Fast-track anesthesia and outcomes in hepatopancreatic cancer surgery: a retrospective analysis.

AIM: To assess the feasibility of a fast-track anesthesia protocol for hepatopancreatobiliary cancer surgery. METHODS: Retrospective analysis of consecutive sample of patients who underwent hepatopancreatic surgery for cancer for a period of 12 months in a high volume cancer center. Blended anesthesia was performed for most patients who were then observed in a recovery room area until achieving a safety score. RESULTS: Data of 163 patients were examined. Fifty-six and 107 patients underwent surgery for pancreatic cancer and liver surgery for primary tumor or metastases, respectively. Most patients were ASA 3. The mean durations of anesthesia and surgery were 322 min (SD 320) and 296 min (SD 133), respectively. Extubation was performed in the operating room in 125 patients. Post-operatory invasive ventilation was maintained in the recovery room in fifteen patients for a mean duration of 72.7 min (SD148.2). Only one patient was admitted to intensive care for 15 h. NIV was performed in three patients for a mean duration of 73.3 min (SD 15.3). The mean recovery room staying was 79 min (SD 80). The mean hospital postoperative stay was a mean of 8.1 days (SD 5.7). No complications were found in 144 patients. Globally, mortality rate was 3%. CONCLUSION: A program of fast-track anesthesia with a short stay in recovery room allowed to achieve a good outcome, limiting the costs of intensive care admission.

Palliative sedation outside a palliative care unit.

PURPOSE: The need of acute transition from an intensive care setting to an end-of-life setting requires collaboration and experience. Variable information exists on palliative sedation in traditional palliative care settings, including home care, hospices or palliative care units. MATERIALS: Four cases which required a rapid decision-making to alleviate suffering in patients close to death are described. RESULTS: Despite having different clinical pathways leading to intensive but medically non-beneficial treatments, patients were converted to a rapid transition of care in the unit where they had been admitted, due to different logistic reasons. An appropriate discussion with relatives about the short prognosis and the need to sedate for controlling suffering in the last hours of life was fundamental in preventing further suffering with intensive treatments. CONCLUSIONS: These clinical notes suggest that palliative care and end-of-life measures should be also expanded in other settings, where palliative care issues are traditionally not properly assessed, implementing the collaboration with other colleagues with different clinical extractions.

Methadone versus morphine for postoperative pain in patients undergoing surgery for gynecological cancer: A randomized controlled clinical trial.

STUDY OBJECTIVE: The aim of this study was to compare methadone and morphine for the management of postoperative. DESIGN: Open, controlled study. SETTING: Postoperative recovering area, ward. PATIENTS: Sixty-four patients, ASA I-III, undergoing gynecological surgery for cancer. INTERVENTIONS: Morphine or methadone 0.15 mg/kg given preoperatively. After operation an intravenous morphine or intravenous methadone infusion at doses of 12 mg/day was started. MEASUREMENTS: Pain intensity and opioid consumption. MAIN RESULTS: Methadone infusion provided a better analgesia in comparison with morphine infusion on the second day. Opioid consumption was significantly lower in the methadone group. No episodes of relevant desaturation or signs of respiratory depression were recorded. CONCLUSION: A preoperative bolus of methadone, followed by a continuous infusion of low doses post-operatively, provided a better analgesia, without adding risk of adverse effects, in comparison with morphine.

Supportive care services in hemato-oncology centers: a national survey.

