Managing Pain and EOL Care Flashcards
Goal for Treating Acute Pain
- should not be zero pain- rather a tolerable level of pain that allows optimal physical and emotional function
- expectations should be discussed with patients and their families
- “The goal is to find the lowest effective analgesic dose as well as the amount needed before re-evaluation is necessary”
Acute Pain Treatment Options
non opiod
opiods
•ANALGESICS- NON-OPIOID
Acetaminophen (↓ production of prostaglandins)
- 4 gram/day limit (325mg, 500 mg)
NSAIDS
- COX-1
- •Ibuprofen (Motrin, Advil)
- •Naproxen (Aleve, Naprosyn)
- •Meloxicam (Mobic)
- COX-2- Celecoxib (Celebrex)
SHORT-ACTING: FOR ACUTE PAIN
- Hydrocodone - Only Combination
- Oxycodone - Alone or Combination
- Hydromorphone (Dilaudid)
- Tramadol- Alone or in Combo
- Codeine – Combination
short vs long acting opiods
SHORT-ACTING: FOR ACUTE PAIN
- Hydrocodone - Only Combination
- Oxycodone - Alone or Combination
- Hydromorphone (Dilaudid)
- Tramadol- Alone or in Combo
- Codeine – Combination
LONG-ACTING: avoid in acute pain
- Oxycodone (OxyContin)
- Morphine sulfate (MS Contin)
opiod side effects
•Somnolence - these medication can make you sleepy
•Depression of brainstem control of respiratory drive
•Urinary retention- make it hard to move your bowels’
•Nausea and vomiting - may make you sick to your stomach’
define multimodal approach
- Uses several agents or techniques, each acting at different sites of the pain pathway
- Reduces the dependence on a single medication and mechanism, and importantly, may reduce or eliminate the need for opioids
- Synergy between opioid and nonopioid medications reduces both the overall opioid dose and unwanted opioid-related side effects
Perioperative Pain Management Goals
optimal strategy??
- to relieve suffering
- achieve early mobilization after surgery
- reduce length of hospital stay
- and achieve patient satisfaction
***The optimal strategy for perioperative pain control consists of multimodal therapy to minimize the need for opioids
Opiod examples
combos
Codeine 15 to 60 mg orally every four to six hours
Oxycodone 5 to 30 mg orally every four to six hours
Hydrocodone 2.5-10 mg orally every four to six hours
Hydromorphone 2 to 4 mg orally every four to six hours
COMBOS- one or two tablets orally every four to six hours
oxycodone-acetaminophen (combinations of 300 to 325 mg acetaminophen/2.5 to 10 mg oxycodone,oxycodone-aspirin (325 mg aspirin/4.8 mg oxycodone,
hydrocodone-acetaminophen (5mg/325mg,7.5 mg/325mg,10 mg/325 mg;
acetaminophen-codeine (Tylenol No. 3, which is 300 mg acetaminophen/30 mg codeine,
*** A dose reduction of approximately ____ and a____ frequency is warranted for
- older or debilitated adults
- patients with impaired liver or kidney functioning
- low cardiac output, or respiratory compromise
*** A dose reduction of approximately 50% and a reduced frequency is warranted for
- older or debilitated adults
- patients with impaired liver or kidney functioning
- low cardiac output, or respiratory compromise
*** A dose reduction of approximately 50% and a reduced frequency is warranted for what pt populations??
older or debilitated adults
patients with impaired liver or kidney functioning
low cardiac output, or respiratory compromise
approach for radicular LBP in weekend warrior
This approach would offer:
- Cyclobenzaprine a muscle-relaxant - address the spasm
- Ibuprofen _anti-inflammator_y - ↓ inflammation of muscles
- Oxycodone an opioid analgesic -offer an analgesic effect to the current presentation
managing LBP
acute
chronic
Acute -
- 6 wk conservative tx (NSAID + activity modifiers)
- muscle relaxant - caution causes sedation
-
Glucocortioic inj - only after failure of 4-6 wk conserv therapy
- MRI is prereq
- speed short term pain but DOES NOT alter dz progression
Chronic
- same as above can include surgical intervention if all other therapy fails (not reccommended for nonspecific LBP)
- radicular sx
- neurgenic claducation from lumbar spinal stenosis
- worsening nuero deficits
- opiods as last resort
pharmacologic vs nonpharm tx for MSK pain
Nonpharm
- PT - preferred tx
- psychological approaches - pts w/ chronic pain likely have anxiety or depression and vice versa
- complementary therapy
Pharm
- Acetametophen / NSAIDs - prongly reccommended
- Muscle relaxants - risk of sedation
- opiods - typically not reccommended
- glucocorticoid inj
nonpharm tx for knee & hip osteoarthritis
PT / lifestyle modifications - FIRST LINE
- excercise to build muscle/ dec weight
Knee Brace - compliant pts
non opiod tx of knee & hip osteoarthritis
Acetametophen - mild sx
Systemic NSAID - alone or in conjugation w/ acetametophen
- INC risk of CV events
- DEC pain in degenerative joint dz
Topical NSAIDs - FIRST line in knee & hand osteoarthitis
- DEC risk of adverse effects / less systemic absorption
Glucocorticoid Injections - DEC pain w/o significant adverse events
Surgery - joint replacement if fail conserv therapy
Opiod tx of osteoarthritis
joint replacement better option
started in select cases
Signs of impending Death
- DEC blood perfusion to skin –> mottled, discolored, cyanotic skin
- DEC level of consciousness or delirium
- DEC CO & intravascular volume –> tachycardia, hypotension
- DEC urinary output –> urinary incontinence & concentrated urine
- Retention of secretions in the pharynx & upper airway ® noisy respirations (“death rattle”)
- Respirations w/ mandibular movements
- Dyspnea
- Profound weakness & fatigue
- Disorientation
- Weight loss/dehydration (third spacing)
- Swallowing difficulties
- DEC peripheral pulses
- Cheyne Stokes Respirations – noisy gurgling respirations due to secretions
Pain at end-of-life –> 3 principles (WHOS step-care approach)
list 3 types of pain
Nociceptive pain
Neuropathic
Inflammatory
type of pain that can be
Somatic or visceral.
