Download Palliative Care Symptom Guide

Palliative Care Symptom Guide
June 2016
Table of Contents
General Principles of Pain and Symptom Management .................................................................................................................... 1
Pain Management ................................................................................................................................................................................
Assessment ................................................................................................................................................................................. 2-3
Select Opiate Products .................................................................................................................................................................. 4
Equianalgesic Dosing .................................................................................................................................................................... 5
Patient Controlled Analgesia (PCA) .................................................................................................................................. 6
Bowel Protocol (and Constipation)............................................................................................................................................. 7-8
Naloxone .....................................................................................................................................................................................9-10
Dyspnea ...............................................................................................................................................................................................
Assessment................................................................................................................................................................................... 11
Treatment ...................................................................................................................................................................................... 12
Nausea and Vomiting Treatment Options ........................................................................................................................................ 13
Delirium ................................................................................................................................................................................................
Diagnosis.................................................................................................................................................................... 14-16
Treatment ..................................................................................................................................................................................17-18
Depression and Anxiety Treatment .............................................................................................................................................19-20
Spirituality Pearls............................................................................................................................................................................... 21
Oral Secretions ................................................................................................................................................................................. 22
Interventional Pain Management ..................................................................................................................................................... 23
Palliative Care and Pain Resources........................................................................................................................................... 24-25
Notes ................................................................................................................................................................................................... 26
Acknowledgements ............................................................................................................................................................................. 27
General Principles of Pain and Symptom Management
Patients with life-limiting illness can experience a wide variety of symptoms. The median number of symptoms is 10.
Principles for the Pharmacologic Management of Pain and Symptoms
1. Inquire about symptoms
- It is important to ask patients about each symptom individually, as patients may not volunteer
information
- Example: Screening Tool for Depression
1. Are you feeling either depressed or hopeless most of the time over the last 2 weeks?
2. Have you found little brings you pleasure or joy over the last 2 weeks?
1.
2.
3.
4.
5.
6.
Prioritize based on degree of severity and bothersome to patient
Understand and identify potential etiologies and/or pathophysiologies
Utilize medications that work within perceived pathophysiology
Consider PRN “rescue dosing” for breakthrough symptoms
Reassess often
* Select information regarding antidepressants on pages 19-20
References:
Homsi J, Walsh D, Rivera N, Rybicki LA, Nelson KA, Legrand SB, Davis M, Naughton M, Gvozdjan D, Pham H. Symptom evaluation in palliative medicine:
patient report vs systematic assessment. Support Care Cancer. 2006 May;14(5):444-53.
Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method of the assessment of palliative
care patients. J Palliat Care. 1991; 7:6-9.
1
Assessment of Pain
For Patients Who Can Communicate:
P: Palliative and Precipitating Factors
Q: Quality
R: Region or Radiating
S: Severity
- When questioning patients about severity it is important to ask what their acceptable or tolerability score is
T: Time (onset) and Temporal (changes throughout the day
U: previous Utilization
V: Values
For Patients Who Are Cognitively Impaired, or Cannot Communicate:
Pain Assessment in Advanced Dementia (PAIN-AD) Scale:
0
Breathing
Independent of vocalization
Normal
2
1
Occasional labored breathing.
Short period of hyperventilation
Negative Vocalization
None
Facial Expression
Smiling, or inexpressive
Occasional moan or groan. Low
level speech with a negative or
disapproving quality.
Sad, frightened or frowning
Body Language
Relaxed
Tense, distressed pacing, or
fidgeting
Consolability
No need to console
Distracted or reassured by voice
or touch
2
Noisy labored breathing. Long
period of hyperventilation.
Cheyne-stokes respirations
Repeated troubled calling out.
Loud moaning or groaning.
Crying
Facial grimacing
Rigid. Fist clenches, knees
pulled up. Pulling or pushing
away. Striking out
Unable to console, distract or
reassure.
TOTAL:
References:
Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir
Assoc. 2003 Jan-Feb;4(1):9-15.
Assessment of Pain (cont.)
1. Utilize assessment methods (as described on the previous slide) based on whether the patient can communicate (or self-report).
2. In opiate naive patients, start with short-acting opioids
7. Determine the dosing schedule.
a. For non-opiate naive patients, use long-acting pain medicine for
(morphine, hydromor- phone, and oxycodone) to control acute,
moderate to severe pain. Never use long-acting opioids to
ongoing pain, not PRN; for opiate naive patients use only prn until
control acute pain.
you have a sense of how much medicine the patient needs.
b. Give 66-75% of patient’s stable daily OME as long acting.
3. When titrating or changing opiate dose, start by calculating the
c. Consider a PCA if the pain requirements are rapidly increasing or
previous day’s Oral Morphine Equivalent (OME).
a. Since all potent opioids produce analgesia by the same
unknown.
mechanism, they will produce the same degree of
8. Determine break through dose (for acute pain in patient with
analgesia if provided in equianalgesic doses (see
otherwise controlled pain).
equanalgesic table).
a. Use the same opiate for short- and long-acting pain when possible.
b. Rectal=oral
b. 5-15% of total daily long acting opiate dose every 3 hr prn.
c. SQ=IM=IV
9. Manage opiate side effects. Constipation must be treated
4. Determine if the dose is adequate for the pain and dose adjust.
prophylactically (see pages 7-8).
a. Titrate at least every 24 hours when the pain is moderate and
10. Determine whether co-analgesics would help.
as often as every four hours when using IV opioids and the
pain is severe.
b. Increase dose 25-50% for moderate pain and 50-100% for
3
severe pain.
5. Determine the opiate that will be used and dose adjust for
incomplete cross tolerance.
a. The only reason to change from one opiate to another is side
effects or renal failure.
b. When rotating opiate, decrease the dose 25-50% to correct
for incomplete cross tolerance.
6. Determine the route the opiate will be given.
a. IM should never be given.
