Pain management Flashcards
What is malignant pain?
Tissue damage caused by malignant tumours. tumour in the tissue/organ. can be constant or ‘breakthrough pain’
nociceptive pain: tissue/organ distortion or injury (somatic = bone, muslce) (visceral = gut, bladder)
neuropathic pain: damage to the nerve fibres
define constant pain
constant pain-
tumour causing pressure (distention / stretch)
not affected by position or activity. more likely in confined space (skull, pelvis)
constant and unchanged
what is breakthrough pain
rare flare-up, rapid onset, moderate=severe intensity, short duration,
define neuropathic pain
damage to nerve fibres, peripheral and central nervous system changes
burn, stabbing, hyperaesthesia
unpredictable
less responsive to opioid analgesics
opiate dose equivalent chart
on st Lukes website) (Ratios
codeine is x10 weaker than morphine (60mg codeine= 6mg morphine)
25mcg of fentanyl = 90mg oral morphine
fentanyl is the least constipating (morphine and codeine are very constipating- prescribe laxative and senna)
what is the ratio for breakthrough doses?
a total daily dose of background dose (240)
divide by 6= 40mg
40mg is the breakthrough dose of oramorph
what is the oral oxycodone and oral morphine ratio?
twice as potent as oral morphine
20mg of morphine
/2
10mg oxycodone
what is the oral morphine to subcutaneous diamorphine ratio?
switch from oral to subcut if unable to swallow, nausea and vomiting, dysphagia, last days of care, coma
ratio divide by 3 subcut diamorphine
subcut morphine divide by 2
neuropathic pain tx
corticosteroids
morphine
gabapentin (anticonvulsant)
tapentadol
renal impairment- opiate toxicity
morphine is metabolised to M6G and relies on the kidneys to excrete so if renal impairment, cannot clear their morphine= side effects
drowsy, confused
pinpoint pupils (muscle contraction)
myoclonic jerks
renal impairment- opiate toxicity
morphine is metabolised to M6G and relies on the kidneys to excrete so if renal impairment, cannot clear their morphine= side effects
drowsy, confused
pinpoint pupils (muscle of the iris contraction)
myoclonic jerks
naloxone to reverse opiates
WHO pain ladder
non-opioid +/- adjuvant
opioid for mild-moderate pain + non-opioid + adjuvant
opioid for moderate to severe + nonopioid + adjuvant
MOA opioids
agonist for specific receptor sites at nerve cell synapse
Mu, kappa, delate receptors
weak opioids
oral codeine transdermal buprenorphien (weekly patches) oral tramadol
strong opioids
use is dictated by the therapeutic need, not by prognosis
morphine, diamorphine, alfenanil (injectable), fentanyl, oycodone, tapentadol, methadone
prescribing oral morphine (oramorph)
immediate release
oramorph liquid 4 hrly, PRN
sevredol tablets
slow release
zoramorph- release over 12hrs
MST tablet bd
MXL capsules bd
oxycodone
strong opioid used 2nd-3rd line
fentanyl
pure mu-opioid
highly lipid-soluble
poor oral absorption
useful in renal failure
transdermal fentanyl skin patch
transmucal? formulations for breakthrough pain
effector (buccal)
alfentanil
10 times as potent as SC diamorphine
common opioid side effects
nausea
constipation
adjuvant analgesics
- corticosteroids
dexamethasone (in palliative)
nerve compression 4-8mg dex
- amitryptiline TCA 10-50mg nocte (night)
- gabapentin 300mg. nerve caclium channel blocker
- pregabalin 25-300mg bd
other adjuvant analgesics
laxatives
antispasmodics (hyoscine bultyblromide- buscopan)
antibiotics (ulcerated and infected tumours)
Interventional techniques
epidural analgesia
intrathecal spinal analgesia
local nerve infiltration
sympathetic plexus blockade
just in case medication
anticipatory medicine
given by injection / syringe pump and to be kept at home in case you need them. try usual oral meds first.
- pain relief
- sickness / nausea
- breathlessness / secretions
- anxiety / restlessness
- diamorphine for severe pain
- cyclizine for sickness
- midazolam for relaxing muscle
- hyoscine or glycopyronium to dry up secretions from the mouth/chest
- haloperidol for anxiety
- water to dissolve other meds
JIC on St Lukes South West Devon Formulary
2 x ampoules of morphine sulfate 10mg/1ml for pain or breathlessness at a dose of 2.5 to 5mg when required s/c*
2 x ampoules of levomepromazine 25mg/mL for nausea and vomiting
3 x ampoules midazolam 10mg/2mL for restlessness, anxiety, agitation and breathlessness
2 x ampoules of haloperidol 5mg/mL for nausea, hallucinations and agitation
3 x ampoules of hyoscine hydrobromide 400 microgram/ml or hyoscine butylbromide 20mg/mL or glycopyrronium 200 micrograms/mL for respiratory tract secretions
amboss pain
Administration of slow-release opioids according to a fixed time schedule and use of PRN medication (fast-acting opioids
, injections)
Opioid dosage should be increased in terminally ill patients to provide sufficient pain relief.
For details, see pain management.
Nociceptive pain
Neuropathic pain
See also pain concepts in palliative care.
amboss GI symptoms
Nausea and vomiting: metoclopramide , haloperidol, levomepromazine , dimenhydrinate
Loss of appetite: dexamethasone or prednisolone
Thirst: oral care
Constipation
: lactulose, macrogol, sodium picosulfate, paraffin
Diarrhea
Addressing the possible cause (paradoxical diarrhea
or administration of laxatives should be excluded)
Fluid and electrolyte replacement from an early stage on
amboss pulmonary symptoms
Dyspnea: fast-acting morphine (e.g., morphine drops); breathing and relaxation techniques
Cough: Treatment depends the type of cough (productive/non-productive) and either involves administration of protussives or antitussives. In refractory disease, hydrocodone may be an option. Corticosteroids may be an alternative.
amboss psychological symptoms
Anxiety and depression: benzodiazepines, antidepressants, antipsychotics, and psychotherapy
Delirium: antipsychotics, benzodiazepines
Fatigue
Regular exercise, physical therapy, and psychotherapy have been shown to have positive effects.
Corticosteroids (e.g., dexamethasone, methylprednisolone) may be used to improve short-term stamina.
amboss final phase meedicines
Restlessness/agitation: midazolam, lorazepam
Delirium: haloperidol
, metoclopramide
Death rattle: butylscopolamine, if necessary [2]
death rattle
due to excessive respiratory secretions
reassure relatives
treat prophylactically:
non sedative- glocopyrronium 200ug sc sta review after 1 hr, 4 hr
sedative-
hyoscine 400ug / 4-8hr SC or via transdermal patch