BACKGROUND: In the field of hemato-oncology, there is paucity of data assessing models of integration between hemato-oncology and other partner specialties. The aim of this national survey was to gather information about the status of the integration of this kind of activity in hemato-oncologic units existing in Italy. METHODS: A national telephone survey was conducted to gather information about the status of the integration of hemato-oncologic and supportive care/anesthesiological services. From the national registry of hemato-oncology units, 149 centers were contacted by phone and a dedicated doctor was identified to gather information about the center through a telephone interview. RESULTS: Eighty-one centers (54.3 %) agreed to participate. A mean of 206 (SD 132) painful procedures/year/center were performed. No significant differences among regions and centers were found (P = 0.680). Of the centers, 41.9 % usually asked for anesthesiological consultation to perform painful procedures. No differences were found between the regions (P = 0.137). A mean of 1.8 (SD 1.2) days elapsed from the request to the procedure performance (P = 0.271). No differences among the regions were found (P = 0.350). A mean of 220 (SD 89) central venous vascular accesses/year/center were performed. No differences among regions were found (P = 0.170). No differences among the centers were found (P = 0.691). A mean of 1.8 (SD 1.2) days elapsed from the request to the performance of procedure. Of the centers, 64.2 % had a palliative care team. No differences among regions were found (P = 0.331). A mean of 31.5 (SD 12.2) consultations/year/center for pain control were required. No differences among the regions were found (P = 0.556). Of the centers, 30.8 % had some beds for palliative care. No differences among the regions were found (P = 0.641). Of the centers, 32 % had a hospice was available. No differences among regions were found (P = 0.298). CONCLUSION: Integration between hemato-oncology and other professionals is unlikely to be optimal in Italy. Such integration is complex and needs great efforts to solve several organizational problems.

Frequency and Indications of Parenteral Nutrition in an Acute Palliative Care Unit.

The aim of this study was to estimate the use of parenteral nutrition (PN) in advanced cancer patients enrolled in an acute pain relief and palliative care unit of a comprehensive cancer center and the appropriateness of the criteria to select patients for PN. Fourteen out of 750 patients (1.8%) admitted to an acute palliative care unit were administered PN. Patients were referred from various settings. The mean age was 58 yr (range 37-79), and 9 were males. The mean hospital stay was 7.7 days (range 3-14), and the mean Karnofsky level was 35 (range 10-50). The principal indication was bowel obstruction. Ten patients (71%) were already receiving PN before admission, and 2 of them discontinued the treatment during admission. Four patients (29%) started PN during hospital admission as decided by the staff. Twelve patients (85%) were discharged on PN. One week after hospital discharge, 9 patients were still receiving PN, 4 patients died, and no data were available for 1 patient. One month after hospital discharge only 2 patients of these were still on PN, 2 patients discontinued PN, and 5 patients died. This study shows that decisions to start or to stop PN were individually based on multiple considerations, not only clinical. Goals may vary from expected clinical benefits to compassionate use. The administration of PN should be assessed carefully and individually approached.

Long-term efficacy and tolerability of intranasal fentanyl in the treatment of breakthrough cancer pain.

PURPOSE: The aim of the present study was to assess the long-term tolerability and efficacy of intranasal fentanyl (INFS) in opioid-tolerant patients with breakthrough cancer pain (BTP). PATIENTS AND METHODS: A 6 months, observational, prospective, cohort study design was employed to follow advanced cancer patients with BTP receiving INFS under routine clinical practice. Eligible adult cancer patients suffering from BTP had been prescribed INFS at effective doses. Data were collected at T0 and at month intervals for six months. The principal outcomes were the evaluation of possible serious adverse effects with prolonged use of INFS, the efficacy of BTP treatment with INFS, the quality of sleep, the rate of INFS discontinuation, and reasons for that. RESULTS: Seventy-five patients were surveyed. Thirty-four patients (45.3 %) had a follow-up at 3 months, and twelve patients (16 %) were followed up at 6 months. The mean opioid doses, expressed as oral morphine equivalents, ranged 111-180 mg/day, while the mean INFS doses were 87-119 µg. Adverse effects were reported in a minority of patients and were considered to be associated with opioid therapy used for background pain. The quality of sleep significantly improved during the first 3-4 months. Finally, efficacy based on a general impression regarding the efficacy of INFS was good-excellent in most patients and statistically improved in time up to the third month. CONCLUSION: The long-term use of INFS in advanced cancer patients is effective and safe. No serious adverse effects were found up to six months of assessment. The level of quality of sleep and patients' satisfaction was relatively good, considering the advanced stage of disease.