SELECT NON-INJECTABLE OPIOID PRODUCTS
Drug
Morphine
Short Acting (mg)
Tabs(15, 30)
MSIR Oral Solution (10 mg/5 mL, 20 mg/5 mL)
Supp(10, 20)
Long Acting (mg)
MS Contin Tabs(q12hr) (15, 30, 60, 100)
Kadian Caps (q12hr or q24hr) (10, 20, 30, 50)()
Avinza Caps (q24hr) (30)()
Oxycodone
Roxicodone Tabs(5, 10, 15, 30) ()
Roxicodone Oral Solution (5mg/5mL)
OxyFAST, Oxydose, Roxicodone Intensol Oral Concentrate (20 mg/mL) ()
Dilaudid Tabs(2, 4, 8) (8 mg brand-name scored)
Dilaudid OralSolution(5 mg/5 mL) () Supp(3)
Tabs (15, 30)
See Note Below
Opana (5)
OxyContin Tabs(q12hr) (10, 15, 20, 30, 40, 80)
Hydromorphone
Codeine
Fentanyl
Oxymorphone
SELECT COMBINATION OPIOID PRODUCTS
Drug
Norco (Hydrocodone/acetaminophen) () ()
Percocet (oxycodone/acetaminophen) ()
Percodan (oxycodone/aspirin)
Tylenol with Codeine (codeine/acetaminophen) ()
Duragesic Transdermal Patch (12.5, 25, 50, 75, 100 mcg/hr)
Opana ER (5, 10, 20, 40)
Formulation/Strength (mg/mg)
Tabs
Tabs
Tabs
Tabs
5/325, 7.5/325, 10/325
2.5/325, 5/325, 7.5/325, 10/325
5/325
30/300 (#3) Oral Solution 12/120 per 5 mL ()
() Orders for concentrated oral opioid solutions must include drug name and strength (e.g. 100 mg/5mL) to avoid confusion with other oral solutions. () Maximum daily dose of acetaminophen
is 4 grams in patients with normal liver function. () Many other brand name products contain similar combinations of opioids. () Formulary restricted. () Non-formulary. () Prescribers must
complete Transmucosal Immediate Release Fentanyl (TIRF) Risk Evaluation and Mitigation Strategy (REMS). () Oxycodone CR (Oxycontin®) will be formulary-restricted to continuation of home
therapy only. No new inpatient starts will be permitted.
Information on newer restricted analgesics:
Tapentadol (Nucynta and Nucynta ER) are not on the UPMC formulary but patients will be allowed to continue outpatient therapy. It is not covered by outpatient
insuranceTransmucosal Immediate Release Fentanyl (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys) are formulary restricted products.
Hysingla ER and Zohydro (hydrocodone ER) are not on formulary at UPMC health system.
4
Oral and Parenteral Opioid Analgesic Equivalencies and Relative Potency of
Opioids as Compared with Morphine*
When converting from one opioid to another, you should use 50–75% of the equivalent dose. Allow for incomplete cross-tolerance
between different opioids (may need to titrate up rapidly and use PRN dose to ensure effective analgesia for the first 24 hours). Avoid IM
injections because of inconsistent absorption and patient discomfort.
Opioid Agonists
Morphine
Oxycodone
Oxymorphone
Hydromorphone
Hydrocodone
Tramadol
Fentanyl
Δ For patch conversion,
see box below
Parenteral (mg)
10
Oral (mg)
30
1
20-30
10
1.5
7.5
0.1 (100 mcg) **
25-30
120
•
•
•
•
•
•
•
•
•
•
•
•
•
Comments
Not recommended in renal dysfunction (CrCl <30 mL/min). Metabolites can
be neurotoxic.
Not dialyzed
Use with caution in patients with hepatic dysfunction
Reduce dose in patients with hepatic dysfunction
Reduce dose in patients with renal dysfunction (CrCl <50 mL/min)
Contraindicated in patients with moderate or severe hepatic impariment.
Reduce dose in patients with mild impairment
Consider safe in dialysis patients
Use with caution in patients with hepatic dysfunction
Reduce dose in patients with severe renal and hepatic impairment
Maximum daily dose: 300 mg
Safe in renal dysfunction. No active metabolites
Pharmacokinetics were not altered in patients with cirrhosis
Consider major interactions with CYP 3A4 inhibitors and inducers
*These are rough approximations; individual patients may vary. ** Equivalency for a one time dose of IV Fentanyl only. For Fentanyl patch conversion, see box below.
- Parenteral opioid: onset of action, 5 minutes; peak, 15 minutes; duration
of effect, 1-2 hours (fentanyl) to 3-4 hours (other opioids)
- Oral opioid: onset of action, 15–30 minutes; peak, 45–60 minutes;
3-4 hours
Δ TWENTY-FOUR HOUR ORAL MORPHINE EQUIVALENT DIVIDED BY 2 IS
EQUAL TO FENTANYL PATCH DOSE IN MCG/HR.
IV FENTANYL DOSE/HR=TRANSDERMAL FENTANYL DOSE
NOTE: PATCH TAKES 12–24 HRS TO ACHIEVE FULL EFFECT. WHEN REMOVING
A PATCH, REMEMBER THE ANALGESIC EFFECT CAN STILL LAST 24 HRS.
References:
Arnold RM, Verrico P and Davison SN. Opioid Use in Renal Failure #161. J Palliat Med. 2007. 10(6):1403.
Gina Carbonara, PharmD. Opioids in Patients with Renal or Hepatic Dysfunction. Practical Pain Management Volume 8, Issue 4.
APS Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (2003); American Pain Society (APS) Guideline for the Management of Cancer
Pain in Adults and Children (2005).
5
Patient Controlled Analgesia (PCA)
The following are suggestions for the PCA order for adults.
Like all opioid orders, doses must be individualized.
Loading
Starting Patient
dose(s)
Administered Dose*
Morphine (6)
1 mg
Opioid naive:
2-4 mg q 15 min
Elderly (>70 yrs.)
0.5 mg
2mg q 20 min.
titrated to pain relief
0.2 mg
Hydromorphone
Opioid naive:
(Dilaudid)
0.2–0.3 mg q 15 min
Elderly: 0.1 mg
Elderly (>70 yrs.)
