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4TH YEAR - CPTP > Pain/Palliative Care > Flashcards

Pain/Palliative Care Flashcards

1
Q

What principles do WHO follow in pain prescription?

A
  • Oral admin when possible
  • Analgesia at regular intervals
  • Prescribe according to pain intensity
  • Adapt dosing to the individual
  • Patient centred decision making
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2
Q

What is step 1 of the WHO ladder?

A

Non-opioids - paracetamol, NSAIDS

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3
Q

What is step 2 of the WHO ladder?

A

Weak opioids - dihydrocodeine, codeine, tramadol

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4
Q

What is step 3 of the WHO ladder?

A

Strong opioids - Hydromoprhine, morphine, fentanyl, oxycodone, diamorphine

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5
Q

What is step 4 of the WHO ladder?

A

Other - nerve block, epidural, PCA pump, spinal stimulation

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6
Q

What adjuvants can be used in the WHO ladder for:

a) raised ICP?
b) neuropathic pain?
c) cramp?
d) bone pain?
e) bowel spasm?

A

a) corticosteroids
b) pregablin, gabapentin, antidepressants, anticonvulsants
c) muscle relaxants
d) bisphosphonates
e) antispasmodics (hyoscine butylbromide)

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7
Q

How does paracetamol work?

A

Unknown, possibly COX2 inhibition

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8
Q

What are the indications, contraindications and side effects of paracetamol?

A

I: First line pain management
CI: None
SE: None

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9
Q

What is the standard dose of paracetamol?

A

1g QDS, max 4g

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10
Q

How do NSAIDS work?

A

Selective inhibition of COX 1 or COX2 and therefore prostaglandin syntehsis

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11
Q

What is the function of COX1?

A

Carries out routine physiological functions

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12
Q

What is the function of COX2?

A

Induced by pain and inflammation

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13
Q

Why do we not just use COX2 inhibitors then?

A

Although the are more specific, they have cardiovascular side effects

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14
Q

What are the indications, contraindications and side effects of NSAIDS?

A

I: inflammatory pain
CI: GI symptoms, renal failure, coagulation disorders, caution with HF
SE: gastric ulcer, bleeding, headaches, HTN

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15
Q

How does codeine phosphate work?

A

Metabolised to morphine by CYP2D6

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16
Q

What are the indications, contraindications and side effects of codeine?

A

I: Mild-moderate pain 1st line
CI: Raised ICP, bronchial asthma, severe respiratorry depression
SE: Constipation, nausea

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17
Q

What is the dose of codeine?

A

20-60mg QDS (PO/PR/IM) - not IV as could cause anaphylaxis

18
Q

How does tramadol work?

A

Synthetic opioids with multiple active metabolites

19
Q

What are the indications, contraindications and side effects of tramadol?

A

I: Chronic pain, after bowel surgery
CI: Renal/liver failure, raised ICP, severe resp depression, elderly
SE: (opiate SEs) N&V, drowsiness, resp depression, pruritus, hallucinations, urinary retention, pinpoint pupils, risk of serotonin syndrome

20
Q

What is serotonin syndrome?

A

High body temp, agitation, hyperreflexia, tremor, sweating and dilated pupils.

This occurs when two or more serotonergic drugs are given at the same time

21
Q

What is the dose of tramadol?

A

50-100mg QDS (PO/IV)

22
Q

What are the indications for dihydrocodeine?

A

Moderate-severe pain, coughing, SOB

23
Q

What is the effect of erythromycin on opiods?

A

Increases effect (enzyme inhibitor)

24
Q

What is the effect of rifampicin and anticonvulsants on opioids?

A

Decreases effect (enzyme inducer)

25
Q

What are the indications for morphine?

A

Severe acute pain and chronic pain

26
Q

How does morphine work?

A

Acts on mu opioid receptors in the CNS

27
Q

What are the side effects of opiates?

A 
Respiratory dperession
Sedation
Euphoria
Pupil constriction
Nausea and vomiting
Constipation
Pruritus
Hypotension
Bronchospasm
Urinary retention
28
Q

What are the signs of opiate toxicity?

A 
Myoclonic jerks
Pinpoint pupils
Hallucinations
Decreased RR
Confusion

(ensure this isn’t bowel obstruction/hypercalcermia)

29
Q

How is opiate toxicity managed?

A 
Reduce opiate dose by 30-50% and check renal function
Switch to different opioids
If severe (RR<8, o2<90) give NALOXONE
30
Q

How do you prescribe an opiate

A
  1. Start at 20-30mg daily if no previous opiod or 40-60mg if previous opiod
  2. Titrate up and review regularly (caution in elderly/frail/renal)
  3. Dose immediate release every 4hr (oramorph) OR modified release every 12hr (zomorph)
  4. Always prescribe PRN alongside this for breakthrough pain
  5. If immediate release, convert to modified release when safe
  6. If pt keeps using PRN dose, review meds
31
Q

How much should a dose for breakthrough pain be?

A

1/6th - 1/10th of the TOTAL regular dose in 24h

32
Q

How do you switch from immediate release morphine to modified release?

A

Add up total morphine and divide by 2

33
Q

If modified release morphine isnt given adequate control, how do you give more?

A

Keep titrating the dose up but dont increase by over 50%

34
Q

Which pain med should never be used for dose titration or acute pain?

A

Fentanyl

35
Q

What is the 1st line drug for neuropathic pain?

A

Pregablin + amitriptylline

36
Q

What is the 2nd line drug for neuropathic pain?

A

Duloxetine (SNRI)

37
Q

What is 3rd line for neuropathic pain?

A

Gabapentin, ketamine or lidocaine patches

38
Q

What should be prescribed at EoL for pain and breathlessness for a patient with

a) eGFR>30
b) eGFR<30

A

a) 2.5mg morphine SC every hour

b) 100micrograms alfentanil SC every hour

39
Q

What should be prescribe at EoL for nausea and vomiting for a patient with

a) eGFR>30
b) eGFR<30

A

a) 50mg cyclizine SC every 8 hours

b) 1mg haloperidol SC every 4 hours

40
Q

What should be prescribe at EoL for agitation for a patient with

a) eGFR>30
b) eGFR<30

A

ALL - 2.5mg midazolam SC every hour

41
Q

What should be prescribed at EoL for excess secretions for a patient with

a) eGFR>30
b) eGFR<30

A

a) 400micrograms hyoscine hydrobromide SC every hour

b) 20mg hyoscine butylbromide SC every hour

42
Q

How do you convert oral opiod dose to palliative SC continuous syringe driver dose?

A
  1. Add up total oral dose in 24hr (PRN +regular)
  2. Divide by 2 to calculate dose
  3. Divide by 6 to calculate PRN
  4. Start syringe driver 4hrs before next oral dose is due, then discontinue it

4TH YEAR - CPTP (19 decks)

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