11/7/2016
1
Francine Arneson, MD
Palliative Medicine Medical Director
Burt 72 year old male with a history of DM, HTN, and
CKD
Creatinine 2.1 baseline
History of smoking
Presented with cough, severe back pain
Workup revealing lung mass, multiple liver lesions, and multiple bony lesions in the spine
Liver biopsy pending
Symptom Management Always looking for lowest dose to achieve
symptom management to limit side effects
Sometimes need to choose between comfort and alertness
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Pain AssessmentHistory and physical
• PQRST:• Provocative/Palliative factors: What makes it better or worse• Quality: Sharp, burning, stabbing….• Region, radiation, referral: Where does it hurt, does it move• Severity• Temporal factors: onset, duration, fluctuations
• Type of pain:• Neuropathic • Nociceptive
• Somatic : Skin, soft tissues, bone, joints• Visceral
• Prior evaluations, treatments
• Psychosocial assessment: impact on function, what does pain mean to the patient
• Patient expectation and goals
• Patient concerns• Nonmalignant pain in palliative medicine, S. Weinstein, D. Walsh, R. Fainsinger, K. Foley, et al
Pain Assessment
Treatment: Etiology○ Reversible (ie fractured hip)
○ Other treatment options (radiation, injections)
Pain Managment
Severity
Classes of pain medications Non-opioid analgesics
○ NSAIDs
○ Acetaminophen
Opiods
Adjuvant analgesics
WHO Analgesia ladder
• Non-opioid• +/- adjuvant
Mild Pain
• Opioid• +/- Non-opioid• +/- Adjuvant
Moderate Pain • Opioid
• +/- Non-opioid• +/- Adjuvant
Severe Pain
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Narcotics
• Mu-agonist
• Equivalent doses, conversions
• Route of administration• Long acting: Cannot crush, can deliver rectally• Short acting
• Contraindications• Avoid morphine in renal failure
Narcotics Oral
Morphine, Oxycodone, Hydormorphone available in long acting formulations Morphine, Oxycodone, Hydrocodone, and Hydromorphone avaiable in short acting
formulations
Transdermal Difficulty swallowing Decreased GI absorption ? Lower risk of constipation Increased absorption with heat
IM avoided, painful and no phamalogical advantage Parenteral/SQ
Morphine, hydromorphone, fentanyl, methadone
Rectal Most can be used rectally, including long acting narcotics Variable absorption
Sublingual Lipophilic meds absorbed quite well through oral mucosa Fentanyl and methadone Hydrophilic drugs have minimal absorption
Narcotics
• Side effects• Constipation• Nausea• Anorexia• Itching• Somnolence• Confusion• Dry Mouth• Urinary retention• Myoclonus• Fatigue • Anti-tussive
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Burt
Next Steps:
A. Start pain meds
B. Consult hospice
C. Complete a history and physical
Burt: C- History and Physical
Pain in back has been poorly controlled, currently 8/10, worse with movement and at night when trying to sleep, started about a month ago and has gotten progressively worse, mid-back
Has been to ER (6 days ago) and given hydrocodone 5mg, which decreased pain to 6/10, but ran out of meds so returned to ER last night and was admitted for workup given abnormal CXR, mild hypoxia, and uncontrolled pain
Has also been taking tylenol 1000mg four times per day and the hydrocodone 4 times per day until he ran out yesterday
The pain has kept him up at night, and is so severe at times that he has felt nauseous, nausea has been worsening over the past week with 2 bouts of emesis yesterday
Normally has 2 BM’s per day, but has only had one BM since ER visit one week ago
Burt- What do we do next?
