Palliative Care Flashcards
What is step 1 for mild pain
Paracetamol 1g 4x daily AND/OR NSAID e.g. naproxen 500mg 2x daily AND/OR Other adjuvant
What is step 2 for moderate pain?
Codeine 30-60mg 4x daily or cocodomol 30/500 2 tabs 4x daily
What is step 3 for severe pain?
Stop codeine and switch to strong opioid - usually morphine
What is commonly used for neuropathic pain?
Gabapentin
Pregabalin
Tricyclic antidepressants such as amitriptyline
Describe management of cancer pain
Gradual release for background pain
Instant release for breakthrough pain
What are examples of drugs used for background pain
Modified Release BD
MST or zomorph
What are examples of drugs that are used for breakthrough pain
Immediate rellease
PRN tablet - sevredol
Or liquid - oramoprh
What dosage should breakthrough pain drugs be?
1/6th of 24 hour background dose
How is the dose of morphine worked out?
Stop codeine if on 60mg 4x daily
Switch to morphine sulphate M/R 10-15mg BD with morphine sulpfate I/R 5mg PRN 4 hourly
Gradually titrate up background M/R morphine depending on amount of I/R PRN used
Is there a maximum dose of morphine?
No
What are common symptoms of morphine toxicity?
Hallucinations Myoclonus Drowsiness Confusion Delirium Pinpoint pupils Resp depression
Why should you think of renal impairment in morphine toxicity?
Morphine is renally excreted and therefore it will accumulate in the body if there is inadequate renal function
What can be used to reverse morphine toxicity?
Naloxone but BEWARE and titrate 400 micrograms in 10ml of saline and give in 18 microgram doses until resp rate returns to normal
Is oxycodone stronger or weaker than morphine?
Oxycodone is twice as strong and therefore if it is being conveted -
Morphine M/R 10mg BD = oxycodone M/R 5mg BD
What are signs of a dying patient?
Worsening weakness and performance status
Worsening physiological status with no reversibility
Struggling to manage oral medicines
Losing interest in food and fluid
Sleeping more, eventual unconsciousness
What are some treatable conditions that can mimic dying?
Opioid/ drug toxicity Sepsis Hypercalcaemia AKI Hypoglycaemia Dehydration Delirum
How can comfort be maintained at the end of life?
Only essential medications continued (stop stating and antioags)
Oral medicines converted to alt route where poss if no swallow
Anticipatory meds for common problems
Don’t miss urinary retention as a cause of agitation
Stop routine obs/ monitoring/ take out unused cannulas
What is the smoothest delivery of medicines?
Continuous subcutaneous infusion using a syringe driver
How is SC access achieved?
Butterfly needle with connector tubing
How many medicines can be mixed together in a syringe driver?
Up to 3; opioids, antiemetics, anxiolytics, dexamethasone, antimuscarinics
How does the dosage of SCUT morphine compare to oral morphine?
Twice as strong - divide total daily morphine dose by 2
What drug is commonly used in palliative care for pain and SOB?
Morphine 2mg SCUT hourly
What drug is commonly used in palliative care for distress?
Midazolam 2mg SCUT hourly
What drug is commonly used in palliative care for nausea?
Levomepromazine SCUT 2.5 - 5 mg 12 hourly
