IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worth reading.
By Dr. Tania Pastrana
IAHPC Research Advisor
Chong PH, Yeo ZZ. J Palliat Med 2021; 24(8): 1154-60. DOI: 10.1089/jpm.2020.0622
Although modern medicine has dramatically improved the management of cancer pain, there are still patients whose pain challenges the current therapeutical options.
In 1991, William Brose and Michael Cousins reported the cases of three cancer patients with refractory pain who received subcutaneous infusion of 10% lidocaine with good response.1 Since then, several studies have reported the use of subcutaneous or intravenous lidocaine for pain treatment. Usage was mainly restricted to a hospital setting, probably due to the antiarrhythmic effect and the narrow therapeutic window, as well as the possibility of precipitating central nervous system disturbances, such as psychosis, in high doses.
Chong and Yeo conducted a systematic review on the use of parenteral lidocaine in outpatients with cancer (at home or in hospice). They included seven articles with a total of 73 patients with nociceptive, neuropathic, or mixed pain. The dosages varied; also, patients received a continuous infusion either with or without a (slow) bolus dose. Close monitoring was suggested in one guideline.
Lidocaine might be a feasible, effective, and safe option as a “second- or third-line intervention to manage different types of complex cancer pain in patients of all ages” or “where conventional therapies such as opioids and adjuvants fail, and aggressive interventions are not appropriate.” Routine monitoring of vital signs and level of consciousness for outpatients was also recommended. However, “more studies are needed to define the best regimen for drug administration, both to maximize treatment effectiveness and reduce care burden and risks involved.”
Do you have experience with parenteral lidocaine in patients with cancer pain in your setting?
1. Brose WG, Cousins MJ. Subcutaneous Lidocaine for Treatment of Neuropathic Cancer Pain. Pain 1991; 45(2): 145-8.
Background: Cancer pain can remain refractory despite escalating opioids and adjuvants. Systemic Lidocaine is an option, but current approaches are hospital centered. While advantageous in advanced cancer, evidence is lacking for parenteral Lidocaine use in community-based care.
Objectives: Review evidence for parenteral lidocaine in complex cancer pain outside the hospital setting.
Design: Systematic review of peer-reviewed articles of any study design, including reviews. Search in four databases used keyword variations of ‘‘cancer,’’ ‘‘pain,’’ ‘‘Lidocaine,’’ and ‘‘parenteral.’’ Search was extended through reference lists of full texts assessed. Abstracted data from articles screened and selected were synthesized narratively by a palliative care clinician in Singapore.
Results: Eight hundred eighty-three articles identified were screened by title and abstract. Twenty-eight full texts were assessed. Seven articles fulfilled criteria for synthesis of findings. A total of 73 patients received parenteral Lidocaine for mixed pains, reported collectively in 1 retrospective chart review, 3 practice guidelines, 2 case series, and 1 case study. Intravenous or subcutaneous Lidocaine was commenced in hospital or hospice and continued at home. Dosages and administration schedules varied, involving slow bolus with continuous infusion or the latter alone, for up to 240 days. All produced positive outcomes, with no severe adverse events. Monitoring included routine vital signs and conscious levels; electrocardiogram, liver, and renal function tests were uncommon. Lidocaine levels were not consistently assessed.
Conclusion: Parenteral Lidocaine can be effective and safe in the community setting. More empirical studies are needed to inform patient selection and treatment protocol, and to validate expected outcomes.
In a 2021 poll in the United States,1 42% of households reported using telehealth “in the past few months,” with wide reported satisfaction (82%). Yet 64% of those same households say they would have preferred in-person care for their last visit. The articles below, selected from recent issues of Barry R. Ashpole’s Media Watch, focus on Telemedicine’s pros and cons as related to palliative care.
BMC Palliative Care | Online – 14 October 2021 –This qualitative study, conducted in the Burgundy region of France, shows that depending on the motive for which the nursing home calls on the mobile palliative care (PC) teams, telemedicine may be more or less suitable as a solution for the delivery of PC. Findings show that requests regarding patient symptoms may be particularly amenable to telemedicine. Conversely, psycho-social distress in a patient likely requires presence-based consultation. This study also identified “influencing factors” that impact on whether or not telemedicine could be used in specific PC situations.
Also: Comparing telemedicine with in-person care: Virtual Care in End-of-Life and Palliative Care: A rapid evidence check
Plos One | Online – 13 January 2022 – Across Australia, there are 242 specialist palliative care (PC) services, mostly located in major cities and large urban areas. People living in rural and remote communities often experience poor access to PC. Poor access to PC services, especially after-hours, can be very distressing for both patients and families especially. This can lead to patients’ symptoms not being managed in a responsive way. By enabling communities in rural and remote communities in Australia to have access to immediate after-hours PC services, telehealth can be useful in servicing these communities and overcoming issues of access and availability.
Also from Australia: Enhancing a Community Palliative Care Service with Telehealth Leads to Efficiency Gains and Improves Job Satisfaction
Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.