A. Start oral morphine (roxanol) at 5 mg q6h prn
B. Start ibuprofen
C. Give a dose of IV dilaudid now, and order prn IV dilaudid
D. Start dexamethasone
E. Consult radiation oncology
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Opioids in Renal Failure
• Morphine• Codeine
Not Recommended
• Hydromoprhone• Oxycodone• Hydrocodone
Use with Caution
• Fentanyl• Methadone
Safest
Nausea
Definition A feeling of sickness with an inclination to
vomit Dictionary.com
Nausea
A: Anxiety/AnticipationV: VestibularO: ObstructiveM: Meds/MetabolicI: Infection/InflammationT: Toxins
Basic and Clinical Pharmacology
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NauseaMechanism Drugs Good For Use In Notes
Serotonin Antagonist Ondansetron (Zofran)Granisetron (Kytril)Dolasetron (Anzemet)
ChemotherapyRadiation
Dopamine Antagonist HaldolChlorpromazine (Thorazine)Prochlorperazine (Compazine)Olanzapine (Zyprexa)
Medication relatedMetabolic related
Can cause dystoniaCan prolong QTc
Anti-histamine Diphenhydramine (Benadryl)Hydroxizine (Vistaril)Promethazine (Phenergan)
VestibularGut receptor
Caution in elderly
Pro-kinetic Agents Metaclopramide (Reglan) Gastric Stasis GI dysmotility
Both dopamine and 5-HT3 antagonist activity
Corticosteroids(unknown mechanism)
DexamethazonePrednisone
Increased ICPMultiple
Beware of long term side effects
NK-1 ReceptorAntagonist
Aprepitant (Emend) Delayed chemotherapy induced
Cannabinoid Receptor Blocker
Dronabinol (Merinol) Poor evidence for efficacy
Benzodiazepines Lorazepam (Ativan)Diazepam (Valium)
AnticipatoryAnxiety
Nausea
Regardless of the etiology…. Assess the cause
Reverse what is reversible
Start with a drug from one class and schedule it
Add a drug from another class
Constipation
Definition: A condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Dictionary.com
Common
Approaches 90% prevalence
with opioid use
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Constipation
Causes: Inadequate fiber
intake
Inadequate fluid intake
Altered bowel habits
Lack of physical activity
Medications:○ Opioids
○ NSAIDs
○ Tricyclicantidepressants
○ Haldol
○ Anti-parkinson agents
○ Diuretics
○ CCB’s
○ Calcium
○ Iron
Constipation
Non-Pharmacologic Treatments Increase fluid intake
Increase fiber (cautiously)○ Must be accompanied by increased fluids
Increase physical activity
Privacy
Constipation
PharmacotherapyCategory Agents Notes
Stimulant Laxative SennaBisacodyl
- Increases enteric muscle contraction/ GI motility- Stimulate mesenteric plexus
Osmotic Laxatives Non-absorbable sugar molecules:- Polyethelyne glycol - Lactulose- SorbitolPoorly absorbed salt-based molecules: - Milk of magnesia - Magnesium citrate
- Limited intestinal absorption increase in colonic intra-luminal water through oncoticpressure. -With increased intra-luminal volume and distension, reflex peristalsis subsequently occurs. -The increase in intra-luminal water also leads to softer stool and allows for easier intestinal transit
Stool Softeners Docusate - Often not adequate alone with opioids
Bulking Agents Fiber Use caution, can “cement” if not enough fluid
Lubricants Mineral Oil Lubricates
Suppositories/Enemas -Bisacodyl: Stimulate rectosigmoid-Glycerin: Lubricant and osmotic agent-Enema: Soften stool and flush it out
Peripheral mu-receptor antagonist
Methylnaltrexone - Refractory opioid inducted constipation
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Constipation
When using narcotics, never forget to think about a bowel regimen
Easier to prevent than fix
Burt
Bowel regimen!!
Violet 98 year old female admitted to hospice care for end stage
COPD, FEV1 15%, on chronic home O2 at 3L
Co-morbid CAD, HTN, DM, AFTT, 20 # weight loss in past 4 months
Cognitively sharp
Moderate dyspnea at rest, severe with minimal exertion, requires 5 minutes of recovery following getting up to the bathroom
Requiring assistance with bathing, getting dressed, toileting independently
Recently admitted to the hospital with pneumonia
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Violet
On hospice admission patient and her son met with the hospice team to create her care plan
Medication recommendation for dyspnea: Liquid morphine 5mg (0.25ml, 20 mg/ml)
q3h prn
Violet
Two days after admission, son calls hospice nurse because mom is really sleepy, not able to get up to the bathroom
Hospice nurse visits
Son misunderstood medication dosing and delivered 2.5ml…… x 2 (50mg)
Narcotics
• Large therapeutic window
• Therapeutic index= Toxic dose/effective dose Valium (100:1)
Morphine (70:1)
Alcohol (10:1)
Digoxin (2:1)
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Dyspnea Complex uncomfortable sensation that includes:
Air hunger Work/effort Chest tightness
Subjective Can be influenced by physical, psychological, social, and spiritual factors
Often described as: Can’t get air Smothering Chest feels tight Breathing feels heavy Breathing is shallow Suffocating Can’t get a deep breath Breathing takes more work
Dyspnea: 3 Categories
1. Work of Breathing- Increased respiratory effort from obstructive or restrictive pathologies
Obstructive Disease: COPD
Bronchitis
Thick Secretions
Tracheobronchial malignant obstruction
Restrictive Disease:• Parenchymal (Fibrosis, radiation,
drugs)
• Pleural (Effusion, pneumothorax, cancer)
• Chest Wall (trauma, neuromuscular, obesity)
Dyspnea: 3 Categories
Hypoxia:-Impaired diffusion across membranes
-Fluid or bacteria overload
-Impaired cardiac pump (valve, ischemia, arrhythmia)
-Anemia
Hypercapnia:-Central in acid-base balance