Tracheal stent to repair tracheal laceration after a double-lumen intubation.

A 59-year-old woman was referred for a diagnostic video thoracoscopy under general anesthesia. At the end of the procedure, the patient presented with subcutaneous emphysema and cyanosis, abdominal distension, and bradycardia. A rigid bronchoscopy showed a longitudinal laceration in the pars membranacea of the trachea. A tracheal silicon stent was positioned on an emergency basis. She was intubated, positioning the tracheal tube cuff distal of the stent under bronchoscopic vision. A computed tomographic scan performed immediately after the procedure showed left pneumothorax, pneumoperitoneum, pneumopericardium, and diffuse subcutaneous emphysema. The subsequent course of the patient was uneventful. The patient was discharged home on postoperative day 4. After 1 year, the stent was removed with the evidence of complete trachel healing.

Switching from oxycodone to methadone in advanced cancer patients.

PURPOSE: The aim of this study was to prospectively evaluate the outcomes and the conversion ratio of switching from oxycodone to methadone in advanced cancer patients admitted to an acute palliative care unit. PATIENTS AND METHODS: A prospective study was carried out on a cohort of consecutive sample of patients receiving oxycodone, who were switched for different reasons mainly because of an inconvenient balance between analgesia and adverse effects. An initial conversion ratio between oxycodone and methadone was 3.3:1. Intensity of pain and symptoms associated with opioid therapy were recorded, and a distress score (DS) was also calculated as a sum of symptom intensity. A successful switching was considered when the intensity of pain and/or DS or the principal symptom requiring switching decreased at least of 33% of the value recorded before switching. RESULTS: Nineteen out of 542 patients admitted to the unit in 1 year underwent a switching from oxycodone to methadone. Almost all substitutions were successful. The prevalent indication for opioid switching was uncontrolled pain and adverse effects (12 patients). No significant changes between the initial conversion ratio and final conversion ratio between the two opioids were found. CONCLUSION: Switching from oxycodone to methadone is a reliable method to improve the opioid response in advanced cancer patients. A ratio of 3.3 appears to be reliable, even at high doses. Further studies should be performed to confirm these results in other settings and with very high doses of oxycodone.

Refractory death rattle: deep aspiration facilitates the effects of antisecretory agents.

Anticholinergic drugs, including atropine, hyoscine butylbromide, and scopolamine, have been shown to be equally effective in the treatment of death rattle. However, anticholinergic drugs may only be effective in reducing the production of further secretions, rather than eliminating the existing ones. A case is described in which a preventive procedure was undertaken to carefully eliminate secretions before starting anticholinergic drugs. Airway aspiration under light anesthesia removed secretions before starting anticholinergic drugs. Low doses of propofol were given intravenously to make a laryngoscopy feasible, allowing the complete aspiration of large amounts of tracheal secretions. No death rattle was perceived until death. Relatives were satisfied with the treatment and the peaceful death. Antisecretory agents may only prevent further accumulation of fluids along the airways and in the pharynx. The use of these drugs, supplemented by this aspiration procedure in carefully selected patients, may help eliminate death rattle in patients with advanced illness who are unable to cough or swallow. Explanation and reassurance to relieve fears and concerns regarding a procedure aimed to improve the quality of end-of-life care are of paramount importance, and active collaboration in decision making facilitates a timely intervention. This preliminary experience may help further research on the best treatment at the end of life.

An Italian survey on the attitudes in treating breakthrough cancer pain in hospice.

