Objectives. Mechanism-Based Therapy. The Approach to Nausea, Vomiting, and Pain at The End of Life

Transcription

1 The Approach to Nausea, Vomiting, and Pain at The End of Life Thomas R. DeGregory D.O. CMD Hospice and Palliative Care Assessment Pathophysiology Treatment Objectives Mechanism-Based Therapy 1. Determine etiology 2. Determine the receptors of the underlying symptoms 3. Choose the correct intervention January 28-31,

2 History Source of nausea Associated symptoms Past medical history Medication history Constipation Physical examination Rectal exam etc. Evaluation Evaluation 1. Hyponatremia 2. Hypercalcemia 3. Azotemia (acute/chronic renal) 4. Medication ie. Antibiotics, opioids, anticholinergics, antidepressants 5. Infection ie. Gram negative endotoxin 6. Impaired gastric emptying, bowel obstruction, constipation, GI bleed, etc 7. Flat plate abdomen Four pathways to nausea and vomiting 1. Chemoreceptor trigger zone 2. Cortex 3. Peripheral pathways 4. Vestibular system January 28-31,

3 Motion Labyrinth disorders Achm H 1 Vestibular System Sensory input Anxiety Meningeal irritation Increased intracranial pressure Projections from vestibular nuclei Cortex Intracerebral projections Drugs Metabolic products Bacterial toxins D 2 (central) 5HT 3 NK 1 Chemoreceptor trigger zone Intracerebral projections Achm H 1 5HT 3 Vomiting center Mechanical stretch (eg. GI obstruction or stasis) GI mucosal injury (eg, metastases, candida infection, GERD, radiation therapy, chemo) Local toxins and drugs Vagus and splanchnic nerves 5HT 3 receptors in GI tract Mechanoreceptors and chemoreceptors in GI tract, serosa, and viscera Vagus, splanchnic, and nerve glossopharyngeal nerves, sympathetic ganglia Peripheral pathways Nausea/Vomiting Input Neuroreceptors Neural Pathways Antiemetics Antiemetic Haloperidol Receptor antagonized D2 in the CTZ Metoclopramide Prochlorperazine D2 in GI Tract 5HT3 D2 in the CTZ Promethazine D2 (CTZ), H1, Achm Antiemetics cont. Antiemetic Scopolamine Receptor antagonized Achm Diphenhydramine H1 Ondansetron 5HT3 January 28-31,

4 N/V in palliative care unit Most common causes: Gastric stasis/outlet obstruction Chemical/metabolic etiology Constipation! Nonpharmalogical Therapy Avoid triggers ie. Smells, motion, etc. Small frequent meals Relaxation techniques (music, massage, pet) Acupuncture Pain Management January 28-31,

5 Facts 80% of patients in a LTC facility experience pain, but only 40-50% are given analgesics 25-40% of elderly patients with cancer in a LTC facility have daily pain Pain is now considered 5 th vital sign Inadequate treatment of pain results in: F-329 tag citation against facility F-501 tag citation against medical director Barriers to Effective Pain Management Opiophobia Dependence Tolerance Addiction Opiophobia The irrational, unwarranted fear that opioids used legitimately for pain relief will lead to addiction January 28-31,

6 Tolerance To analgesic effect: The need for escalating the dose to maintain analgesic effect Solution? Consider opioid rotation Usually means progression of disease or new reason for pain Dependence Physiologic response Withdrawal symptoms upon abrupt cessation Barriers of Effective Pain Management Patient reluctance to report pain Patient reluctance to use opioid analgesics Fear of addiction Physician reluctance to prescribe opioids Fear of opioid-induced respiratory distress and premature death January 28-31,

7 Acute Pain...characterized by a well-defined temporal pattern of onset. It is generally associated with subjective and objective physical signs and hyperactivity of the autonomic nervous system Decreases with time Chromic Pain...persists longer than six months in which adaptation of the autonomic nervous system occurs. Patients with chronic pain lack the objective signs common to acute pain In certain circumstances, can be considered chronic after 4-6 weeks for unrelieved pain Increases with time Pain Assessment Components Complete history, preferably from the patient History of Pain Location Intensity (use pain scale) Quality Duration Radiation Physical examination VAS visual-analog scale 1-10 Wong Baker FACES Pain AD Flacc (Pediatrics) Establish pain diagnosis or diagnoses Institute an appropriate plan of care based on pain assessment January 28-31,

8 P-Q-R-S-T P alliative P rovocative Q uality R adiation S everity T emporal + B elieve Pneumonic to Assess Pain What makes the pain better? What makes the pain worse? How would you describe the pain? To where does it spread or travel? On a scale of 0 to 10, how bad? Is the pain constant of does it come and go? The patient has pain if they say they do! Non-verbal Indications of Pain Crying Restlessness Rigid posture Lack of concentration Facial grimaces Gasp or scream when touched or bed bumped Increased immobility Change in sleep patterns Pain Management: K.I.S.S approach K eep I t S imple S tupid January 28-31,

9 Follow the K.I.S.S. Rules BY By The Clock By The Mouth ONE s ONE Drug ONE Route Example of K.I.S.S. 69 year old female admitted to me December 2013 with metastatic renal carcinoma. Her pain medications consisted of: 1. Fentanyl 200 mics q72 hours (patch) 2. Ibuprofen 800 mg q8h prn po 3. Oxycodone 15 mg q6h prn po 4. Oxycontin 30 mg q12 hours po 5. Dilaudid 4 mg q4h prn po By The Clock RTC dosing NOT prn PRN = pain relief never Dose adequately, with breakthroughs Appropriate dose = ENOUGH January 28-31,

10 By The Mouth Controls 95% of pain Oral dosing gives adequate blood levels Sustained release opioid products Plus, breakthrough doses Allows patient to control analgesia Other routes reserved for special cases Buccal & sublingual Transdermal/topical Rectal IV Clysis (subcut) Conversions MS po : MS iv MS : Oxy MS : HydroM HydroM po : HydroM iv MS : HydroC MS : Codeine MS : Meperidine MS : Fentanyl MS : Methadone 3:1 1.5:1 4:1 5:1 1:1 1:7 1:10 25mcg=50 to 180mg? Variable conversion ratio Keeping the previous KISS slide more simple 1. Keep Fentanyl 200 mcg q72h (discussion) 2. I elected to use Fentanyl plus dilaudid for breakthrough 3. Oxycontin 30mg q12h = 90mg of morphine 4. Oxycodone 15mg (twice per day) = 45mg morphine 5. Total = 135mg morphine in 24 hours divided by 4 = 33.75mg dilaudid 6. Dilaudid tabs are provided in even doses only ie. 2,4,8mg s 7. I elected to use 10mg every 6 hours prn and evaluate the prn usage in 48 hours (she was in a lot of pain) 8. The patient is now only on two meds January 28-31,

11 C MAX T MAX Morphine, *Hydrocodone, Oxycodone, Hydromorphone ROUTE ONSET (min) PEAK (min) DURATION (hours) IV SQ PO *Hydrocodone PO only Anticipate and Treat Complications and Side Effects Constipation Nausea and vomiting Sedation Other opioid-related side effects Opioid withdrawal Opioid tolerance Adjuvant Pain Medication (Co-analgesics) 1. Antidepressants a. Tricyclics 1. Nortriptyline (less sedating) 2. Amitriptyline b. SSRI-NRI 2. NMDA Antagonists a. Methadone b. Ketamine 3. Steroids 4. Bisphosphonates and RANKL January 28-31,