LÜTFİYE PİRBUDAK, Ertuğrul KILIÇ, Alper SEVİNÇ, Göktürk MARALCAN

Pain management with intrathecal clonidine in a colon cancer patient with opioid hyperalgesia: case presentat

Hiperal jezi normalde ağrılı olan uyarana karşı verilen cevabın artmasıdır. Opioid hiperal jezisi, genellikle morfinin çok yüksek doz- larda kullanılması sonucu görülmektedir. Kırk yaşında, 45 kilogram ağırlığında erkek hastaya 2.5 yıl önce evre IV kolon kanseri tanısı konuldu. Hasta son bir yıl süresinde artan ağrıları için kontrolsüz ve gelişigüzel nonsteroid antienflamatuvar ilaçlar, opioid anal jezikler ve steroid preperatları kullandığı öğrenildi. Ağrı kontrolü için beş kez başvurdu. Son kontrolde, epidural anal jeziğe cevap vermeyen şiddetli abdominal, kasık, rektal ağrıları (VAS 8) olan hasta uykusuz, huzursuz ve panik halindeydi. Opioid toleransı dü- şünülerek hastaya intratekal 1 mg morfin uygulandı. İşlem sonrası bir saat içinde giderek artan ağrıları (VAS 8-9) olması nedeniyle opioid hiperal jezisi (OIH) düşünülerek hastaya i.v. deksketoprofen, diazem verildi. Şikayetlerinde gerileme olmadı. Sonra i.v. bolus deksmedetomidin (1µg/kg) takiben deksmedetomidin infüzyonu (0.2 µg/kg/h) başlandı. Şikayetleri gerileyen hastaya üç gün sonra diagnostik intratekal klonidin (30 µg) uygulandı, 30 dakika sonra ağrıları (VAS 1-2) rahatlayan hastaya intratekal port yerleştirildi. 90 µg/gün klonidin ile hem kanser ağrısı hem de OIH kontrol altına alındı. Hasta çok rahatladı, ağrısı ölünceye kadar dayanabilir düzeydeydi. İntratekal klonidin uygulanması OIH tedavisinde etkili bir yöntem olabilir.

Opioid hiperaljesi olan kolon kanserli hastada intratekal klonidin ile ağrı yönetimi: Olgu sunumu

Hyperalgesia is normally an increase in the response to a painful stimulant. Opioid-induced hyperalgesia (OIH) is a situa- tion frequently encountered in algology clinics. Its treatment is complicated and problematic and often requires alternative methods. A 40-year-old male patient 45 kg weighing had been diagnosed with stage IV colon cancer 2.5 years ago. He had used non-steroid antiinflammatory drugs, opioid analgesics and steroid preparations casually for his increased pain without any monitoring for one year. He was admitted five times for pain control. In the last visit, he complained of severe abdominal, pubic and rectal pain (visual analogue scale [VAS] 8), which was unresponsive to epidural analgesic, and later presented to the algology clinic; he was sleep-deprived, restless and in a panic state. Intrathecal morphine (1 mg) was applied considering his opioid tolerance. Because of increased pain (VAS 8-9) one hour after surgery for abscess in the liver and peritonea, the patient was given intravenous dexketoprofen trometamol and diazem considering his OIH. Then, bolus dexmedetomidine (1 µg/kg) followed by dexmedetomidine infusion (0.2 µg/kg/h) was started. Three days later, diagnostic intrathecal cloni- dine (30 µg) was applied, and the patients complaints regressed. With the patient reporting relaxed pain (VAS 1-2) after 30 minutes, an intrathecal port was placed. Both cancer pain and OIH were controlled with clonidine 90 µg/day. He was more relaxed, and his pain was tolerable until his death. Intrathecal clonidine administration may be an effective method for the treatment of OIH.

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