si/sx of somatic vs visceral pain
Nociceptive pain
Somatic: Aching, throbbing, stabbing, pressure
Visceral: gnawing, cramping, sharp, stabbing – internal organs
Continuous dysesthesias, chronic lancinating or paroxysmal
described as “burning or electrical”
Tx??
Neuropathic
- Tricyclics
- SNRI
- antidepressants
tx of nocioceptive pain
NSAIDs
corticosteroids
possibly opioids
pain seen in RA, IBD.
similar to what type of pain?
Tx?
Inflammatory- released inflammatory mediators. RA, IBD.
similar to nociceptive pain in terms of character.
Tx: Anti-inflammatory
differetiate acute vs chronic pain
examples of each
Acute Pain: Lasting < 3 months and is a neurophysiological response to noxious injury that should resolve with normal healing process.
- Fx in bones, post labor pain, appendicitis
Chronic Pain: Lasting more than 3 month or beyond the expected course of an acute disease.
- Extends beyond the time of normal wound healing with the development of neurophysiological changes in CNS
- Low back pain, neck pain, chronic pancreatitis
define break through pain and how to manage
occurs when patient has pain between doses of long-acting formulations
- Hospice/ Terminal patients on average experience breakthru pain 3 times a day rating it 7 out of 10
Immediate release preparations are helpful
- Each dose should be 10-30% of the total daily dose of sustained release
- 60mg of OxyContin a day = breakthru will be 15mg q 4 hours.
Opioid Tolerance can develop, may need to rotate through other pain medications
pt experiencing break through pain:
Frequent immediate release use –> _____ in sustained release dosing.
Frequent immediate release use –> increase in sustained release dosing.
pain mgt challenges
Failure to recognize or differentiate pain from anxiety
- “pain catastrophizing” Magnification, rumination, helplessness
Lack of education to health care providers
Safety concerns, fear of patient addiction or prescription legality.
Lack of pre-existing Patient-healthcare provider relationship
Pressure to see patients rapidly
Unstable patients may not be able to verbalize/ express their pain appropriately
Stereotypes
Genetics/ Ethnicity: some groups are known to carry genetic mutations of the liver CYP450 enzyme and may metabolize some pain medications more rapidly.
describe adult nonverbal pain scale (0-2)
face
activity
guarding
physiology
respiratory
opiods MOA
Mu receptor is 7 trans-membrane G Protein coupled receptor
- Binding stabilizes the membrane so neuron can’t fire (↓ neuron transmission)
- Located in the PERIPHERY, dorsal root ganglia of spinal cord, grey matter in brainstem, midbrain and gut
weak vs strong opiods
WEAK Opioids = Codeine, Hydrocodone, Oxycodone
STRONG Opioids = Hydromorphone, Fentanyl, Morphine
formulationf of opiods
PO
IV
Buccal
TD
IV- Morphine, Hydromorphone, Fentanyl
PO – Morphine (LA, SA), Hydromorphone, Oxycodone, Hydrocodone, Methadone
BUCCAL & TD– Fentanyl
opiod C/I in AKI / Renal failure
Why??