As recognition and treatment of breakthrough cancer pain (BcP) depend on the education and knowledge of palliative care physicians, it is important to systematically explore the attitudes of palliative care physicians in hospices or palliative care units. The aim of this study was to assess the knowledge and attitudes of hospice physicians in Italy regarding BcP and its treatment. All hospices existing in Italy were interviewed to gather information about provision of BP medication, drugs of choice, preferred route of administration, methods to choose the dose, and choice of BcP medication based on opioid administered for background analgesia. Of 158 hospices registered, 122 centers agreed with the interview (77.2%). Morphine was more frequently used, either orally or parenterally. In some hospices, oral transmucosal fentanyl (OTFC) was unavailable. Most physicians provided doses of opioids proportional to the opioid basal regimen, independently of the preferred opioid or the route of administration. The choice of dose titration was equally used in patients who were prescribed OTFC or parenteral morphine. The choice of breakthrough medication on the basis of opioid basal regimen was equally distributed. These findings suggest the need for improved education on behalf of physicians on the assessment and treatment of BcP, particularly in a potentially specialized setting, such as palliative care units. The choice of BcP medications should be based on the best cost-efficacy ratio rather than solely on economical considerations.

The use of opioids for breakthrough pain in acute palliative care unit by using doses proportional to opioid basal regimen.

OBJECTIVES: To determine the efficacy and safety of different opioids used in doses proportional to the basal opioid regimen for the management of breakthrough pain (BP). METHODS: In 66 patients consecutive patients admitted to a pain relief and palliative care unit, the efficacy and safety of different opioids used in doses proportional to the basal opioid regimen for the management of breakthrough pain (BP) were assessed. The choice of the opioid to be administered as rescue medication was based on the characteristics of patients, clinical stability, compliance, preference, and so on. For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging problems when pain became severe (T0), and to re-assess the patient 15 minutes after the opioid given as a rescue medication (T15). RESULTS: Six hundred twenty four episodes of BP were recorded during admission. Intravenous morphine (IV-MO) and oral transmucosal fentanyl (OTFC) were most frequently administered. Of 503 events available, 427 episodes were defined as successfully treated, while 76 episodes required a further administration of opioids. Pain intensity significantly decreased at T15 in all the groups (P<0.001). In 97.2% and 90.7% of cases treated with IV-MO, BP events had a reduction in pain intensity of more than 33% and 50%, respectively. In 99.2% and 97.6% patients receiving OTFC, BP events had a reduction in pain intensity of more than 33% and 50%, respectively. DISCUSSION: This survey suggests that doses of opioids for BP proportional to the basal opioid regimen, are very effective and safe in clinical practice, regardless the opioid and modality used.

Low doses of transdermal buprenorphine in opioid-naive patients with cancer pain: a 4-week, nonrandomized, open-label, uncontrolled observational study.

OBJECTIVE: The aim of this study was to evaluate the effect and tolerability of low doses of transdermal (TD) buprenorphine patches in opioid-naive patients with cancer pain. METHODS: This was a nonrandomized, open-label, uncontrolled study in consecutive opioid-naive patients with advanced cancer and moderate pain. TD buprenorphine was initiated at a dose of 17.5 microg/h (0.4 mg/d), with patch changes every 3 days. Doses were then adjusted according to the clinical response. Pain intensity, opioid-related adverse effects, TD buprenorphine doses, and quality of life were monitored over 4 weeks. The time to dose stabilization and indexes of dose escalation were also calculated. RESULTS: Thirty-nine consecutive patients completed all 4 weeks of the study. Low doses of TD buprenorphine were well tolerated and effective in these opioid-naive patients with cancer pain. Pain control was achieved within a mean of 1.5 days after the start of TD buprenorphine therapy. The mean TD buprenorphine dose was significantly increased from baseline beginning at 2 weeks after the start of therapy and had doubled by 4 weeks (P < 0.05). Pain intensity was significantly decreased from baseline beginning at 1 week and continuing through the remaining weekly evaluations (P < 0.05). The mean buprenorphine escalation index, calculated as a percentage and in milligrams, was 41.2% and 0.2 mg, respectively. Quality of life improved significantly over the study period (P = 0.007). There were no significant changes in opioid-related symptoms between weekly evaluations. CONCLUSION: Observations from this study suggest that randomized, controlled, double-blind studies of TD buprenorphine 17.5 microg/h in opioid-naive patients with cancer pain may be warranted.

