Makindo Medical Notes

Related Subjects: |Analgesia and Pain management |Sedation and Analgesia on ITU |Neuropathic Pain Management |Codeine |Dihydrocodeine |Diamorphine |Morphine |Paracetamol (Acetaminophen)

About

• Always check the BNF link here for precise dosing

Nausea and vomiting

• Nausea is common due to uraemia and comorbidity or side effect of other drugs.
• Antiemetics for nausea and vomiting that occurs with opioid therapy are usually only needed for the first four or five days.
• Good mouth care (eg, keeping the mouth clean with foam sticks and saline) is needed for those who are unable to drink.
• Removal of stimuli (eg, sights, smells and certain fatty, spicy or salted foods), relaxation, distraction and massage.
• Acupuncture and ginger have been shown to be effective for chemotherapy-induced emesis and anticipatory nausea

Raised intracranial pressure

• Dexamethasone 8 mg od (bd if severe symptoms) for 5 days titrating down according to symptoms/response. Discuss with Oncologist radiotherapy.
• Consider gastroprotection; steroids alone do not significantly increase risk of GI bleed but do by around a factor of 4 when given with NSAIDs
• Initiate anticonvulsants after first seizure; Levetiracetam 250mg od starting dose is recommended-consider specialist neurological advice

Breathlessness

• This at the stage where time is short and diagnosis such as PE or Pneumonia often not being pursued
• Discuss with patient and those important to patient
• Breathless consider it may be due to pulmonary oedema, acidosis, anxiety or lung disease
• In some cases removing fluid from a large pleural effusion may give some temporary relief but weigh up risks.
• In others fluid restriction will help pulmonary oedema.
• When all options unreasonable manage symptoms with opiates
• A fan blowing air may help. Oxygen may occasionally be useful if hypoxic
• Anxiety component so consider Diazepam and Midazolam
• Bronchodilators e.g. salbutamol may help wheeze
• Prednisolone 60 mg OD for SVC or tumour obstruction +/- stenting
• Anticoagulation where felt to be in best interest if suspected PE
• Suffering may be less if Opiates started rather than specific causes explored

Terminal Breathlessness (for opioid naive patient) titrate dose to symptoms Doses for breathlessness tend to be less than for pain

Analgesia: Mild - Moderate Pain

Moderate to Severe Pain (for opioid naive patient) titrate to symptoms

Hepatic distension syndrome (liver capsule pain):

• First line: follow WHO analgesic ladder; usually responds well to opioids.
• If pain uncontrolled, consider Dexamethasone under specialist advice.

Palliation: Respiratory secretions

• This at the stage where time is short and diagnosis such as PE or Pneumonia often not being pursued
• Discuss with patient and those important to patient

Assessment

Dose range: titrate to symptoms. Doses for breathlessness tend to be less than for pain

References

• Scottish Palliative Care Guidance