CONTROL OF SEVERE PAIN IN CHILDREN WITH TERMINAL MALIGNANCY

Objective: To identify the characteristics of the subset of children w ith malignancy in whom massive opioid infusions are needed during the terminal phase. Design: Retrospective review of the records of the 199 patients who died of malignancy after treatment at Children's Hospita l, Boston, from March 1989 to July 1993, identifying characteristics o f patients who required massive opioid infusions (operationally define d as infusion of >3 mg/kg per hour of morphine dose equivalent) during the terminal phase. Results: Twelve patients (6%) required massive op ioid infusions, and eight of these patients required extraordinary mea sures (epidural or subarachnoid infusion and/or sedation) to achieve a dequate analgesia. The duration of epidural or subarachnoid infusions in three patients ranged from 3 to 9 days, and minimal complications o ccurred. The duration of sedation ranged from 1 to 15 days. Maximal in travenous opioid dosing ranged from 3.8 to 518 mg/kg per hour of morph ine equivalent. The maximal infusion rate (exceeding all previous publ ished reports) occurred in an infant with an isolated metastasis in th e periaqueductal gray matter, a brain-stem site linked to mediating an algesia and defense reactions. The need for massive opioid dosing in 1 1 of 12 patients was associated with tumor spread to the spinal nerve roots, nerve plexus, large peripheral nerve, or spinal cord compressio n. Conclusions: Standard dosing of opioids adequately treats most canc er pain in children; however, a significant group requires more extens ive management. These problems occur more commonly among patients with solid tumors metastatic to spine and major nerves.