0.2mg q 20 min
titrated to pain relief
EDUCATE FAMILIES NOT TO PRESS THE PCA BUTTON!
Lockout
Interval
8–20 min.
One-hour Dose
Limit (optional)
7–10 mg
8–20 min.
4–6 mg
8–20 min.
0.7–1.4 mg
8–20 min.
0.4–0.6 mg
Continuous infusion
rate in mg/hr
When indicated,
calculate based on
intermittent PCA use
or previous opioid
requirement.
6
*Opioid tolerant and chronic/cancer pain patients may require higher doses
and continuous infusions.
- Capnography (EtCO2) monitoring is mandatory for all patients
receiving PCA therapy. See updated PCA policy for exemptions. In
patients with a RR <6 bpm for 1-2 minutes, PCA pump will alarm and
pause from administering medication.
- PCA alone is a maintenance technique. Patients should receive
loading doses (delivered through the infuser) that are titrated to
achieve an adequate level of analgesia (pain score less than or
equal to 4/10).
- Quantity delivered when button is pressed. Reduce doses by
30-50%in elderly and patients with liver disease. Do not increase dose
based on increased body weight; this is especially important in
patients with Obstructive Sleep Apnea. Dosing depends on the patient
—young vs. elderly/opioid naive vs. tolerant.
- How frequently demand dose can be activated. Patient must be able
to press the button and be able to comprehend instructions on when to
press the button. In the elderly, consider a longer lockout interval.
- The hour limit should not be less than the available total hourly
patient administered dose. Bolus doses and the continuous infusion
are included in the one-hour dose limit count.
- Not recommended for patients who are opioid naive, the elderly,
patients with altered mentation, or with Obstructive Sleep Apnea,
COPD, or asthma.
- Morphine is generally the opioid of choice. Hydromorphone is
preferred in patients with impaired renal function.
If pain unrelieved following administration of loading dose(s),
increase loading dose by 50% and titrate to pain score less than or
equal to 4/10.
Bowel Regimen (and Constipation)
Any given time if there is no bowel movement for 4 or more days a sodium phosphate or mineral oil enema should be administered. If this is not effective, a
high colonic tap water enema should be administered. Be aware of the possibility of bowel obstruction or fecal impaction. Except on neutropenic patients, a
digital rectal exam should be performed prior to starting a bowel regimen and if no BM for 4 days.
Other drugs that can exacerbate constipation: anticholinergics (tricyclic antidepressants, scopolamine, oxybutynin, promethazine, diphenhydramine), lithium,
verapamil, bismuth, iron, aluminium, calcium salts.
Maximum Daily Dose
Medication
Usual Starting Dose
Site and Mechanism of
Onset of Action
Action
Stimulant Laxatives
Bisacodyl
5-15 mg x1
30 mg
Colon; stimulates peristalsis
6-10 hr
Bisacodyl (PR)
10 mg x1
10 mg
Colon; stimulates peristalsis
15 min-1 hr
Senna
2 tabs qhs
34.4 mg
Colon; stimulate myenteric
6-10 hr
plexus, alters water and
electrolyte secretion
Osmotic Laxatives
Lactulose
15-30 ml q12-24 hr
60 mL (or 40 g)
Colon; osmotic effect
24-48 hr
Polyethlyene Glycol
17g (1tbsp) powder in 8oz
17 g
GI tract; osmotic effect
48-96 hr
water q24 hr
Sorbitol
15-30 ml q12-24 hr, max
27-40 g
Colon; delivers osmotically
24-48 hr
7
150 ml/d
active molecules to the
colon
Saline Laxatives *
Magneisum Citrate
120-240 ml x1; 10 oz q24
6.5-10 ounces
Small and large bowel;
30 min-3 hr
hr
attracts and retains water in
the bowel lumen
Magnesium Hydroxide
30 ml q12-24h
8 tablets or 60 mL
Colon; osmotic effect &
30 min-3 hr
(MoM)
increased peristalsis
Surface Laxatives
Docusate Δ
100 mg q12-24 hr
200 mg
Small and large bowel;
24-72 hr
detergent activity; softens
feces
Δ Docusate is no better than placebo (in combination with senna) in improving bowel movements
*Avoid use of MOM and related products (including sodium phosphate enema products) in patients with renal dysfunction because of risk of hyperphosphatemia Reference: Reuben DB,
Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips 2009, 11th edition. New York: The American Geriatrics Society; 2009
References:
Tarumi Y, Wilson MP, Szafran O, Spooner GR. Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in
hospice patients. J Pain Symptom Manage. 2013 Jan;45(1):2-13.
Agents for Refractory Opioid Induced Constipation (OIC)
Few exceptions, all patients on opioid therapy needed individualized bowel regimen. When the effective regimen is found it must be continued for the duration of the opioid
therapy. Bulk laxatives alone are not useful in the treatment of opioid induced constipation.
Refractory OIC is defined as less than 3 spontaneous bowel movements/week, despite laxative therapy. Peripherally acting Mu opioid receptor antagonists can only be
considered for patients who have been receiving opioid therapy for at least 2-4 weeks.
Currently approved and available Peripherally Acting Mu Opioid Receptor Antagonists (PAMORAs) are:
Methylnaltrexone (Relistor): SQ
• Requires approval by pain, palliative care, oncology, critical care, or GI service
• Dosing:
Pounds
<84
84-136
137-251
>251
Patient weight
Kilograms
<38
38-62
63-114
>114
Dose
0.15mg/kg
8mg
12mg
0.15mg/kg
• In patients with severe renal impairment (CrCl <30ml/min), reduce doses by half
• About 50% of patients will experience a bowel movement within 4 hours of a given dose
Naloxegol (Movantik): PO
Requires approval by pain, palliative care, oncology, critical care and GI services. May continue inpatient if home therapy.
