4 Palliative care, part 4 (Tanghal)

Question 1

remarks on morhpine

Answer 1

cheap
avoid morphine in moderate or severe liver/renal impairment

Question 2

remarks on fentanyl

Answer 2

more potent and less constipating than morphine
safer opioid in severe renal impairment

Question 3

remarks on oxycodone

Answer 3

twice as potent as morphine
metabolism and side-effect profile are similar to morphine

Question 4

indications for opioid switch

Answer 4

unacceptable side-effects
renal or liver failure
stable pain and difficulty swallowing
patient refuses morphine despite explanation

Question 5

opioid toxicity

Answer 5

first sign: sedation
late sign: hypotension

management:
- stop opioid
- ensure good hydration
- gentle verbal/mechanical stimulation
- caution with naloxone reversal (use small 400 mcg boluses)

Question 6

Steps in rapid opioid titration

Answer 6

1. select drug
2. select dose
3. set frequency
4. monitor
5. follow up

Question 7

IV morphine rapid opioid titration

Answer 7

dilute 1 ampule of injection morphine (10 mg / 1mL) with 9 mL of normal saline to achieve 1 mg/mL strength

Patient on doses morphine ≥60/day?
No: give 1 mg boluses q3-5 mins
Yes: give 2 mg boluses q3-5 mins

Question 8

IV fentanyl rapid opioid titration

Answer 8

dilute 1 ampule of injectionfentanyl (100 mcg/2 mL) with 8mL of normal saline to achieve 10 mcg/mL strenth

Patient on doses Fentanyl patch ≥25 mcg/hour?
No: give 10 mcg boluses q3-5 mins
Yes: give 20 mcg bolluses q3-5 mins

Question 9

remarks on opioid administration

Answer 9

target achieve acceptable subjective analgesia, or reduction of pain severity by 50%

stop when patient starts to get drowsy, dizzy, or adequate pain relief

remember sedation sets in before respiratory depression and hypotension

Question 10

what parameters to monitor when performing rapid opioid titration

Answer 10

1. time
2. pain score
3. respiratory rate
4. sedation (alert or drowsy)
5. opioid dose

take note of total effective dose of opioid, then give that dose every 4 or 2 hours (duration of action of morphine/fentanyl respectively)

Question 11

when to refer to pain or palliative care team?

Answer 11

if pain is persistent after 3 or 4 boluses

Question 12

examples of disorganized thinking

Answer 12

rambling speech/irrelevant conversation
unpredictable switching of subjects
unclear or illogical flow of ideas

Question 13

pharmacologic management of delirium

Answer 13

Haloperidol
commonly used as first-line drug
1-2 mg PO
or
1-2.5 mg stat IV/SC 6 hourly
5-10 mg/24 hour continuous SC infusion

Midazolam
mainly used as an adjunct to antipsychotic
(use with caution in the frail and elderly)
1-2.5 mg stat IV/SC
5-10 mg/24 hours continuous SC infusion

Question 14

remarks on fentanyl patches

Answer 14

do not initiate a patch in an acute pain setting
do not remove a patch in an acute pain setting

Question 15

where to apply a fentanyl patch

Answer 15

upper chest
outer arm
lower abdomen
hip

remember:
1. rotate skin site at each change of patch
2. in an agitated patient, choose a site that’s not easily accessible
3. ensure site is clean, dry, and free of creams

Question 16

remarks on SC infusion

Answer 16

infusion rate of medication should not exceed 2.5 mL/hour

change the SC catheter every 96 hours or whenever complications are evident

Question 17

sites of SC access

Answer 17

outer arms (needle directed upward)
abdomen (needle directed medially)
upper thighs

area with good depth of subcutaneous tissue
site that’s easily accessible

Question 18

common drugs used for SC infusion

Answer 18

morphine
fentanyl
haloperidol
midazolam
buscopan

Question 19

drugs contraindicated for SC infusion

Answer 19

diazepam
pethidine
prochlorperazine
chlorpromazine (antipsychotic)