palliative care Flashcards
management of cancer pain
- nonopiod +/- adjuvant - aspirin, paracetamol or NSAID
- weak opiod (codeine) +/- non-opiod +/- adjuvant
3, strong opioid (morphine) +/- non-opioid +/- adjuvant
different types of morphine
slow release morphine
- lasts 12hrs + taken twice daily
- prescribed as “morphine sulphate M/R”
- brands - MST + Zomorph
- for around clock pain
immediate release morphine
- lasts 4hrs + taken PRN
- for breakthrough pain (approx 1/6 total background dose)
- prescribed as “morphine sulphate I/R”
- brands - Oramorph + sevredol
dose change to morphine from a patient currently on codeine 60mg 4x a day
stop codeine
morphine sulphate M/r 15mg twice daily
morphine sulphate I/r 5mg PRN 4hrly
gradually titrate up background M/R morphine dose depending on amount of PRN I/R morphine used
no max dose but monitor pain, make sure its actually working + no unwanted side effects
opioid toxicity presentation
hallucinations
myoclonus - brisk jerk, spilling drinks, cant text
drowsiness
usually respond to dosse adjustment/switching to another strong opioid
management of opioid toxicity
naloxone 80mg IV bolus every 2 mins to avoid pain reversal
morphine may be switched to if side effects
- oxycodone - common 2nd line
fentanyl + alfentanil = safest opioids in severe renal impairment
dose changes when switching between different type of strong opioid - oxycodone is 2x as strong as morphine
complications of opiod toxicity
respiratory depression -> naloxone can reverse morphine very quickly
update renal function when become opioid toxic - if renal function impaired morphine will accumulate as it is RENALLY EXCRETED
treatable conditions that can mimic dying
opioid/drug toxicity
sepsis/infection
hypercalcaemia
AKI
hypoglycaemia
-> think about reversibility if deterioration has been sudden
*how actively you treat depends on wishes - weigh up benefits + burdens
prioritising comfort + dignity to dying patient
- Only essential medication – stop statins, anticoagulants
- Essential oral medications (esp opioids) converted to alternative route if no swallow
- Anticipatory medication prescribed for common symptoms at the end of life
- Don’t miss urinary retention as a cause of agitation
- Stop routine obs/monitoring/take out unused cannulas
- Appropriate environment + equipment in place
- Offer holistic + spiritual support to family, regular updates
syringe drivers
smoothest delivery of medicines via continous subcutaneous infusion using syringe driver
- oral route not possible
via butterfly needle with connector tubing
infused over 24hrs, changed daily
portable
how to change dose when changing from oral to subcutaneous (SCUT) morphine
SCUT is 2x as strong as oral
SCUT dose = daily total morphine divided by 2
eg
oral 10mg twice daily
- 20mg oral over 24hrs
–> 10mg SCUT morphine over 24hrs via syringe driver
how long do syringe drivers take to reach affect?
4hrs to take maximum affect
(CSCI usually started 2-3hrs before next dose of MR opioid is due)
SCUT medication + dose for pain / SOB
morphine 2mg SCUT hrly
(or approx 1/6 background dose if already established on an opioid, use same opioid for background + PRN)
SCUT medication + dose for distress
midazolam 2mg SCUT hrly
SCUT medication + dose for nausea
levomepromazine 2.5mg SCUT 12hrly
SCUT medication + dose for secretions
buscopain 20mg SCUT hrly