• Dosing: 25mg PO once daily on an empty stomach
• In patients with CrCl <60ml/min, reduce dose to 12.5mg PO once daily
• All other laxatives should be discontinued prior to initiation of naloxegol. Patients may resume laxative therapy if OIC symptoms continue after 3 days of
naloxegol therapy.
References:
Product Information: RELISTOR(R) subcutaneous injection, methylnaltrexone bromide subcutaneous injection. Salix Pharmaceuticals, Inc. (per FDA), Raleigh, NC, 2014.
Product Information: MOVANTIK(TM) oral tablets, naloxegol oral tablets. AstraZeneca (per manufacturer), Wilmington, DE, 2014.
8
Guidelines for Inpatient Naloxone Administration and Patient Monitoring
1. Nurses may administer naloxone without a physician’s
order when patients who have received an opioid meet
the following criteria:
(a) Sedation Scale = 3 (Somnolent; Difficult to arouse), (b)
RR < 8 OR Oxygen Saturation < 92% and RR < 12
2. If the criteria listed above are met, stop the administration
of the opioid (including fentanyl patches) and
benzodiazepines.
3. Provide oxygen via face mask STAT.
4. Method for naloxone administration: Naloxone 0.04 mg IV
q 1 minute until a change in alertness is observed. Dilute
0.4mg naloxone (one ampule) with NSS to a total volume of
10ml (1 ml = 0.04 mg) in a 10 ml syringe.
5. Notify the primary physician and/or house staff of the
need to immediately evaluate the patient. If the house
staff does not arrive within five minutes or if the nurse
assesses the need, a “Condition C” should be called.
6. Titrate the prescribed naloxone until the patient is responsive.
The half-life of naloxone (ONE HOUR) is shorter than the halflife of opioid agonists. Naloxone administration should not
cause pain to return or precipitate opioid withdrawal. If a
response is not obtained after one ampule of naloxone (10 cc
of diluted solu- tion) is administered, examine the patient for
alternate causes of sedation and respiratory depression. For
assistance with further naloxone dosing, please contact the
UPMC MedCall (412-647-7000).
7. Re-evaluate the events leading to the need for naloxone
administration. In cases where the prescribed opioid dosing
was too high, reassess the therapeutic plan for pain
management. Consider decreasing the opioid dose by 50%.
Resume opioid administration when the patient is easily
aroused, is beginning to experience pain, and after the RR
increases to >9.
9
Guidelines for Outpatient Intranasal Naloxone Prescribing
Patients that should be considered for outpatient intranasal prescribing at discharge:
1) >100mg oral morphine equivalents/day
2) Recent (within previous 6 months) healthcare visit for opioid dependence
3) Recent (within previous 6 months) ER visit (for any indication)
Others include:
- In the previous 6 months the patient has a healthcare visit involving: chronic hepatitis or cirrhosis, bipolar or schizophrenia,
chronic pulmonary disease (i.e., emphysema, chronic bronchitis, asthma, pneumoconiosis), chronic kidney disease with
clinically significant impairment, an active traumatic injury (excluding burns), or sleep apnea
- If the patient consumes: an extended-release or long-acting (ER/LA) formulation of any prescription opioid, methadone, or
oxycodone immediate release (IR)
- If the patient’s current prescribed opioid dose is: 50-100mg oral morphine equivalents/day
PA Act 139:
• This legislation allows first responders including law enforcement, fire fighters, EMS or other organizations the ability to
administer naloxone
• The law also allows individuals such as friends or family members that may be in a position to assist a person at risk of
experiencing an opioid related overdose to obtain a prescription for naloxone
• Additionally, Act 139 provides immunity from prosecution for those responding to and reporting overdoses
In May 2015, ACHD Director Dr. Karen Hacker issued a county-wide standing order, citing PA Act 139 , allowing licensed
pharmacies (which choose to participate) to dispense naloxone to individuals at risk of a heroin or opioid-related overdose,
or those who may witness one.
• Communicate with your hospital’s ER to see if intranasal naloxone kits are available
• To find a local pharmacy that carries intranasal naloxone visit: http://www.overdosefreepa.pitt.edu/find-naloxone/
References:
Zedler B, Xie L, Wang L, Joyce A, et al. Development of a risk index for serious prescription opioid-induced respiratory depression or overdose in
Veterans' Health Administration patients. Pain Med. 2015 Aug;16(8):1566-1579.
10
Dyspnea: Assessment
For Patients Who Can Self Report: (similar to the assessment of pain)
S: Severity:
0
1
2
3
4
5
6
7
No Shortness of Breath
8
For Patients Who Are Unable Self Report:
Respiratory Distress Observation Scale (RDOS)
0 Points
1 Point
2 Points
Heart Rate
< 90 bpm
Respiratory Rate
≤ 18 breaths/min
19-30 breaths/min
> 30 breaths/min
Restlessness (non purposeful
movements)
None
Occasional, slight
movements
Frequent movements
Paradoxical Breathing Pattern
(abdomen moves on inspiration)
None
Accessory Respiratory Muscle Use
(rise in clavicle during inspiration)
None
Grunting at End-Expiration (guttural
sound)
None
Present
Nasal Flaring (involuntary
movements in nares)
None
Present
None
Eyes wide open, facial
muscles tense, etc.
Look of Fear
9
10
Worse Shortness of Breath Imaginable
Present
Slight rise
Pronounced rise
Instructions for Use:
• RDOS is not a substitute for patient self-report
if able.
• RDOS is an adult assessment tool.
• RDOS cannot be used when the patient is
paralyzed with a neuromuscular blocking agent.
• RDOS is not valid in bulbar ALS or
quadriplegia.
• Count respirations and heart rate for one
11
minute; auscultate if necessary.
• Grunting may be audible with intubated
patients on auscultation.
• Fearful facial expressions
• A score of 7 or higher should prompt a call
to the physician/NP/PA.
RDOS
Total
Respiratory
Distress Level
0-2
Minimal
3
Mild
4-6
Moderate
≥7
Severe
References:
Campbell ML, Templin T, Walch J. A Respiratory Distress Observation Scale for patients unable to self-report dyspnea. J Palliat Med. 2010 Mar;13(3):285-90.
