Epidural analgesia provides safe and effective pain control in patients undergoing ISBT. Epidural delivery of narcotics with ropivacaine improves pain control and lowers oral and intravenous narcotic requirements without increased risk of adverse effects.
Ashley K. Amsbaugh, MD, Mark J. Amsbaugh, MD, Moataz N. El Ghamry, MD, Brian M. Derhake, MD, MS; Department of Anesthesiology, Department of Radiation Oncology, University of Louisville
PURPOSE: To determine optimal epidural analgesia for patients receiving interstitial brachytherapy (ISBT) for gynecologic cancer.
MATERIALS AND METHODS: Records of all patients who underwent interstitial brachytherapy (ISBT) at our institution between January 2009 and July 2014 were reviewed. ISBT was delivered over the course of 2 to 3 days, and maximum pain scores (measured on a scale from 1 to 10 points) were recorded every 8 hours. The primary analgesia method was epidural catheter. In addition to epidural anesthetic, patients received “as-needed” medications (intravenous narcotics, oral narcotics, and acetaminophen) from a standard order set. Antiemetics and diphenhydramine were available for nausea and pruritus, respectively. Pain scores and administered medications were collected, and all narcotic medications were converted to intravenous morphine equivalent (IVME). Statistical analysis was performed with SAS (Statistical Analysis System) software (SAS Institute, Cary NC).
RESULTS: Epidural catheters were successfully placed in 71 of 73 patients. Twelve patients received ropivacaine alone, 14 patients received ropivacaine with fentanyl, and 45 patients received ropivacaine with hydromorphone. Patients receiving ropivacaine alone had higher pain scores than patients receiving ropivacaine with fentanyl or ropivacaine with hydromorphone on the morning of day 2 (4.2 vs 1.71 vs 0.6; P = .001), the afternoon of day 2 (4.9 vs 2.5 vs 1.7; P = .005), and the night of day 2 (2.4 vs 2.0 vs 0.6; P < .001). Patients receiving narcotics in their epidural had lower pain scores on the night of placement (P = .050), the morning of day 2 (P < .001), the afternoon of day 2 (P = .002), and the night of day 2 (P < .001). Patients receiving ropivacaine alone used more oral narcotics than those receiving ropivacaine with fentanyl or ropivacaine with hydromorphone on day 3 (5.9 mg vs 3.8 mg vs 2.8 mg IVME) and received more intravenous narcotics on day 1 (5.8 mg vs 0.0 mg vs 0.7 mg IVME; P = .004) and day 2 (20.6 mg vs 4.8 mg vs 1.0 mg IVME; P = .042). There were no differences in antiemetic use on days 1 (P = .146), 2 (P = .266), or 3 (P = .360). There were no differences in diphenhydramine usage on days 1 (P = .829), 2 (P = .678), or 3 (P = .413). No epidural complications occurred.
CONCLUSIONS: Epidural analgesia provides safe and effective pain control in patients undergoing ISBT. Epidural delivery of narcotics with ropivacaine improves pain control and lowers oral and intravenous narcotic requirements without increased risk of adverse effects.
Proceedings of the 97th Annual Meeting of the American Radium Society- americanradiumsociety.org