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Palliative Care > Pain management > Flashcards

Pain management Flashcards

1
Q

What is malignant pain?

A

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

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2
Q

define constant pain

A

constant pain-
tumour causing pressure (distention / stretch)
not affected by position or activity. more likely in confined space (skull, pelvis)
constant and unchanged

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3
Q

what is breakthrough pain

A

rare flare-up, rapid onset, moderate=severe intensity, short duration,

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4
Q

define neuropathic pain

A

damage to nerve fibres, peripheral and central nervous system changes

burn, stabbing, hyperaesthesia
unpredictable
less responsive to opioid analgesics

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5
Q

opiate dose equivalent chart

on st Lukes website) (Ratios

A

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)

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6
Q

what is the ratio for breakthrough doses?

A

a total daily dose of background dose (240)

divide by 6= 40mg

40mg is the breakthrough dose of oramorph

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7
Q

what is the oral oxycodone and oral morphine ratio?

A

twice as potent as oral morphine

20mg of morphine
/2
10mg oxycodone

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8
Q

what is the oral morphine to subcutaneous diamorphine ratio?

A

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

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9
Q

neuropathic pain tx

A

corticosteroids
morphine
gabapentin (anticonvulsant)
tapentadol

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10
Q

renal impairment- opiate toxicity

A

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

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11
Q

renal impairment- opiate toxicity

A

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

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12
Q

WHO pain ladder

A

non-opioid +/- adjuvant

opioid for mild-moderate pain + non-opioid + adjuvant

opioid for moderate to severe + nonopioid + adjuvant

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13
Q

MOA opioids

A

agonist for specific receptor sites at nerve cell synapse

Mu, kappa, delate receptors

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14
Q

weak opioids

A 
oral codeine
transdermal buprenorphien (weekly patches)
oral tramadol
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15
Q

strong opioids

A

use is dictated by the therapeutic need, not by prognosis

morphine, diamorphine, alfenanil (injectable), fentanyl, oycodone, tapentadol, methadone

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16
Q

prescribing oral morphine (oramorph)

A

immediate release
oramorph liquid 4 hrly, PRN
sevredol tablets

slow release
zoramorph- release over 12hrs
MST tablet bd
MXL capsules bd

17
Q

oxycodone

A

strong opioid used 2nd-3rd line

18
Q

fentanyl

A

pure mu-opioid
highly lipid-soluble
poor oral absorption
useful in renal failure

transdermal fentanyl skin patch

transmucal? formulations for breakthrough pain
effector (buccal)

19
Q

alfentanil

A

10 times as potent as SC diamorphine

20
Q

common opioid side effects

A

nausea

constipation

21
Q

adjuvant analgesics

A
  1. corticosteroids
    dexamethasone (in palliative)

nerve compression 4-8mg dex

  1. amitryptiline TCA 10-50mg nocte (night)
  2. gabapentin 300mg. nerve caclium channel blocker
  3. pregabalin 25-300mg bd
22
Q

other adjuvant analgesics

A

laxatives
antispasmodics (hyoscine bultyblromide- buscopan)
antibiotics (ulcerated and infected tumours)

23
Q

Interventional techniques

A

epidural analgesia

intrathecal spinal analgesia

local nerve infiltration

sympathetic plexus blockade

24
Q

just in case medication

anticipatory medicine

A

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
25
Q

JIC on St Lukes South West Devon Formulary

A

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

26
Q

amboss pain

A

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.

27
Q

amboss GI symptoms

A

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

28
Q

amboss pulmonary symptoms

A

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.

29
Q

amboss psychological symptoms

A

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.

30
Q

amboss final phase meedicines

A

Restlessness/agitation: midazolam, lorazepam
Delirium: haloperidol

, metoclopramide
Death rattle: butylscopolamine, if necessary [2]

31
Q

death rattle

A

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

Palliative Care (7 decks)

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