Dyspnea: Treatment
1. Opioid Naive Patients (all doses are for morphine):
2. Non-Opioid-Naive (or Opioid-Tolerant) Patients:
• Loading dose: 2-5 mg IV push.
• For patients who have been taking opioid pain medications
within last 24 hours calculate the equianalgesic parenteral
• If distress not relieved in 15 minutes after initial loading
dose of morphine for the last 24 hrs (see page 4 for opioid
dose, give bolus equal the loading dose increased by 50
equivalencies).
percent. If severe distress persists repeat the dose every
15 minutes until comfortable.
• Divide the total 24 hour IV morphine dose by 24 to
determine initial hourly infusion rate (mg/hour, IV). Start
• For increased pain/distress give extra bolus dose/s equal
continuous infusion at this rate.
to the last given bolus dose every 30 minutes as needed.
• If patient pain/distress use loading dose = hourly infusion
• If using more than 2 bolus doses over a 6-hour period,
rate.
consider starting a continuous infusion. To calculate the
• If distress not relieved in 15 minutes after initial loading
continuous infusion rate divide the total dose over last 6
dose or the patient in increased pain/distress, administer
hours by 6.
the loading dose increased by 50 percent and repeat every
15 minutes until comfortable.
• If using more than two bolus doses over 6-hour period,
determine new continuous infusion rate by recalculating
total dose given over last 6 hours and dividing it by 6.
12
Nausea and Vomiting: Treatment
Maximum Daily
Dose
(for nausea)
5 mg
Drug
Common Clinical
Indications
Starting
Dose/Route
Haloperidol
Opioid Induced N/V
Metoclopramide*
Impared GI motility
Opioid Induced N/V
0.5-4 mg PO or
SQ or IV Q6h
5-20 mg PO or
SQ or IV AC and
HS
Prochlorperazine
Opioid induced N/V
N/V of unknown
etiology
Motion induced N/V
5-10 mg PO or IV
every 6 h or
25mg PR Q6h
1.5 mg
Transdermal
patch every 3 d
40 mg
Ondansetron
Chemotherapy or
radiation induced N/V
32 mg
Dexamethasone
N/V related to
Increased ICP
4-8 mg PO as a
pill or dissolvable
tablet or IV every
4-8 h
4-8 mg QAM or
BID, PO (as pill
or liquid) and IV
Scopolamine
60 mg
1 patch q72 h
8-16mg
*Metoclopramide is first line for empiric therapy
Other agents should be utilized based on perceived pathophysiology
Comments/ Side
Effects
Cost
IV has less EPS
compared to PO
EPS, esophageal
spasm, and colic in
GI tract obstruction
EPS and sedation
$
Dry mouth, blurred
vision, ileus,
urinary retention,
and confusion
Headache, fatigue,
and constipation
$
Agitation,
Insomnia,
Hyperglycemia
$
$
$
$
13
Delirium: Diagnosis
DSM IV criteria for delirium include four components:
A. Acute onset, over hours to days
B. Behavioral disturbands, marked by reduce clarity in the patient’s awareness of the environment, with impaired ability to focus,
sustain or shift attention. The patient may be agitated, irritable, and emotionally labile, OR drowsy, quiet, and withdrawn
C. Consciousness level fluctuates over the course of the day
D. Different from dementia, delirium cannot be accounted for by a patient’s preexisting, established, or evolving dementia
Delirium is conceptualized as a reversible illness, except in the last 24-48 hours of life
Delirium occurs in at least 25-50% of hospitalized cancer patients, and in a higher percentage of patients who are terminally ill.
Delirium increases the risk of in-hospital and six month mortality.
Differential diagnosis
D: Drugs (Opioids, anticholinergics, sedatives, benzodiazepines, steroids, chemo - and immunotherapies, some antibiotics)
E: Eyes and Ears (poor vision, hearing, isolation)
L: Low flow states (hypoxia, MI, CHF, COPD, shock)
I: Infections
R: Retention (urine/stool)
I: Intracranial (CNS metastases, seizures, subdural, CVA, hypertensive encephalopathy)
U: Under hydration, Under - nutrition, Under - sleep
M: Metabolic disorders (sodium, glucose, thyroid, hepatic, deficiencies of Vitamin B12, folate, niacin, and thiamine) and Toxic
(lead, manganese, mercury, alcohol)
14
Delirium: Diagnosis
3D CAM (Confusion Assessment Method) for the diagnosis of Delirium
Diagnosis positive with 1 and 2 and either 3 or 4.
Feature
Questions asked*
8. During the past day have you felt
confused?
1. Acute Onset 9. During the past day did you think that you
OR- Fluctuation were not really in the hospital?
10.During the past day did you see things
that were not really there?
Observations at bedside
Fluctuation in level of consciousness
Fluctuation in attention during interview
Positive Answer 11
Any answer other than 'no' is positive
Any positive observation is a yes
Fluctuation in speech or thinking
-AND-
2. Inattention
4. I am going to read some numbers. I want
you to repeat them in backwards order from
the way I read them to you. For instance, if I
say "5 - 2", you would say "2 -5". OK? The
first one is "7-5-1"(1-5-7)
5. The second is "8-2-4-3"(3-4-2-8).
6. Can you tell me the days of the week
backwards, starting withSaturday?.
7. Can you tell me the months of the year
backwards, starting withDecember?
Did the patient have trouble keeping track of what was being
said during the interview?
Did the patient appear inappropriately distracted by environmental
stimuli?
Anything other than 'correct' is coded as
positive
Either observation is positive
15
-AND EITHER-
3. Disorganized
Thinking
1. Can you tell me the year we are in right
now?
2. Can you tell me the day of the week?
3. Can you tell me what type of place is this?
Was the patient's flow of ideas unclear or illogical, for example tell
a story unrelated to the interview (tangential)?
