Pain + Syringe Driver Flashcards
What should patients be offered when starting Rx if advanced disease
Oral morphine modified release (MR) or immediate release
+
Oral immediate release for breakthrough pain
What dose should breakthrough pain be
1/6 of daily dose
What is usual starting dose and when would you consider lower dose
20-30mg MR a day
15mg BD
Combined with 5mg oral morphine solution for breakthrough
Lower dose if elderly, low BMI, renal impairment
What is preferred to transdermal
Oral MR morphine
What should be given to all patients on strong opioid
Laxative
Constipation is usually persistent
What are other SE
N+V
Drowsiness
Dry mouth
Usually transient
What can you give if not transient
Anti-emetic for drowsy
Alter dose if drowsy
What is 1st line if unable to swallow but not for syringe
Morphine / dimorphine SC
Fentanyl transdermal patch
When should you be caution when prescribing opiotes and what is preferred
CKD
Avoid morpine / codeine and precaution with oxycodone in renal impairment
Preferred
- Fentanyl
- Buprenorphine
- Tramadol
- Alfentanil
How do you treat metastatic bone pain
Strong opioid = most evidence
Biphosphonates
Denosumab
RT
If increasing dose as not enough what should you increase by
30-50% every 24 hours
What is an alternative to morpine and why
Dose reduction - 25%
Oxycodone
Less sedation / vomting and itch
Usually causes more constipation
What do you do to dose if going from codeine / tramdaol to morphine
Divide dose by 10
What do you do if going from oral morphine to oxycodone
Divide by 2 as oxycodone 2x as strong
If going from oral morphine to SC morphine
Divide dose by 2
If going from oral morphine to SC diamorphine
Divide dose by 3
If going from oral oxycodone to SC diamorphine
Divide dose by 1.5
How is morphine metabolised
Liver to active metabolites
Excreted by kidney
Accumulates in kidney failure
Largely unaffected by hepatic failure
What does opioid toxicity lead too
Delerium Altered consciousness / sedation Confusion Vivid dreams Hallucination Myoclonus Pinpoint pupil + resp depression = late sign
What can aggravate opioid toxicity
AKI
What do you do if only mild morphine toxicity
Explain to nurse
Look for renal impairment
Reduce dose
Hydration
Check for malignant hypercalcaemia (reversible cause of delirium)
Consider intracranial bleed / renal failure
Sepsis screen for derlerium
Antagonist is NOT required for mild - only use if life threatening
How do you manage pain if opioid toxicity
Senior advise
Reduce dose
Consider opioid switch
Add non-opioid analgesia
When do you use a syringe driver
Unable to take oral Nausea Dysphagia Obstruction Weakness Coma
What do different colours suggest
Blue = mm per hour Green= mm per 24 hours
Most drugs are compatible with water but what drugs require 0.9% saline
Ketamine
Octreotide
Odansetron
Ketorolac
What is preferred opioid for pain
Diamorphine
If patient is controlled how do you convert to modified release
Add total PRN and divide into 2 12 hour MR
What are drugs that are largely septic metabolise so useful in renal failure
Fentanyl
Buprenorphine
EXPERT advice needed
What can you do for morphine resistant pain
Methadone Ketamine Adjuvants such as NSAID, steroid, muscle relacant Nerve block Nerve pain
Know drug conversion
OK
What is Step 1 WHO pain ladder palliative care
Non-opiod e.g. paracetamol
WITH weak opioid PRN
+- NSAID with PPI
What is Step 2
Weak opioid e.g. regular codeine / tramdol
WITH strong opioid PRN
+ PRN anti-emetic and laxative
+_ NSAID with PPI
What is step 3
Strong opioid e.g. regular morphine
With PRN strong opioid (1/6 of 24 hour dose in 4 hourly interval )
+ PRN anti-emetic and laxative
What do you do when pain well controlled
Consider switching to sustained release morphine MST
What is diamorphine preferred for
Injections as rapidly soluble
What should you avoid in renal failure
Oramorph
Parenteral morphine sulphae
Dimorphine
Oxycodone
What is difference between oxycontin and oxynorm
Oxycontin = slow release 12 hour Oxynorm = immediate release
If current pain controlled on oromorph 10mg every 4 hours how do you switch to sustained release
MST 30mg BD
+ oromorph 10mg PRN
Patient confortable meds but changing to syringe
MST continuous 30mg BD PO
Glycopyrrinium 200mg 6 hourly SC
CYclizine 50mg TDS PO
Morphine sulphate 30mg + Glyco 800mg + Cyclicine 150mg in 24ml of water over 24 hours
PRN morphine sulphate SC 5mg max 2 hourly for pain
PRN glyco SC 200mg 4 hourly for secretion
PRN midazolam SC 2.5mg for agitation
PRN levomepromazine SC BD for nausea