Morphine
•bc toxic metabolites will accumulate causing neuroexcitation/CNS effects (ex. jitters, spasms)
opiod C/I in cachexia
•Fentanyl – need to have subcutaneous fat to be effective
opiod drug of choice in renal failure
Hydromorphone – inactive metabolites
considerations when prescribing Methadone
Phase I metabolism and may cause QTC prolongation
- caution when changing from one opioid to methadone
- need three doses
- EKG before and at every visit/ day if in hospital
tx of uncontrolled pain
nerve bloks
Why are Morphine Mg Equivalents is useful in treating a patient’s chronic pain
Useful when determining a treatment threshold and recognizing at what dose a patient is at risk for overdose
50 MME/day
- Hydrocodone 50 mg/day
- Oxycodone 33 mg/day
- Methadone 12 mg/day
Most frightening symptom for patients, families and healthcare team during EOL care
causes?
Dyspnea
Causes (mismatch in supply/demand)
- Airway obstruction
- Muscle weakness
- Cardiac Causes
- Anemia
- Intra abdominal process
- Psychological
- Can also be exacerbated by anxiety of the patient and anxiety of the families
pharmacological tx of dyspnea
Oxygen: may help even when not measured to be hypoxic
OPIODS: Morphine sulfate (fentanyl, hydromorphone, oxycodone)
- Venodialators, sedatives work by decreasing the sensitivity of the ribcage muscles to decrease perception of dyspne (Does not increase PCO2)
- If currently on opioid for chronic pain, dose by 25-50%
- Most effective relief of dyspnea correlates to a steady-state blood level of opioids (AVOID peaks & valleys)
BENZODIAZEPINES/ ANXIOLYTICS: (Ativan 0.25-2mg)
- Decrease anxiety/ decrease thoracic-abdominal response
bronchospasm, SVC Obstruction, lymphangitic carcinomatosis, tracheal obstruction–> S_TEROIDS: Dexamethasone,_ Prednisone
- (dec inflammation in airways / nothing else then use it)
THORACENTESIS or PARACENTESIS – pleural effusions
Palliative Radiation if caused by mass lesion
Inhaled bronchodilators if bronchospasm
nonpharm tx of dysnpea
- Avoid exacerbating activities but be sensitive to isolation
- Reduce temp and maintain humidity (cool & moist air)
- Window, bring patient outside
- Avoid irritants
- Elevated HOB
- Relaxation Therapy – Reiki, meditation, play soothing music
if patient on opioid for pain and then develops dyspnea, increase dose by ___-___%
, if patient on opioid for pain and then develops dyspnea, increase dose by 25-50%
MOST EFFECTIVE Relief of dyspnea best correlates with ???
MOST EFFECTIVE Relief of dyspnea best correlates with steady-state blood levels of opioids.
- Suppression of respiratory drive happens with PEAKS AND VALLEYS. (don’t want – need steady-state)
tx of excessive oropharyngeal secretions
atropine opthalamic 1% drops
Glycopyrollate / Hyoscyamine - most used
scopralamine transdermal patch - avoid in elderly may cause confusion
causes of nausea, vomiting
mediators?
Nausea: Caused by stimulation of GI Lining, chemoreceptor trigger zone in base of the 4th ventricle, vestibular apparatus or cerebral cortex
Vomiting: a neuromuscular reflex centered in the medulla oblongata
Mediators: Serotonin, dopamine, acetylcholine, histamine
etiologies of N/V
Think the Ms
- Mets
- Meningeal irritation
- Movement
- Mentation
- Medications
- Mucosal irritants
- Mechanical Obstruction
- Motility
- Metabolic
- Mircobes
- Myocardial
nonpharm tx of N/V
Relaxation
Cognitive Training
TEMS/ Acupuncture
pharm tx of N/V
Dopamine Antagonists - pramipexole dihydrochloride, roprinole
- activates receptors in the brain that produce dopamine, a chemical that helps regulate movement and mood
Histamine Antagonists – Diphenhydramine, Meclizine,
Anticholinergics - Promethazine (Phenergan), Scopolamine (↓oral secretions)
Serotonin Antagonists – Zofran (cause constipation & HA)
Pro-kinetic Agents – Metoclopromide – get gut moving –
- CI in anyone w/ Bowel obstruction
Antacids - Tums
Steroids – Dexamethasone consider in suspected malignant BO or w/ ↑ICP)
anticipatory nausea
Cannabinoids – synthetic and natural & BDZ – Ativan
N/V med that cause constipation & HA
Zofran
N/V med that gets gut moving & CI in anyone w/ Bowel obstruction
Pro-kinetic Agents – Metoclopromide
N/V med that also ↓oral secretions
Anticholinergics - Promethazine (Phenergan), Scopolamine
list Dopamine Antagonists used to tx N/V
pramipexole dihydrochloride, roprinole
•activates receptors in the brain that produce dopamine, a chemical that helps regulate movement and mood
etiology & Dx of constipation
Etiologies: Drugs!!! (Opioids in particular), Metabolic, Diet, Decreased Motility, Spinal Cord Compression, Mechanical Obstruction, Dehydration, Autonomic Dysfunction, Ileus
Rectal Exam to detect : mass, impaction, hypotonia
Tx of the CAUSE may not always be appropriate in advanced stages
nonpharm tx of constipation
Scheduled toileting
Position to sit upright
Encourage fluids
AVOID bulking agents such as bran, may precipitate the obstruction
pharm tx of constipation
Laxatives:
- •Stimulant laxatives
- •Osmotic Laxatives
- •Detergent laxatives (Stool softeners)
Enemas: lubricant and large volume
Opioid antagonists: Methylnaltrexone – reverse effects of opioids on constipation )
- NO bowel obstruction or ileus
Methylnaltrexone used to tx
C/I??