Was the patient's conversation rambling, for example did he/she
give inappropriately verbose and off target responses
Any answer other than 'correct' is coded as
positive
Answer is 'yes'
Was the patient's speech unusually limited or sparse? (e.g.
yes/no answers
-OR-
4. Altered Level
Of
Consciousness
Was the patient's speech unusually limited or sparse? (e.g.
yes/no answers)
Either observation is positive
*Questions are numbered in the order of their listing in the 3D CAM instrument.
11 Incorrect also includes "I don't know", and No response/non-sensical responses.
Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Medicine. 1990;
113:941-8.
Delirium: Diagnosis
The scale is completed based on information collected from each item over an 8 hour shift or the previous 24 hours.
Obvious manifestation of an item = 1 point
No manifestation of an item or no assessment possible = 0 point
The Intensive Care Delirium Screening Checklist (ICDSC)
Patient evaluation
Altered Level of consciousness
Day 1
Day 2
Day 3
Day 4
Day 5
If A or B do not complete patient evaluation for the period
Inattention
Disorientation
Hallucinations-delusion-psychosis
Psychomotor agitation or retardation
Inappropriate speech or mood
Sleep/wake cycle disturbance
Symptom fluctuation
Total Score
Level of consciousness: A: no response
B: response to intense and repeated stimulation (loud voice and pain)
C: Response to mild or moderate stimulation
D: normal wakefulness
E: exaggerated response to normal stimulation
16
No score
Noscore
1
1
1
Inattention: Difficulty in following a conversation or instructions
Disorientation: Any obvious mistake in time, place, person
Hallucinations, delusion or psychosis: Overt clinical manifestation of hallucination or behavior related to hallucination or delusion
Psychomotor agitation or retardation: Hyperactivity requiring restraints or drugs, clinically noticeable psychomotor slowing
Inappropriate speech or mood: Disorganized or incoherent or inappropriate speech. Inappropriate display of emotion related to events of situation
Sleep/wake cycle disturbance: Sleeping <4 hours or waking frequently at night (not initiated by staff or loud environment), sleeping during most of the day
Symptom fluctuation: Fluctuation of any item over 24 hours
Reference: See www.icudelirium.org for more information
Delirium: Treatment
Benzodiazepines are NOT effective in treating delirium, may worsen delirium, and should be used cautiously only as adjunct
therapy with neuroleptics when relief of agitation is required.
Neuroleptics are used for treatment of delirium. Haloperidol is the standard neuroleptic for treatment of delirium. Risperidone,
olanzapine, and quetiapine are atypical neuroleptics, generally with fewer side effects. All neuroleptics can cause QT
prolongation.
Supportive care to prevent and reduce delirium includes frequent orientation (well-lit rooms, caregivers, calendars, clocks,
communication), therapeutic activities (patient mobilization 3x/day when possible), non-pharmacologic sleep aids (see page
12), treatment of hearing and vision problems, treatment
of incontinence, and volume repletion. Confusion increases the risk of falls. Pay attention to patient safety. Constant supervision
(sitter) may be more beneficial than restraints or sedation.
Generic name
(Common brand)
Starting
dose
Dosing
interval
Max q24h
dose
Formulation
EPS
Anticholinergic
Sedation
QTc
prolongation
Comments**
Haloperidol
(Haldol®)
0.5-1 mg
(2 mg in
ICU*)
0.5-1 hour
for urgent
symptoms.
Otherwise or
Q8H
20 mg
Tabs: 0.5, 1, 2, 5 Oral
Solution 2
5 mg/ml injectable
solution
+++
+
++
PO:+ (IV:++)
IV has less
EPS compared
to PO.***
(continued)
17
Delirium: Treatment (cont.)
Generic name
(Common brand)
Starting
dose
Dosing
interval
Max q24h
dose
Formulation
EPS
Anticholinergic
Risperidone
(Risperdal®)
0.25-1 mg
BID or up to
Q6H PRN
6 mg
++ +
+
Olanzapine
(Zyprexa®)
2.5-10 mg
DAILY
+
+++
++
+
Debilitated
or elderly:
2.5 mg.
IM: Q2H
Tabs: 0.25, 0.5, 1, 2, 3, 4 mg
Oral solution 1 mg/ml
M Tabs (ODTs): 0.5, 1, 2,
4 mg
Tabs: 2.5, 7.5, 10, 15, 20 mg
Injectable product 10 mg IM
ODTs: 5, 10, 15, 20 mg
Patients with hypoactive
delirium, >70years CNS
malignancy may not
respond well.
Quetiapine
(Seroquel®)
12.5- 50
mg
BID
800 mg
+
++
+++
++
Start DAILY at 4pm for
sundowning † and then
time subsequent,
additional doses based
on symptoms.
Aripiprazole
(Abilify®)
5-15 mg
Q AM
30 mg
++
+
++
0/-
Useful for hypoactive
delirium. Can cause
insomnia if given at
night
20 mg
Tabs: 25, 50, 100,
200, 300, 400 mg
Tabs: 2, 5, 10, 15, 20, 30 mg
Oral Solution 5 mg/5mL
Discmelt ODTs: 10, 15mg
Sedation
QTc
prolongation
++
Abbreviations: EPS: extrapyramidal symptoms; IM: intramuscular; IV: intravenous; ODT: oral disintegrating tablet; SQ: subcutaneous.
Deinition: †Sundowning: Onset of confusion in the elderly that typically begins in the evening
*Refer to the UPMC Presbyterian Shadyside “Acute Agitation Management” order set.
** The FDA has determined that the use of antipsychotic medications in the treatment of behavioral disorders in elderly patients with dementia is
associated with increased mortality. This risk appears to be highest during the first two weeks of use.
*** Use IV haloperidol with caution in patients with prolonged QT interval. Increased risk of arrhythmia and sudden death exists with high IV doses.
Comments**
Caution renal
failure.