-Excess of CO2 sends signal to the brain resulting in dyspnea
Chemical Causes (Hypercapnia and Hypoxia) Oxygen= FUEL
Carbon Dioxide= WASTE
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Dyspnea: 3 Categories
Neuromechanical Dissociation Mismatch between brain expectation and
the signal it receives
Example:○ Anxiety: Short, fast breaths
Volumes lower than brain expects
Leads to worsened dyspnea
Dyspnea: Pathophysiology
Dyspnea: Assessment
Subjective Patient report is gold standard of severity
History and Physical
Workup for reversible/treatable conditions Depending on goals of care
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Dyspnea: Correctable AbnormalitiesB: Bronchospasm- Duonebs, steroid
R: Rales- Decrease volume in, diuretics, if pneumonia consider treating
E: Effusions- Thoracentesis, PleurX
A: Airway Obstruction/Aspiration- Suction, modified diet, aspiration precautions
T: Thick Secretions- If strong cough, loosen with guaifenesin, if dying glycopyrrolate
H: Hemoglobin Low- Consider transfusion
A: Anxiety- Fan, calming music, relaxation techniques, counseling, treat underlying dyspnea, can use benzo/SSRI
I: Interpersonal Issues- Social/financial issues, SW and counseling, respite
R: Religious Concerns- Chaplaincy support
Dyspnea Treatment- General Measures Reduce need for exertion
Reposition: Upright, bad lung down, pursed-lip breathing
Skin care for buttocks
Improve Air Circulation Fan or open windows- Study supports decrease in dyspnea (V2, trigeminal nerve) Adjust humidity, temperature Avoid strong odors, fumes, smoke Increase O2 flow temporarily
Address Anxiety and Reassure Spiritual support, companionship (isolation can exacerbate) Discuss meaning of symptoms Anticipate plan for when symptoms worsen Identify triggers Relaxation strategies
Dyspnea: Opioids First line pharmacologic agents
for dyspnea in advanced disease
Mechanism not well understood:○ Decrease chemoreceptor
response to hypercapnia○ Increase peripheral vasodilation○ Decrease in cardiac preload○ Decrease anxiety and subjective
feeling of dyspnea
Increase exercise tolerance in COPD
Improve dyspnea in CHF and terminal cancer
No studies demonstrate a superior agent
Treating for respiratory distress Tachypnea Nasal flaring Retractions Grunting
Respiratory depression follows sedation, unlikely if patient is arousable
Careful with naloxone: Completely blocks opioidreceptors
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Dyspnea: Anxiolytics
Trigger Causing Dyspnea
Panic
Quick Shallow
Breathing
Worsened Dyspnea
Worsened Panic
Opioids remain first line
Benzodiazepines can be used in conjunction for refractory symptoms
Clonazepam good choice for chronic dyspnea
Lorazapam a good shorter acting choice
Anxiety
Chronic: SSRI’s
Acute, episodic: Benzos
Underlying symptom causing distress (pain, etc)
Secretions Congestion from volume overload
Diuresis
Upper Airway Secretions If strong cough and able to clear airway
○ Cough/suction○ Guaifenesin to loosen
Weak cough, unable to clear airway, bothersome to patientand family○ Anticholinergics
Glycopyrrolate Atropine drops Scopolamine
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Delirium Acute onset
Need to know baseline mental status
Fluctuating Course Waxes and wanes over hours or days
Altered level of Consciousness Hyperactive Hypoactive Mixed
Inattention
Cognitive Impairments Altered Orientation Disorganized thought Delusions or hallucinations (visual or auditory) Emotional lability Disruption of sleep wake cycle Psychomotor agitation or retardation Memory impairment
Delirium Common
Can persist for weeks to months
Risk Factors Limited cognitive reserve (previous brain insult) Sleep disturbance Serious medical problem Auditory or visual impairment Hospitalization ICU admission
Delirium: Assessment History and Physical
Common and
Treatable
•Medications•Medication Withdrawal• Infections•Constipation or Urinary Retention•Uncontrolled Pain
Less Common
but Treatable
•Electrolyte Disturbance•Anemia causing Hypoxemia•Dehydration•Immobilization•Depression and Social Isolation•Vision and /or Hearing Impairment•Emotional Distress•Unfamiliar Environment
Less Common and Less Treatable
•Organ Dysfunction at End Stage•Cardiac Failure•Pulmonary Failure•Renal Failure•Liver Failure•Neurological Failure
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Delirium: Management
Non-Pharmalogical Strategies• Reorientation and cognitive stimulation
• Vision and hearing assessment
• Removal of unecessary lines, catheters, restraints
• Proper sleep/wake cysles
• Relaxation techniques
• Music
•Address psychosocial and spiritual concerns
•Change environment or bring familiar objects
Pharmalogical Strategies• Common Psychtropics
• Haldol• Quetipine• Olanzapine• Risperidone• Valproic Acid
• Always think of uncontrolled pain
• In hyperactive delirium may have to add a benzodiazepine
• In hypoactive delirium may consider a stimulant
• In refractory terminal delirium, may consider palliative sedation
Treat reversible causes if it aligns with patient goals Critical
Can be dangerous to patients and caregivers (increased mortality) Emotionally disturbing
Fatigue
Persistent sense of tiredness that interferes with usual functioning
Typically unrelieved by rest
May affect both physical and mental capacity
Very common in end-stage disease
Fatigue Potentially Reversible Causes
Endocrine dysfunction (thyroid, hypogonadism)
Anemia
Malnutrition
Depression
Pain
Infection
Chronic comorbids
Medications