Palliative Care Flashcards
Pain management guidelines
if mild pain (1-3 out of 10 on scale), use step 1 non-opioid analgesics (aspirin, acetaminophen or NSAID)
if moderate pain (4-6 out of 10 on scale), use step 2 weak opioid analgesics (tramadol or low dose strong opioid)
if severe pain (7-10 out of 10 on scale), use step 3 strong opioid analgesics (morphine, hydromorphone, oxycodone, fentanyl, methadone or codeine)
1st line strong opioid is morphine, which is the gold standard for treating severe cancer pain
demerol (meperidine, pethidine) should not be given due to risk of neurotoxicity from its active metabolite
at any step, additional therapy such as palliative radiation therapy, palliative chemotherapy, palliative surgery and hormone therapy if indicated
if pain is significantly reduced, then step down to a lower step
Preferred route of opioid administration
Oral –> SC –> IV
Routes of administration for different opioids
opioids that can only be given orally (PO): tramadol and oxycodone
opioids that can be given orally (PO) or parenterally (IV, SC): morphine, hydromorphone, codeine
opioids that can only be given parenterally (IV, SC, transdermal): fentanyl
How often should breakthrough opioid dosing be prescribed
breakthrough opioid dose is Q2H PO PRN or Q1H SC/ IV PRN
How many breakthrough doses should a patient use in a day
patient should only be allowed no more than 5 breakthrough doses in a day, where need for >3 breakthrough doses should prompt reassessment and readjustment of treatment
if inadequate pain control or >3 breakthrough doses used per day, then increase regular dose by 25-50%
Write out a usual morphine prescription regimen for a palliative care patient requiring pain control
1) Morphine 5mg PO Q4H
2) Morphine 5mg PO Q2H PRN for breakthrough pain
3) Senna (stimulant) 1 tab PO OD + Lactulose (osmotic) 10mL PO OD + docusate (stool softener)
4) Metoclopramide 5-10mg PO/SC/IV Q4H PRN for nausea (preferred because it negates the mechanism through which opioids cause nausea - activation of dopamine chemoreceptor in brain stem)
5) PRN dose with dulcolax suppository or micro fleet enema
How should opioid prescribing change in patients with renal failure and why should it be changed?
in renal failure patients, opioid dose should be decreased but given more regularly to decrease active opioid metabolite level
all opioids (except for methadone or fentanyl) have active metabolite that tend to accumulate and cause neurotoxicity in renal failure
In what patients should the opioid dose be halved
in frail / weak patients
or patients with COPD
or patients with non-cancer pain due to organ failure
Nausea management in palliative care
1st line = Metoclopramide (if no bowel obstruction) or Haloperidol, because most common cause of nausea & vomiting due to chemoreceptor trigger zone
2nd line = adding Dexamethasone if nausea and vomiting still unresolved or if brain edema
if anti-emetic is not completely effective, reassess patient and either add another anti-emetic or replace with another anti-emetic
add other anti-emetic as per suspected aetiology of nausea & vomiting
if bowel obstruction, consider adding Dexamethasone, Octreotide and Buscopan
if chemotherapy or radiation induced, consider adding Ondansetron
if brain tumor, consider adding Dexamethasone
if vestibular related (e.g. motion sickness, vertigo), consider adding Dimenhydrinate
if anxiety or anticipatory nausea & vomiting, consider adding Benzodiazepine
prevent constipation, which may exacerbate nausea & vomiting
Bowel clearance regimen for established constipation
1st line = increase dose of laxative (stimulant (Senna) + osmotic (Lactulose))
2nd line = phosphosodium (Fleet) enema or bisacodyl suppository or other enema or other suppository
3rd line = oral Magnesium Citrate
last line = manual disimpaction
Agent to consider for opioid induced constipation
Methylnaltrexone
Palliative care dyspnea management
- Assess and address underlying cause
- Relieve symptom
oxygen if hypoxic or patient notes relief with use
1st line =
low dose opioids such as morphine (Morphine 2.5mg PO Q4H)
may consider adding benzodiazepine (Midazolam) if patient is anxious (Midazolam 0.5mg SC Q1H PRN)
non-pharmacological interventions include
fan directed toward face
relaxing and open environment
positioning for most comfortable breathing
cool humid air
pulmonary or palliative rehabilitation
optimize nutrition
non-invasive positive pressure ventilation (e.g. BiPAP) note that BiPAP is very uncomfortable and usually only used transiently to allow patient get through episode of dyspnea, BiPAP most commonly used for ALS patients
3) Re-evaluate
What is opioid induced neurotoxicity
OIN is a syndrome of neuropsychiatric side effects due to opioid therapy with ANY opioid caused by accumulation of metabolite and imbalance in CNS cholinergic and dopaminergic system
OIN presentation
sedation hallucination cognitive impairment delirium myoclonus seizure hyperalgesia and allodynia
OIN management
hydration (oral, IV or SC) and any of the following
A) opioid dose reduction, where an adjuvant analgesic / therapy may be added for pain to compensate for lower dose opioid
B) opioid rotation (switching to another opioid)