18
Depression and Anxiety
Commonly used antidepressants: dosing, formulations
Category
Generic
(Common Brand Name)
Starting PO dose
(depression)*
Dosing
interval
Target dose
/day range*
SSRIs
Citalopram
(Celexa®)
10-20 mg
DAILY
10-60 mg
10, 20, 40 mg (tablets)
Oral Solution 10 mg/5 mL
Escitalopram
(Lexapro®)
5-10 mg
DAILY
10-20 mg
5, 10, 20 mg (tablets)
Oral Solution 5 mg/5 mL
Sertraline
(Zoloft®)
25-50 mg
DAILY
50-200 mg
25, 50, 100 mg (tablets)
Oral Solution 100 mg/5 mL
Venlafaxine
(Effexor®)
Venlafaxine XR
(Effexor XR®)
75 mg/day divided
BID-TID
150-375 mg
25, 37.5, 50, 75 mg (tablets)
37.5-75 mg
DAILY
75-225 mg
37.5, 75, 150 mg (capsules)
Duloxetine
(Cymbalta®)
Methylphenidate
(Ritalin®)
20 mg
BID
30-60 mg
2.5-5 mg
BID 8a,12p
5-40 mg (for
depression)
20, 30, 60 mg (delayed-released
capsules)
5, 10, 20 mg
(tablets)
SNRIs
Stimulants
Formulations (mg)
Abbreviations: CR, SR, XL, XR: sustained-release products SSRIs: Serotonic Specific Reuptake Inhibitors, SNRIs: Serotonin Norepinephrine Reuptake Inhibitors
Others: Use the following w/caution in renally impaired patients: all SNRIs, all formulations of buproprion and mirtazapine
Use the following w/caution in hepatically impaired patients: All SSRIs, methylphenidate, all SNRIs and bupropion
*The therapeutic dose/day range varies from the minimum efficacious dose up to the maximum tolerated or daily recommended amounts. Maximum daily doses are
dependent upon indication for use and should only be used as a guide. Initial doses should be low in elderly patients and increased gradually. Doses of up to 300 mg
of venlafaxine XR have been used in practice, but are not FDA-approved. The doses for methylphenidate can be higher than 20mg but are generally not recommended.
19
Commonly used antidepressants: costs, side effects, comments
Drug (Common
brand name)
Citalopram
(Celexa®)
Escitalopram
(Lexapro®)
Sertraline
(Zoloft®)
Venlafaxine
(Effexor®)
Venlafaxine XR
(Effexor® XR)
Anticholinergic Insomnia GI Distress Comments**
+
+
++
+
+++
++
Mild to moderately activating, few drug
interactions.
t1/2 similar to Sertraline and Citalopram
--
+
+++
Moderately activating.
+
+++
+++
+
+++
++
Duloxetine
(Cymbalta®)
++
++
++
Methylphenidate
(Ritalin®)***
--
Dual serotonin/norepinephrine action at doses of
150-225mg which is effective in neuropathic pain
and is mildly activating. On switching from the
venlafaxine XR to venlafaxine, the shorter half life
of venlafaxine requires frequent dosing to reach
the same dose of venlafaxine XR.
Use with caution in patients with hypertension.
FDA-approved for diabetic neuropathy and offlabel use for urinary incontinence. Do not use in
patients with liver dysfunction. Use caution in
patients with seizure disorder.
Energizing, may increase appetite.
+++
+
Abbreviations: ODT: oral disintegrating tablet; t1/2 : half-life.
*Cost per day of a typical daily dose was calculated based on generic products when available. Cost data was extrapolated from www.drugstore.com.
**Activating antidepressants tend to cause insomnia.
***Not FDA-approved for treatment of depression. Differences in arrythmogenicity are not clinically relevant among these groups.
20
Spirituality Pearls
Spirituality is defined as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they
1
experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred”
How to ask:
What gives you strength?
What helps you during difficult times?
Who /what is important to you?
Religious faiths and practices during sickness and end of life
Catholic
Orthodox
Christian
Islamic
Religious leader
Priest
Priest
Imam*
Specific prayer
for sick/dying
Sacrament of
the sick
Unction
Recite Quran
Special prayers
Same gender care
giver
No
Yes
Yes
Caregiver present
at all times also
after death
No
Yes
Yes
Body positioning
after death
Life support
No extraordinary
measures necessary
Amish
Elders*
Jewish
Protestan
Rabbi*
Minister/Pastor/Other
Psalms “shema”
Varies (anointing)
Varies
Yes
No
No
Yes
No
Face Mecca
Eyes closed arms/
fingers extended
Family decides
Hastening death not
Permitted
Patient and/or family
decide
*Family may consult for health care decisions.
Resources:
keyword: interfaith guide (infonet)
keyword: Loma Linda religion health care (internet)
FICA mnemonic for taking a spiritual history found at www.capc.org
Contact chaplain: chaplains available 24 hours 7 days a week. Call the hospital operator to page the chaplain on call.
1. Puchalski CM, Ferrell B, Viriani R, et al. Improving the quality of spiritual care as a dimension of palliative care:
Consensus conference report. J Palliat Med. 2009;12(10): 885-903.
21
Oral Secretions at the End of Life
As the level of consciousness decreases in the dying process,
patients lose their ability to swallow and clear oral secretions. As air
moves over the secretions, the resulting turbulence produces noisy
ventilation with each breath, described as gurgling or rattling noises.
Death rattle is a good predictor of near death; one study indicated the
median time from the onset of death rattle to death was 16 hours.
Non-pharmacological treatments: Position the patient on their side
or in a semi-prone position to facilitate postural drainage. Reassure
family about noise; can compare to snoring.
While there are no evidence-based guidelines, the standard of care is
to use muscarinic receptor blockers (anti-cholinergic drugs).
Drug
Route
Starting Dose
Onset
Maximum Daily Dose
Scopolamine
Transdermal
1 (~1 mg/3 days)
12 hrs.
1 patch q72h
Levsin
Drops, Tabs(oral)
0.125mg
30 min.
1.5 mg
Glycopyrrolate
PO
1 mg
30 min.
