Patient-controlled versus staff-controlled analgesia with pethidine after allogeneic bone marrow transplantation

Abstract

Patients treated by allogeneic bone marrow transplantation (aBMT) suffer prolonged oropharyngeal mucositis pain. The aim of this study was to prospectively compare patient-controlled analgesia (PCA) with an established regimen of staff-controlled analgesia using pethidine (meperidine). Twenty patients undergoing aBMT for haematologic neoplasias or malignant lymphomas randomly received pethidine intravenously either continuously plus supplemental bolus doses on request through the transplant unit staff or by PCA. Pain intensity was assessed by patient self report using a visual analogue scale (VAS) and daily pethidine intake was documented. In addition, the pethidine consumption of 20 aBMT-patients receiving staff-controlled analgesia prior to initiation of the study, but not reporting pain, was compared retrospectively with that of patients receiving the same analgesia regimen under study conditions. PCA significantly diminished both pethidine consumption and pain intensity compared with staff-controlled analgesia. The maximum pethidine intake was 440.1 +/- 111.8 mg/24 h in the patient-controlled and 640.9 +/- 128.9 mg/24 h in the staff-controlled analgesia group (mean +/- 95% CI). Mean pain scores remained under 50% but reached 70% in the staff-controlled analgesia group. Pethidine dosage by staff-controlled analgesia increased under study conditions, suggesting that mere pain-assessment and a 'competing' analgesic method motivated the BMT-unit staff to administer higher pethidine doses. This observation is discussed as a possible Hawthorne effect. Previous studies using morphine demonstrated that PCA diminishes opioid requirement compared to continuous or staff-controlled application in bone marrow recipients. In contrast to these studies, PCA additionally improved pain relief in the present investigation.

Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis

“…Guideline: The panel recommends patient‐controlled analgesia (PCA) with morphine as the treatment of choice for oral mucositis pain in patients undergoing HSCT ( level of evidence, I; grade of recommendation, A ). Control of mucositis‐induced pain is achieved by PCA with intravascular morphine sulfate 41–49. Level I evidence supports PCA for oral mucositis pain in patients who undergo HSCT, but there is little evidence to recommend its use in other patients and settings.…”

Palliative care in BMT

“…But over the years, this mantra has slowly shifted to more of 'Do everything possible to obtain remission and a chance of cure without sacrificing too much quality of life.' Transplant teams have been at the forefront of supportive care with emphasis on management of infections, mucositis, 1 nutrition, [2][3][4][5][6] pain during transplant [7][8][9] and even truthful communication about prognosis. 10 Transplant clinicians may not realize that PC is not the same as hospice care.…”

“…morphine or other opioids for pain in BMT showed similar benefit, but, less consumption when patients had control of their medication administration. 8,9,17 Comparison of the different opioids was performed in transplant patients in 1996 by Coda et al, 7 who recommended that morphine be the first choice of opioids for patients undergoing high-dose therapy and transplantation. As in PC, due to its effectiveness and easy titration as well as dose conversion to other narcotic pain medications, PCA morphine has become the standard for pain management for BMT programs.…”

Zirkadianer Rhythmus des PCA-gesteuerten Opioidverbrauchs bei Kindern mit chemotherapiebedingter Mukositis

“…Sogar bei Erwachsenen setzten 1998 weltweit nur 2 der 27 befragten Knochenmarktransplan tationszentren die PCA zur Therapie von Mukositisschmerzen ein [38]; neuere Da ten und solche aus der Pädiatrie fehlen. In den 3 verfügbaren pädiatrischen Stu dien erweist sich die PCA jedoch als ei [15,23].…”