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Palliative Care + Oncology > Pain + Syringe Driver > Flashcards

Pain + Syringe Driver Flashcards

1
Q

What dose should breakthrough pain be?

A

1/6 of daily dose in 24h

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2
Q

Describe the 5 steps of titrating morphine from starting dose up to MR

A
  1. Begin on starting dose 4 hourly with same dose available for breakthrough pain
  2. Review requirements every 24h
  3. Adjust dose as rqd (no more than 30-50% at each step)
  4. Once good pain control is achieved, total 24h requirement converted to
  5. Modified release
    MR is given BD with breakthrough medication available at 1/6th of 24h dose
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3
Q

What is preferred to transdermal

A

Oral MR morphine

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4
Q

What should be given to all patients on strong opioid

A

Laxative

Constipation is usually persistent

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5
Q

What are other SE of opioids [8]

A
  • respiratory depression (hypoxaemia and acidosis)
  • constipation
  • urinary retention (sphincter contraction and decreased peristalsis)
  • N&V
  • bradycardia or tachycardia, palpitations
  • muscular rigidity
  • confusion, mood changes
  • toxicity
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6
Q

What is 1st line if unable to swallow but not for syringe

A

Fentanyl transdermal patch

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7
Q

When should you be cautious with prescribing opiotes [1] and what is preferred [3]

A

CKD patients - be cautious when prescribing opiates

Fentanyl
Buprenorphine
Alfentanil

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8
Q

How do you treat metastatic bone pain? [4]

A

Strong opioid = most evidence
Biphosphonates
Denosumab
RT

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9
Q

If increasing dose what should you increase by

A

30-50%

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10
Q

What is an alternative to morpine and why ?

A

Oxycodone
Less sedation / vomting and itch
But causes more constipation

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11
Q

What do you do to dose if going from codeine / tramadol to morphine

A

Divide dose by 10

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12
Q

What do you do if going from morphine to oxycodone

A

Divide by 2 as oxycodone 2x as strong

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13
Q

What is the equivalent dose of morphine for 12 microgram fentanyl transdermal

A

30mg daily

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14
Q

What is the equivalent dose of morphine for 10mg buprenorphine transdermal

A

24mg daily

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15
Q

If going from oral morphine to SC morphine

A

Divide dose by 2

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16
Q

If going from oral morphine to SC diamorphine

A

Divide dose by 3

17
Q

If going from oral oxycodone to SC diamorphine

A

Divide dose by 1.5

18
Q

How is morphine metabolised [2]
Is metabolism of morphine affected by kidney failure?
Is metabolism of morphine affected by liver failure?

A

Liver to active metabolites
Excreted by kidney
Accumulates in kidney failure
Largely unaffected by hepatic failure

19
Q

What does opioid toxicity lead too [6]

A 
Delerium
Altered consciousness
Confusion 
Vivid dreams
Hallucination
Myoclonus
Pinpoint pupil + resp depression = late sign
20
Q

What can aggravate opioid toxicity [1]

What opioids are preferred in CKD [3]

A

AKI

  • Afentanil
  • Brupernorphine
  • Fentanyl
21
Q

What do you do if only mild morphine toxicity [7]

A 
Explain to nurse
Look for renal impairment
Reduce dose
Hydration 
Check for malignant hypercalcaemia (reversible cause of delirium) 
Sepsis screen for derlerium 
Antagonist is NOT required
22
Q

How do you manage pain if opioid toxicity [4]

A

Senior advise
Reduce dose
Consider opioid switch
Add non-opioid analgesia

23
Q

When do you use a syringe driver [6]

A 
Unable to take oral
Nausea
Dysphagia 
Obstruction
Weakness
Coma
24
Q

Most drugs are compatible with water but what drugs require 0.9% saline [4]

A

Ketamine
Octreotide
Odansetron
Ketorolac

25
Q

What is preferred opioid for pain

A

Diamorphine

26
Q

Contraindications to opioids [3]

A

Acute Respiratory Depression
Risk of paralytic ileus
Raised ICP

27
Q

WHO analgesic ladder

A

Assess, titrate and maintain
Non-opioid = NSAID + PCM
Weak opioids: DHC, codeine, tramadol
Strong opioids: MORPHINE, DIAMORPHINE, etc

28
Q 
Paracetamol
MOA
Indication [2]
Caution [3]
SE [2]
Education
A 
MOA: COX-1 blocker
•	Ind: mild to moderate pain, fever
•	Caution: alcohol dependency, hepatic impairment, dehydration 
•	SE: toxicity and liver failure
•	Education: warn of overdose risk
29
Q

NSAIDS
Eg [4]
MOA [2]
Indications [3]

A

E.g. IBUPROFEN, NAPROXEN, DICLOFENAC, ASPIRIN

  1. Inhibitors COX-1 and COX-2 from converting arachidonic acid
  2. to thromboxanes and prostaglandins

Ind: mild to moderate pain (especially bone and soft tissue incl. bone mets), fever, inflammation

30
Q

NSAIDS

SE [9]

A
  • GI upset and mucosal irritation causing peptic ulcer disease
  • renal damage
  • precipitate asthma
  • HTN
  • nausea, diarrhoea
  • headache, dizziness
  • drowsiness, insomnia
  • fluid retention
  • SJS
31
Q

What is the neuropathic co-analgesic pain ladder

A
  • Steroid
  • Tricyclic anti-depressant
  • Anti-convulsant
  • NDMA antagonist
  • Neuroaxial therapies
32
Q

What are neuroaxial therapies [2]

A
  • epidural, intra-thecal (diamorphine, levobuvicaine and clonidine)
  • coeliac plexus block, stellate ganglion block, sympathectomy)
33
Q

TCA
Eg [2]
MOA [3]
Indications [[3]

A

E.g. AMITRYPTILINE, NORTRYPTILINE

Block monoamine (serotonin and noradrenaline) reuptake by antagonising the amine transporter meaning more monoamine concentration at synapse

Ind:

  • neuropathic pain syndrome
  • depression, migraine prophylaxis
  • abdominal pain unresponsive to traditional IBS regimens
34
Q

TCA
SE [5]
Interactions [3]

A

SE:

  • anti-cholinergic SEs, arrhythmia and heart block, sedation (or insomnia, agitation and confusion in elderly)
  • reduced seizure threshold
  • hyponatraemia due to SIADH
Interactions: 
Do not combine with:
- other sedatives
- drugs which cause QT prolongation (amiodarone, soltalol, antipsychotics)
- MAOIs and SSRIs
35
Q

Anti-convulsants
Eg [2]
MOA [2]
Indication [2]

A

Eg. GAPAPENTIN and PREGABALIN
MOA:
- Blocks T type calcium channels
- inhibits other modulators and neurotransmitters

Ind:
- peripheral neuropathic pain, migraine prophylaxis

36
Q

Anti-convulsants

SE [4]

A
  • N&V, diarrhoea, abdo pain and constipation
  • HTN, mood changes, depression
  • headache
  • ataxia
37
Q

NDMA receptor antagonist
Eg
MOA
Indication [4]

A

Eg. Ketamine
MOA:
- prevents central sensitisation of dorsal horn neurones
Ind:
- neuropathic pain, complex ischaemic pain or phantom limb pain, anaesthesia

38
Q

NDMA receptor antagonist

SE [4]

A

hypertension, tachycardia, respiratory depression, hallucinations

Palliative Care + Oncology (5 decks)

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