Opioid switching and burst ketamine to improve the opioid response in patients with movement-related pain due to bone metastases.

OBJECTIVE: To improve opioid repsonse in patients with movement-related pain by using opioid switching adding a burst of ketamine. METHODS: Two patients with incident bone pain who had adverse effects with increasing doses of opioids were switched to methadone and a burst of 100 mg/d of ketamine for 2 consecutive days was added. RESULTS: Basal pain and pain on movement significantly improved. CONCLUSIONS: The development of breakthrough pain due to movement (incident pain), associated with bone metastases is so rapid that no medication as needed has such a short onset to parallel this temporal pattern of pain firing. Experimental studies have shown that bone metastases are characterized by a specific pattern of spinal hyperexcitation requiring higher doses of opioids. Optimization of basal opioid regimen may improve mobilization. However, adverse effects may more likely occur. The role of opioid switching and burst ketamine to further improve the opioid response has never been assessed in this context. Further studies in animals could confirm these preliminary data, with specific design to parallel this clinical context.

Frequency, indications, outcomes, and predictive factors of opioid switching in an acute palliative care unit.

The aim of this study was to prospectively evaluate the frequency, indications, outcomes, and predictive factors associated with opioid switching, using a protocol that had been clinically applied and viewed as effective for many years. A prospective study was carried out on a cohort of consecutive cancer patients who were receiving opioids but had an unacceptable balance between analgesia and adverse effects, despite symptomatic treatment of side effects. The initial conversion ratio between opioids and routes was as follows (mg/day): oral morphine 100=intravenous morphine 33=transdermal fentanyl 1=intravenous fentanyl 1=oral methadone 20=intravenous methadone 16=oral oxycodone 70=transdermal buprenorphine 1.3. The switch was assisted by opioids used as needed, and doses were changed after the initial conversion according to clinical response in an acute care setting. Intensity of pain and symptoms associated with opioid therapy were recorded. A distress score (DS) was calculated as a sum of symptom intensity. A switch was considered successful when the intensity of pain and/or DS, or the principal symptom necessitating the switch, decreased to at least 33% of the value recorded before switching. One hundred eighteen patients underwent opioid substitutions. The indications for opioid switching were uncontrolled pain and adverse effects (50.8%), adverse effects (28.8%), uncontrolled pain (15.2%), and convenience (4.2%). Overall, 103 substitutions were successful. Ninety-six substitutions were successful after the first switching, and a further substitution was successful in seven patients who did not respond to the first switch. The mean time to achieve dose stabilization after switching was 3.2 days. The presence of both poor pain control and adverse effects was related to unsuccessful switching (P<0.004). No relationship was identified between unsuccessful switching and the opioid dose, opioid sequence, pain mechanism, or use of adjuvant medications. Opioid switching was an effective method to improve the balance between analgesia and adverse effects in more than 80% of cancer patients with a poor response to an opioid. The presence of both poor pain relief and adverse effects is a negative factor for switching prognosis, whereas renal failure is not.

Effects of red blood cell transfusion on anemia-related symptoms in patients with cancer.

