Pain management and palliative care Flashcards
List types of morphine formulations
1) Fast-acting tablets and capsules - usually 4 to 6 times a day
2) Slow-release granules, tablets and capsules - usually 1 to 2 times a day
3) Liquid - usually 4 to 6 times a day
4) Suppositories - usually 4 to 6 times a day
5) IV or S/C injections - usually 4 to 6 times a day (can be in a syringe driver)
List S/E of morphine
Constipation Nausea, vomiting Dizziness and vertigo Confusion Drowsiness Headaches Itchiness and rash
Contraindications of morphine use
Allergies
Renal dysfunction/CKD
Main symptoms during end-of-life that requires medication support
fatigue, pain, nausea, dyspnoea, noisy breathing and agitated delirium
5 core medications used in end-of-life care
morphine 10 mg/mL injection
metoclopramide 10 mg/2 mL injection
haloperidol 5 mg/mL injection
clonazepam 1 mg injection (clonazepam liquid drops 2.5 mg/mL can be used as an alternative to clonazepam injection)
hyoscine butylbromide 20 mg/mL injection.
Example of palliative care drug order
An example of medication orders for CPCS is:
morphine 2.5–5 mg via subcutaneous injection one-hourly PRN for pain or dyspnoea
metoclopramide 10 mg subcutaneous injection four-hourly PRN for nausea or vomiting
haloperidol 0.5 mg subcutaneous injection four-hourly PRN for agitation or delirium
clonazepam two to six drops sublingually PRN for severe agitation or if sedation required in delirium. Note: clonazepam has a long half-life and can accumulate with repeated dosing; however, it is accessible in the community and easy to administer sublingually. If available, subcutaneous midazolam is an alternative, given its rapid onset and short duration of action; however, it is more difficult to obtain in the community and requires a syringe driver for sustained effect
hyoscine butylbromide 20 mg subcutaneous injection four-hourly PRN for excessive secretions.
Describe signs/symptoms of metastatic spinal cord compression.
What should be done if this is suspected?
severe unremitting lower spinal pain
spinal pain aggravated by straining (eg stool, coughing, sneezing)
band-like pain around the torso
localised spinal tenderness
nocturnal spinal pain preventing sleep
neurological symptoms including radicular pain
any limb weakness
difficulty walking
sensory loss, bladder or bowel dysfunction
neurological signs of spinal cord or cauda equina compression on examination.
If MSCC is suspected, it is important to make urgent contact with the patient’s treating specialist or seek emergency department review
Having identified the possibility of a spinal cord compression, moderate-to-high dose dexamethasone (8–16 mg daily) should be initiated while investigations are arranged. Magnetic resonance imaging (MRI) of the spine is the investigation of choice and should be organised urgently (unless contraindicated). If consistent with patient goals of care and the clinical scenario, definitive treatment (whether radiotherapy or surgery) should be planned within 24 hours of suspected spinal cord compression to optimise treatment outcomes. Some patients with a previously good performance state, localised disease and a reasonable prognosis may benefit from surgical decompression, and a neurosurgical review should be arranged urgently for these patients
Anti-emetics in palliative care
- Metoclopramide is not recommended in patients with chronic kidney disease as it can accumulate and cause extrapyramidal side effects. But if no CKD, and if cause is gastroparesis, then metoclopramide ideal
- Domperidone prolongs QT interval but does not cross BBB
- Ondansetron/granisetron is safe in patients with kidney disease but may worsen constipation
- Haloperidol at half the usual dose is the best option in CKD
Analgesics suitable in renal failure, and those that are unsuitable
Suitable:
1) Fentanyl S/C or infusion (or transdermal - provided patient is not opioid naive)
2) PO paracetamol
Avoid:
1) NSAIDs - nephrotoxic
2) Morphine - accumulation of toxic metabolites
3) Oxycodone, buprenorphine and hydromorphone require low doses, and frequent monitoring
PEPSI COLA of palliative care mx
P - physical, symptoms, medication,
E - emotional, expectations, depression
P - personal - spiritual, inner journey, QOL
S - social support - financial, carer
I - information/communication - patient, carer, team
C - control, choice - dignity, AHD, place of death
O - out of hours/continuity - drugs/eqpmt
L - late - terminal care, comfort cares, rattle, agitation
A - afterwards - bereavement, family support
Four commonly described trajectories of decline - list examples
sudden death (e.g MI, accidents) a short period of evident decline (e.g terminal illness, cancer) long-term limitations with intermittent serious episode (e.g CCF, CKD) prolonged dwindling (e.g dementia, parkinson's, alzheimers)
Delirium
Acute onset & fluctuating course
Fluctuating, variable alertness & attention
Altered level of consciousness - drowsiness, stuporous, comatose, hypervigilant
Causes of delirium
Infection
Drugs - anti-depressants, opioids, benzos, steroids, metoclopramide, H2 antagonists
Hyponatremia, hypoxia, hypovolemia
Hypercalcaemia
Types of dementia
Alzheimer disease is characterised by an insidious onset of symptoms, with initial forgetfulness
progressing over time to profound memory impairment with accompanying dysphasia, dyspraxia
and personality change. Noncognitive symptoms may include decreased emotional expression
and initiative, increased stubbornness and suspiciousness, and delusions.
Vascular dementia usually starts suddenly, with focal neurological signs and imaging evidence
of cerebrovascular disease. There may be emotional lability, impaired judgment, gait disorders,
with relative preservation of personality and verbal memory. It often occurs in combination
with Alzheimer disease.
Lewy Body dementia is characterised by cognitive impairment that affects memory and the ability
to carry out complex tasks, and fluctuates within 1 day. It is associated with at least one of the
following: visual or auditory hallucinations, spontaneous motor parkinsonism, transient clouding
or loss of consciousness, and repeated unexplained falls.
Frontal lobe dementia features include impaired initiation and planning, with disinhibited
behaviour and mild abnormalities on cognitive testing. Apathy and memory deficit may
appear later.
BPSD tx (behavioural and psychologist symptoms of DEMENTIA)
Non-pharm:
Pharm: Risperidone
:Antidepressants
Avoid TCAs in Alzheimers - exacerbates cognitive impairment
:Benzos - can worsen cognition, falls risk
Can use OXAZEPINE for anxiety, aggression
DO NOT use Haloperidol in Parkinson’s and Lewy body dementia - extrapyramidal sx, ineffective, sedative anticholinergic S/E
**Lewy body dementia - CONTRAINDICATION for atypical antipsychotics