Opioid antagonists: –reverse effects of opioids on constipation
•NO bowel obstruction or ileus
Signs and Symptom of terminal delirium
can be reversible & look for reversible causes)
- agitation
- myoclonic jerks or twitching
- irritability and impaired consciousness
- hallucinations
- paranoia
- confusion and disorientation.
nonpharm tx of terminal delirium,
Create a familiar environment
Reassure the family, explain common in terminally ill.
Give the patient permission to let go
Use touch, soothing touch
Maintain Sleep-Wake cycles
pharm tx of terminal delirium
Benzodiazepines – Lorazepam, Midazolam
Nueroleptics – Haldol, Chlorpromazine (Treat Seziures)
EOL symptom Frequently seen with Asthenia,
anorexia
pharm tx of anorexia
Steroids: mechanism is unclear – prostaglandin inhibition, DEXAMETHSONE 2-4 mg PO BID, benefit will likely decrease after 4-6 weeks
Progesterone Drugs: inhibit production of Cachexin,
- TNF – MEGACE 200mg q6-8 hrs
Mitrazapine 15-30 QHS
Androgens
Cannabinoids
Easy tiring, generalized weakness, or mental tiredness
May be seen as sign of “failure” or “giving up” by dying person and loved ones
Asthenia
Causes of asthenia
- Direct tumor effects on energy
- Paraneoplastic syndromes
- Humoral and hormonal influences
- Anemia
- Chronic infections
- Sleep disturbances
- Fluid & electrolyte disturbances
- Drugs
- Over-exertion
Most distressing symptom in dying patients
Asthenia
nonpharm tx of asthenia
- Develop a plan with patient and families to allow them to perform enjoyed activities:
- Coordinate activities with times of most energy
- Arrange for help from family, home care, CCAC, hospice, nursing home
- Use energy conservation strategies (occupational/PT consult)
- Change medications and/or times
- Daytime rest and effective sleep at night
pharm tx of asthenia
Among the most difficult symptoms to treat
Steroids: mechanism not clear –? Euphoria (dexamethasone)
Metamphetamines: act as psychostimulant
- Methylphenidate
- Side Effects: tremulousness, anorexia, tachycardia, insomnia &myocardial ischemia
Causes of Terminal Delirium and Agitation
Opioid toxicity- High or prolonged opioid administration -> sedation, neuroexcitation and agitated delirium.
Pain Uncontrolled and severe pain can cause agitation
Drug interactions - Many drugs used in palliative care,
- hypnotics
- antimuscarinics
- anticonvulsants
Fever or sepsis - The onset of delirium can occur with fever (which can reduce cerebral oxidative metabolism).
Hypercalcemia the most common life-threatening metabolic disorder in cancer patients.
- It can lead to a confused and agitated state
- calcium levels should be monitored.
Raised intracranial pressure- Brain tumors or cerebral metastasis can increase intracranial pressure, leading to an agitated state.
delirium may be due to an imbalance b/w acetylcholine & dopamine
the most common life-threatening metabolic disorder in cancer patients.
Hypercalcemia.
- It can lead to a confused and agitated state
- calcium levels should be monitored.
familt education points about Exsanguination
Will occur suddenly and high-volume arterial bleed can cause death within minutes
- Educate the family about this risk of bleeding.
- Explain to family members that death due to exsanguination is extremely rapid and thus most patients are dead almost instantaneously and thus their suffering is unlikely to be prolonged.
causes of exsingunation deaths
head and neck tumors which erode into the carotid artery.
nonpharm and pharm tx of exsinguination
Nonpharm - Remove all white bed linen and replace with a dark color linen (green or brown preferred)
Pharm - parenteral benzodiazepine to alleviate anxiety/ suffering
- “midazolam 5 mg sub cutaneous stat on bleeding, may repeat once after 5 minutes for evidence of suffering.”
Meds in Hospice Comfort Kit
define
Bereavement
Anticipatory grief
Bereavement - grief that occurs after the death
Anticipatory grief is a normal grief reaction to perceived loss during the dying process. Dying people (and their loved ones) prepare for death by mourning the various losses implicit in the death.
N/V med you use in suspected maligannt BO or INC ICP
corticosteroid - dexamethosone