The aim of this study was to assess the effects of red blood cell transfusion, and the subsequent increase in hemoglobin values, on anemia-related symptoms in a cohort of patients with cancer with different survival times. A red blood cell transfusion was recommended to a consecutive sample of patients with hemoglobin levels of 8 +/- 0.5 g/dL. The number of units to be ordered was decided according the hemoglobin values with a mean target of increasing the hemoglobin values by approximately 2 g/dL. Hemoglobin values, anemia-related signs and symptoms, including well-being, fatigue, and dyspnea, were recorded at admission (T0), 1 day after the last transfusion (T1), and 15 days afterward (T2) by telephone contact or visit. Well-being, fatigue, and dyspnea were measured on a numerical scale of 0-10. Sixty-one patients were recruited in the period of study. One hundred thirty-three units of red blood cells were transfused (mean 2.18, 95% confidence interval [CI] 0.6). Complete data were available for 40 patients. Hemoglobin values and well-being significantly increased after transfusion (T1), maintaining acceptable values 15 days afterward (T2). Significant changes in fatigue and dyspnea were found immediately after transfusion, although the effect was partially lost 15 days after transfusion. No statistical differences were found between patients with different survival times. Fatigue was significantly lower in patients with longer survival times in comparison with patients with shorter survival times (p = 0.04). Blood transfusion in patients with hemoglobin values of approximately 8 g/dL improved anemia-related symptoms on a short-term basis. This benefit is independent of the stage of disease and survival. However, the effects on dyspnea and fatigue tend to decrease within 15 days, despite the maintenance of hemoglobin values attained after transfusions, suggesting that other factors may play a role.

High-dose furosemide and small-volume hypertonic saline solution infusion for the treatment of leg edema in advanced cancer patients.

Peripheral edema is a common feature in populations with advanced cancer, although it is seldom recognized. Diuretics are commonly employed and may show some benefit, but there are insufficient clinical trial data to draw useful conclusions about their clinical use. The aim of this prospective study was to evaluate the efficacy and tolerability of high-dose furosemide and small-volume hypertonic saline solution infusion in reducing leg edema in patients with advanced cancer treated unsuccessfully with diuretics. A prospective study was performed in a consecutive sample of 24 patients admitted to a pain relief and palliative care unit over a period of 18 months. To be eligible to enter the trial, advanced cancer patients had to have diffuse bilateral leg edema unresponsive to common doses of diuretics. A solution of 60 mEq of NaCl, 250 mg of furosemide, and 150 mL of normal saline were infused over 20 minutes. The treatment was repeated twice a day for two days and eventually continued on the basis of the clinical outcome. Circumferences were measured at the foot, ankle, calf, and thigh before starting the treatment (T(0)) and at intervals of 24 hours (T(1) and so on). At the same intervals, diuresis was determined. Patients were asked to score their sensation of leg weakness/heaviness on a numerical scale from 0 to 10, before (T(0)) and after the treatment (T(end)). An appreciable improvement in the sensation of weakness/heaviness (score reduction of at least two points) was recorded in all the patients. A small decrease in leg circumferences at the different sites was found, and a mean of 3600 mL/day of diuresis was recorded. These observations suggest that high-dose furosemide and small-volume saline may be an effective strategy for the treatment of peripheral edema in patients with advanced cancer.

Controlled sedation for refractory symptoms in dying patients.

Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. A prospective cohort study was performed on a consecutive sample of dying patients admitted to an acute pain relief and palliative care unit within a cancer center. Indications for sedation, opioid and midazolam doses, level of delirium and sedation, nutrition, hydration, rattle, inability to cough and swallow, pharyngeal aspiration, duration of sedation and survival, and use of anticholinergics or other drugs were recorded. Family members were interviewed. Forty-two of 77 dying patients were sedated, and had a longer survival than those who were not sedated (P=0.003). Prevalent indications for sedation were dyspnea and/or delirium. Twelve patients began with an intermediate sedation, and 38 patients started with definitive sedation. The median sedation duration was 22 hours. Opioid doses did not change during sedation. Agitated delirium significantly decreased with increasing doses of midazolam, whereas the capacity to communicate concomitantly decreased. Interviewed relatives were actively involved in the process of end-of-life care, and the decision to sedate, and the efficacy of sedation, were considered appropriate by almost all relatives. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.

A randomized-controlled study of intrathecal versus epidural thoracic analgesia in patients undergoing abdominal cancer surgery.