8 mg
Glycopyrrolate
SC, IV
0.2 mg
1 min.
800 mcg
Atropine
Inj
Atropine
SL drops
0.1 mg
1 min.
2 mg
1 gtt (1%)
30 min
48 drops
*Use atropine ophthalmic drops.
Tertiary amines which cross the blood-brain barrier (all but glycopyrrolate) cause CNS toxicity (sedation, delirium).
Reference:
K Bickel; R Arnold. Fast Fact and Concept #109: Death Rattle and Oral Secretions, 2nd Edition. End-of-Life/Palliative Education Resource
Center (www.eperc.mcw.edu) 2003.
22
Interventional Pain Management
Interventions that minimize systemic opioids and help with pain relief in a targeted fashion can be considered for a lot of patients. At UPMC, the chronic pain
and palliative care services collaborate to identify patients who are most likely to benefit from such interventions. Examples of available interventions which
are best supported by evidence are listed below:
COMMON NERVE BLOCKS
Block Type
Celiac Plexus Block
Superior Hypogastric Block
Lumbar Sympathetic Block
Pudendal Nerve Block
Indications
Abdominal visceral pain from:
- pancreatic cancer
- other upper abdominal tumors
Pelvic visceral pain from:
- gynecological, colorectal or GU cancers
Intractable LE pain:
- Peripheral Vascular Disease
- Chronic Regional Pain Syndrome
Vaginal Pain
Penile/Scrotal Pain
Perineal Pain
Sphenopalatine/Trigeminal Nerve Blocks
Facial Pain
Epidural Steroid Injection
Low back pain – often for non-malignant pain
CENTRALLY IMPLANTED PUMPS/STIMULATORS
Hardware Type
Indications
Intrathecal pump
- Pain refractory to systemic opioids; and
- Prognosis > 3 months for insurance to cover
Tunneled epidural catheter
- Pain refractory to systemic opioids; and
- Prognosis < 3 months
Spinal cord stimulator
- Most helpful in refractory neuropathic limb pain (especially in non-operative
ischemic limb)
Exclude patients who are:
•
Neutropenic/Septic
•
Infection in the region of the proposed procedure
•
Coagulopathic (INR>1.4 or platelets<100K)
•
On anticoagulants/antiplatelet agents that are not safe to hold or reverse
23
UPMC Palliative Care and Pain Treatment Resources
Inpatient Supportive and Palliative Care Services
PUH/MUH Supportive & Palliative Care Service
412-647-7243, pager: 8511
Shadyside Supportive & Palliative Care Service
412-647-7243, pager: 8513
Magee Womens Hospital of UPMC Supportive and
412-647-7243, pager: 8510
Palliative Care Service
Children's Hospital of Pittsburgh of UPMC Supportive Care
Program
412-692-3234
VA Palliative Care Program Inpatient and Oncology:
412-688-6000 Ext. 816178; or pager - 645-2345
Geriatric palliative care: pager 412-958-0215
UPMC Altoona Supportive and Palliative Care Service
814-889-2701
UPMC East Supportive and Palliative Care Service
412-858-9565
UPMC Hamot Supportive and Palliative Care Service
814-877-5987
UPMC McKeesport Supportive and Palliative Care Service
412-664-2717
UPMC Mercy Supportive and Palliative Care Service
412-232-7549
UPMC Northwest Supportive and Palliative Care Service
814-677-7440
UPMC Passavant Supportive and Palliative Care Service
412-367-6700
UPMC St Margaret Supportive and Palliative Care Service
412-784-5111
Inpatient Medical Ethics Services
PUH/MUH Medical Ethics
647-7243, pager: 2881
Shadyside Medical Ethics
263-8347
Pain Treatment Services (inpatient)
412-647-4991
PUH/MUH Chronic Pain Service
Shadyside Chronic Pain Service
412-665-8030, after hours call 412-665-8031
PUH/MUH Acute Interventional Perioperative Pain
Service (AIPPS)
Shadyside Acute Interventional Perioperative Pain
Service (AIPPS)
412-647-7243, pager: 7246 (PAIN)
412-692-2333
24
Benedum Geriatric Center Supportive Care Clinic
Outpatient Services
412-692-4200
Hillman Cancer Center's Cancer Pain and Supportive Care
Program
412-692-4724
UPMC Heart and Vascular Institute's Advanced Heart
Failure Clinic
Magee Women's Cancer Center
Magee Gynecologic Cancer Program
Renal Supportive Care Clinic
412-647-6000
Magee - Chronic non malignant/spine/muscular
skeletal pain (outpatient)
UPMC Presbyterian Pain Medicine (outpatient)
St. Mar garet Pain Medicine (outpatient) and Chronic Pain
Family Hospice and Palliative Care
412-901-2891
412-641-4530
412-641-5411 or 412-641-5566
412-802-3043
412-692-2234
412-784-5119 (outpatient) or 412-784-4000 (Hospital)
412-572-8800
25
Notes
26
Notes
27
Notes
28
29
Indications for Palliative Care Referral:
Pain in patients with life-limiting illness
Management of other symptoms such as nausea, vomiting,
shortness of breath, delirium
Negotiating goals of treatment or end-of-life decision making
Family support for a patient with a life-limiting illness
Psychological or spiritual counseling for patients and
their families
Discharge planning and interface with local hospices
Bereavement services in the event of death
Outpatient palliative care follow-up
Questions or comments regarding this information, contact Robert Arnold, MD (rabob@pitt.edu), 692-4834. This information provided by the UPMC
Supportive and Palliative Care Programs are merely in the form of recommendations and do not replace the service of a physician. Authors: Mamta
Bhatnagar, MD with Jennifer Pruskowski, PharmD and contributions from Monika Holbein, MD and Scott Freeman, MD. This pain card was made
possible with the assistance of Colleen Kosky and the generous support of the UPMC Palliative and Supportive Institute. Produced in cooperation
with the University of Pittsburgh.
UMC-1486-0416
VERSION 10.0 PAIN CARD
UPMC-1486-0416
30