Application of palliative tunneled patient-controlled epidural analgesia in children with refractory cancer-related visceral pain and breakthrough pain: case report

Managing refractory cancer-related pain in pediatric patients with terminal-stage malignancies presents significant challenges, particularly when complicated by intestinal obstruction and cachexia. Conventional systemic analgesics often prove inadequate or intolerable. A 10-year-old female with pelvic rhabdomyosarcoma and multiple metastases developed refractory cancer-related visceral pain and breakthrough pain. After three weeks of standardized intravenous opioid therapy, analgesic effect remained unsatisfactory, and the patient developed severe intestinal obstruction and cachexia, rendering oral analgesics intolerable. Following multidisciplinary evaluation, tunneled patient-controlled epidural analgesia (PCEA) was initiated using a subcutaneous tunneling technique with an individualized regimen of sufentanil, ropivacaine, lidocaine, dexmedetomidine, and dexamethasone. The patient received PCEA for over one month, achieving significant pain relief with VAS scores reduced from 4 to 6 to 0–1 between breakthrough episodes. Breakthrough pain frequency decreased from 15 to 20 to 6–8 episodes per day, with rapid resolution within 3–6 min post-bolus. Muscle strength remained unaffected, activities of daily living and sleep quality improved markedly. Adverse effects were limited to mild hypotension and nausea/vomiting; no serious complications such as infection occurred. The patient maintained emotional stability and family interaction until peacefully passing away from tumor cachexia after 44 days of PCEA therapy. This case suggests that palliative tunneled PCEA may be safely and effectively used for pain management in children with terminal-stage refractory cancer-related visceral pain and breakthrough pain, potentially improving quality of life during the end-of-life period when conventional analgesic approaches fail.