BACKGROUND: We sought to determine the effectiveness of continuous intrathecal thoracic analgesia (ITA) in comparison with continuous epidural thoracic analgesia (ETA) for the management of postoperative pain after abdominal cancer surgery in a randomised controlled study. MATERIALS AND METHODS: Catheters were inserted at T8-10 level for both techniques. Sixty patients were randomized to receive ITA providing levobupivacaine 0.25%, at 0.5-0-7 ml/h, associated with a single bolus of morphine 0.15 mg, or ETA with levobupivacaine 0.25% 4-6 ml/h and a single bolus of epidural morphine 2-3 mg. Data were collected before discharging from recovery room to the surgical ward, 1, 2, 3, 8, 12, 24 h, and 48 h after operation. The primary outcome was pain intensity evaluation. Postoperative morphine consumption, hemodynamics, fluids, and blood losses for the first postoperative 48 h, surgical outcome, hospital stay, and complications were also collected. RESULTS: Pain intensity at rest mean values ranged from 1.12 to 1.44 and from 1.04 to 1.20 in ITA group and ETA group, respectively. Dynamic pain intensity mean values ranged from 1.28 to 1.70 and from 1.16 to 1.80 in ITA group and ETA group, respectively. No significant differences were found between the two groups. Total amount morphine consumption was minimal in both groups, 4.4 mg (+/-2.9) and 3.1 mg (+/-2.4), for ITA and ETA groups, respectively. There were no severly sedated patients. Hemodynamic variables, diuresis, amounts of fluids, and red cell transfusion were equivalent between the groups. No important technical complications were reported in both groups and postoperative surgical complications were not related to the examined techniques. CONCLUSION: ITA and ETA produced the same levels of analgesia, without relevant complications.

Peritoneal catheter for continuous drainage of ascites in advanced cancer patients.

INTRODUCTION: Advanced cancer patients with refractory ascites do not often respond to dietary sodium restriction and diuretics. While paracentesis is effective, the condition invariably recurs, necessitating repeated procedures. A continuous peritoneal drainage by an indwelling catheter has been reported to be hugely beneficial symptomatically, avoiding the hazards and disadvantages of multiple repeated procedures and direct and indirect costs. MATERIALS AND METHODS: Forty patients with advanced cancer patients admitted to an acute pain relief and palliative care unit, who presented symptomatic ascites, were recruited for continuous drainage of peritoneal fluid. A central venous catheter set for Seldinger technique was used. Technical failure was defined as an unsuccessful drainage of fluid through the catheter. Immediate and late complications, including hypotension, haemorrhage, tube blockage, dislodgment and sepsis were recorded. Record of daily drainage during admission were noted. At time of discharge, patients were asked to rate their global symptom burden as improved, unchanged or worsened. The follow-up was performed with frequent phone contacts or day-hospital admission in case of problems. RESULTS: The mean patients' age was 68 years, and 21 were men. Patients were receiving unsuccessfully a mean dose of furosemide of 32 mg/day. The technique was not painful and was easily accepted by patients. Insertion was technically successful in almost all patients. Mean admission time was 5.5 days (range 2-14), and the mean drained volume during admission was 8,499 ml (range 800-20,700), 2,850 ml (300-4,200) being drained on the first 24 h. No immediate complications were recorded. Six patients died during admission. The mean survival was 38.9 days (range 1-120). Of the 34 patients who were discharged home, 22 patients stated that symptom burden had improved, while in 10 patients symptom burden did not change or worsened, probably due to the advanced status of diseases and multiple contributing factors. Five, two, and one patients required skin sutures at 1, 2 and 3 months, respectively. About one third of patients had mechanical problems, some of them requiring a catheter replacement. No infection was recorded. CONCLUSION: In conclusion, a permanent peritoneal catheter was a valuable method to remove abdominal fluids and reduce symptom burden attributable to ascites and was also easy to use at home. Complication rate was acceptable and balanced by the benefits of the technique which avoided frequent paracentesis and associated complications.