Hospice and Palliative Medicine Flashcards
Constant, dull, aching, localized, changing with movement pain
Somatic
Deep, aching, cramping, poorly localized pain
Visceral
Burning, shooting, tingling, or shock-like pain
Neuropathic
Pain levels expected to interfere with function and sleep
Moderate (4-6/10) or greater
Pain levels expected to interfere with concentration
Severe (7-10)
Opioid selection in renal insufficiency?
Fentanyl and methadone
Opioid selection in hepatic insufficiency?
Fentanyl, hydromorphone, oxycodone, and methadone with caution
Methadone receptor profile
Mu and delta receptor agonist, NMDA receptor antagonist
Methadone re: serotonin
Inhibits reuptake
Methadone re: norepinephrine
Inhibits reuptake
Methadone Absorption
Lipophilic, Through the stomach, No transdermal application
Methadone Metabolism
Hepatic, with no known active metabolites
Methadone Elimination
Fecal
Methadone EKG effects
QT prolongation
Nociceptive Pain Mechanism
stimulation of intact pain receptors and transmission along normal nerves
Nociceptive Pain Prevalence
Most common type of pain
Nociceptive Pain Quality
aching, throbbing, sharp
Nociceptive Pain Examples
arthritis, myofascial pain
Neuropathic Pain Mechanism
injury to or disease of peripheral or central nerves
Neuropathic Pain Prevalence
Less common and often more difficult to treat
Neuropathic Pain Quality
tingling, burning, electrical, lancinating
Neuropathic Pain Examples
postherpetic neuralgia, diabetic neuropathy, complex regional syndromes
The only valid measure of pain is…
Self-report
% elderly with chronic pain?
70-80%
% elderly with constant pain?
30%
% of elderly with constant pain with regular pain medication available?
less than 1/3 (33%)
Verbal Agitation
High association with pain or other physical symptoms
PQRST of Pain History “P”
Palliative or Precipitating factors
PQRST of Pain History “Q”
Quality of life impact
PQRST of Pain History “R”
Radiation/distribution
PQRST of Pain History “S”
Severity
PQRST of Pain History “T”
Temporal patterns
piper methysticum (Kava Extract)
Effective in treating anxiety, causes Hepatotoxicity
Cognitive Behavioral Therapy
Best risk/benefit ratio for insomnia. Better than relaxation techniques.
Opioid Induced Neuroexcitability Symptoms
Increased Agitation, Hyperalgesia, Agitation
Aspiration pneumonia
Most common mechanism of death in dementia
Opioid Related Nausea
Try antiemetics, then rotate opioids
Complication from Transjugular Intrahepatic Portosystemic Shunt
Encephalopathy
Absence of pupillary or corneal response
High predictor of mortality in comatose patients
Malignant Spinal Cord Compression Diagnosis
MRI for patient with worsening back pain
Malignant Spinal Cord Compression Treatment
Surgery followed by radiation
Have opioids or benzos been shown to hasten death?
