Authors (including presenting author) :
HUI GK(1), CHEUNG E(2), FUNG WL(1), CHU MC(1), CHU HM(1)
Affiliation :
(1) Department of Anaesthesia, Pamela Youde Nethersole Eastern Hospital (2) Department of Oncology, Pamela Youde Nethersole Eastern Hospital
Introduction :
Brachytherapy is an essential component in the definitive treatment of locally advanced cervical cancer. The practice at PYNEH involves 4 fractions of image guided intracavitary and interstitial brachytherapy over 2 weeks, after external beam radiotherapy and concurrent chemotherapy. It consists of 2 separate procedures of applicator insertion under spinal or general anaesthesia. After each applicator insertion, 2 brachytherapy fractions are delivered on the same day and the following day with applicator and needles kept in-situ overnight. Pain control is essential given the invasiveness of procedure, prolonged immobilisation, and frequent patient transfer.
Retrospective review of peri-procedural pain control between October 2020 to December 2021 revealed that up to 40% of patient-applications required continuous morphine infusion on top of non-opioid analgesia. All cases involved interstitial needle use which is well recognised to cause more pain than intracavitary brachytherapy alone.
In response to the demand to optimise pain control, a multidisciplinary team (MDT) was formed to develop a protocol involving the use of intrathecal(IT) morphine during spinal anaesthesia .
Objectives :
To describe the implementation of a multimodal analgesic protocol with specific focus on IT morphine, for patients receiving image guided brachytherapy, and report on early outcomes.
Methodology :
A dedicated MDT of Clinical Oncologists, Anaesthetists, Specialist Pain and Oncology Nurses was formed in March 2022 with a new multimodal analgesic protocol involving the use of IT morphine introduced in May 2022. Pain score, extra morphine requirement and relevant side-effects were recorded.
Result & Outcome :
IT morphine was given whenever spinal anaesthesia was indicated in the period of May to December 2022. N=33 patient-applications were identified.After a pilot period, an optimal dose of 0.1mg IT morphine was established. Significant decrease in the requirement of continuous morphine infusion (p<0.05) was noted. . The new analgesia regime was safe and well tolerated in all patients.
Conclusion
Image guided brachytherapy for locally advanced cervical cancer is a complex process with high demand for multidisciplinary peri-procedural pain management. Implementation of a multimodal analgesic protocol involving IT morphine improves the quality of analgesia and promotes holistic care provision.
