded this vomiting as the most distressing part of the chemotherapy and two patients had reached the point of refusing treatment. Patients were admitted overnight for chemotherapy which was given in the late afternoon or evening. A dose of standard antiemetic (perphenazine 5 mg) was given one hour before chemotherapy and lorazepam 4-5 mg i.v. given immediately before chemotherapy. 2 mg oral lorazepam up to 4 hourly was prescribed to keep patients asleep but such top-up was rarely needed. Standard parenteral antiemetics were prescribed as required. All patients were sleepy but easily rousable within 5-15 min of the lorazepam. If they did vomit they were awake enough to use a bowl. Recall of the injection and several hours after was very significantly reduced; one patient found it difficult to believe she had had her chemotherapy at all. The patients were all fit for discharge the next morning and no respiratory or cardiovascular depression was observed. Vomiting was reduced to a maximum of twice in all but one patient, and in three out of four patients anticipatory vomiting was abolished. The one patient who continued to vomit during the night after a combination of DTIC, doxorubicin, cyclophosphamide, and vincristine had anticipatory vomiting abolished in 3 of 6 courses studied and had very blurred recall of his vomiting and the associated anxiety and distress was very considerably reduced. All 7 patients requested that chemotherapy be given this way again and the 2 patients refusing treatment were prepared to continue if lorazepam were used.