No
Management of Hiccups
Gabapentin
Accupuncture
Effective in Pain Management
Antihypertensive associated with constipation
Verapamil
Fee for service Medicare
Less likely to be referred to hospice
Prevents burnout
Activities that enhance mindfulness
Continue antibiotics
May be compatible with comfort only care
Agitated Delirium Treatment
Chlorpromazine
Status Epilepticus treatment without IV access
Midazolam
Treatment of myoclonus and seizures related to uremia
benzodiazepines
Manage secretions and minimize delirium
glycopyrrolate
Does not improve survival after elective extubation
BiPAP
Immediate intervention for SVC syndrome
Endovascular stent
Metabolic abnormalities cause nausea by stimulating this
Chemoreceptor Trigger Zone
Sensory input, anxiety, meningeal irritation, and increased ICP cause nausea by stimulating this
Cerebral Cortex
Helpful pain assessment dimension
Temporal pattern-pain fluctuations
Prognosis after electively stopping dialysis
7 to 9 days
Mortality after intracerebral hemorrhage
50%
Meaningful recovery after intracerebral hemorrhage survival
20%
Noninvasive treatment of pruritis in end stage liver disease
Naltrexone
Prognosis for independent functional recovery in myoclonus status epilepticus after circulatory arrest
1%
“Wind-up” pain is mediated by
NMDA receptors in the dorsal horn of the spinal cord
Most distressing symptoms to parents of dying children
low energy and decreased consciousness
Olanzapine method of action
Blocking dopamine receptors in the CTZ
Olanzapine trade name
Zyprexa
Useful complementary therapy for pain, anxiety, and fatigue and may improve quality of life
Massage Therapy
Common side effect of Ketamine
Psychomimetic symptoms
Acute fluctuating pattern and inattention
Delirium
Useful in treatment of odor in wounds with superficial anaerobic infection
Metronidazole
Cause of early satiety in cancer patients
Neuroendocrine alterations
Symptoms of systemic seratonin syndrome
Mental status changes, autonomic dysfunction, neuromuscular hyperactivity
Relative potency - Morphine (IV) : Morphine (PO)
3:01
Relative potency - Morphine (PO) : Oxycodone (PO)
3:02
Relative potency - Morphine (PO) : Hydrocodone (PO)
1:01
Relative potency - Morphine (PO) : Hydromorphone
4:01
Oral daily Morphine dose 60 to 134 mg
Transdermal Fentanyl 25 mcg/hour
Oral daily Morphine dose 135 to 224 mg
Transdermal Fentanyl 50 mcg/hour
Oral daily Morphine dose 225 to 314 mg
Transdermal Fentanyl 75 mcg/hour
Hopelessness
Frequently associated with requests for hastened death
Faster onset than typical oral opioids
Fentanyl buccal lozenge
Act at the NMDA receptor
Methadone, ketamine
Three major classes of opioid receptors
Mu, kappa, and delta
Mechanism of opioid action
Bind to receptors that inhibit calcium channels and prevent or induce the release of neurotransmitters
Preferred bowel regimen for opioid naive patient
Senna and docusate
The four components of total pain
Physical, emotional, social, spiritual
Unreliable markers for chronic and subacute pain
Physiologic signs of acute pain such as pulse and blood pressure
Meaningful pain relief with intolerable side effects from oral opioid therapy
Indication for neuraxial opioid infusion
Symptoms of opioid induced hypogonadism
Fatigue, erectile dysfunction, and depressed mood
Confer higher risk for future aberrant drug use
Psychiatric illness, personal or FHx of alcohol or drug abuse
causes of cortical nausea
CNS tumors, increased ICP, anxiety, uncontrolled pain
Have best evidence for use in delayed chemotherapy-induced nausea and vomiting
Ondansetron and aprepitant
Antineurokinin antiemetic
Aprepitant
Helpful in management of hypoactive delirium or apathy
Methylphenidate
First line treatment of nonspecific dyspnea in patients with advanced disease
Opioids
Always associated with opioid induced respiratory depression
Sedation
Frequently found in men with cancer cachexia
Hypogonadism
Effective short-term treatment of malignant colorectal obstruction
Self expanding metal stents
Opioid Induced Neuroexcitability Treatment
Rotate Opioids, add benzos
Changes prognosis in pts with advanced dementia with aspiration pneumonia
Nothing
Generic Percocet
Oxycodone/Acetominophen brand name
Generic Dilaudid
Hydromorphone brand name
Generic Vicodin
Hydrocodone/Acetominophen brand name
Generic Oxyfast, Oxycontin, Oxy IR
Oxycodone brand name
Generic MS Contin, MS IR
Morphine Sulfate brand name
ACC/AHA Stage C Heart Failure
Prior or current symptoms of heart failure
ACC/AHA Stage D Heart Failure
Refractory heart failure requiring specialized interventions
Lung volume reduction surgery outcome
Improved lung function, exercise capacity, and QOL
“B” in the BODE index
Body Mass Index
“O” in the BODE index
airway Obstruction (FEV1)
“D” in the BODE index
Dyspnea (MMRC dyspnea index)
“E” in the BODE index
Exercise tolerance measured by 6 minute walk
