Treatment in Palliative Care

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Treatment in Palliative Care

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Symptom management

• evaluation
• individualized treatment
• explanation
• supervision
• attention to detail

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• ACUTE PAIN
• Rapid pulse
• Raised blood pressure
• Dilated pupils
• Quiet, rubbing part, guarding painful area
• Reports pain

• CHRONIC PAIN
• Normal blood pressure
• Normal pupil size
• Normal activity, perhaps limited in nature
• May not even mention pain unless questioned

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Main problems

• Pain
• Constipation
• Lack of appetite
• Loss of weight
• Sleepnessness
• Anxiety
• Nausea and vomiting
• Powerlessness
• Dyspnoe

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Main problems
Symptom Bedard 1991N952 () Coyle 1990 N90 ()
Pain 12-30 34
Dyspnoea 9 28
Nausea 16 13
Vomites 16 -
Sleepnessness 5 57
Orientation disorders 4 28
Fatique - 52
Anorexy 14 6
Incontinency of urine 4 6
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Pain is what the patient says hurts
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Total pain

• Physical pain basal disease, coexisting
  illnesses, results of treatment
• Psychological suffering anxiety, depression
• Spiritual suffering existential and religious
  problems,
• 
  DAME CECILY SAUNDERS

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• PAIN

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PHYSICAL
PSYCHOLOGICAL
SOCIAL
TOTAL PAIN
SPIRITUAL
Saunders 1967
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Skale bólu

• Skala wzrokowo- analogowa
• Skala oceny liczbowej NRS
• 0
  10
• Brak bólu
  ból nie do
  zniesienia
• 1
  10
• Brak ulgi w dolegliwosciach
  calkowita ulga

1 2 3 4 5 6 7
8 9 10
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Pain

• ACUTE - CHRONIC
• NOCICEPTIVE
• NEUROPATHIC
• PSYCHOLOGICAL

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Nociceptive pain

• STIMULATION OF NERVE ENDINGS
• visceral ( colic, migraine, cancer)
• somatic ( cancer, infection, tension headache,
  cramp, bone)
• muscles tension

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Neuropathic pain

• nerve compression
• nerve injury
• peripheral (de-afferentation)
• - Somatic (peripheral neuropathy, phantom)
  - Visceral ( infiltration of para-aortic visceral
  
  nerves)
• central ( poststroke, spinal cord
  compression) sympathetically maintained (
  causalgia)

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Analgetic Ladder WHO 1986

• I0 non-opioids adjuvants
• II0 weak opioids non-opioids
  adjuvants
• III0 strong opioids non-opioids
  adjuvants

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Principles of analgesic use

• By the mouth
• By the clock
• By the ladder
• Individual treatment
• Supervision
• Adjuvant drugs

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But...

• Chronic pain needs to be treated by slow acting
  medicine PERSISTANTLY...
• Breakthrough pain ( predictable ,
  non-predictable, pain of the end dose) needs
  using occasionally short acting medicine.

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Non opioids

• Paracetamol
• Non- steroid Antiinflamatory Drugs (COX1)
• Ibuprofen
• Diclofenac
• Ketoprofen
• Piroxicam etc
• Non- steroid Antiinflamatory Drugs (COX2)
• Acetylsalicylic acid

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Weak opiois ( II0 WHO)

• Tramadol 1/5
• Codein 1/10
• Dihydrocodein 1/10
• Oxycodon 1,5 / 1
• Dextropropoxyphen
• Pentazocin DO NOT USE !!!

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Tramadol

• caps 50mg, tabl. forte 100mg,
• SR-tabl. retard- 150, 200mg guttae 1g/10ml
  (1ml40gtt.)
• agonist of µ -,d-, ?- receptor
• presynaptic bloker of rec. MAO
• convulsions threshold is lowered

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Pentazocin ( Fortral)

• Partial agonist µ receptor
• Agonist ? receptor
• Pure antagonist d receptor
• Short acting 2-3 h
• Psychotomimetic effects
• DO NOT USE IN CHRONIC PAIN

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Strong opioids III0 WHO

• Morphine hydrochloride ( substance, Sevredol,
  Vendal,)
• Morphine sulphate (Doltard, MST-Continuous,
  M-Eslon, Vendal, )
  1/1
• Fentanyl ( Durogesic TTS)
  150/1
• Buprenorphine (Bunondol, Transtec TTS) 60/1
• Methadone
  5-10/1
• Diamorfina ( heroin)
  2/1
• Dextromoramid (Palfium)
  2/1
• Pethidine (Dolargan) 1/8 DO NOT USE!!!

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Morphine

• Pure agonist of ? receptor
• Without ceiling-effect
• M6G is 10-20x ? , M3G (toxic),
• First dose 30 mg/24h ( 15mg/24h )
• Dose is arised 50 if ineffective
• 10 of Codein is metabolised to M6G

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Morphine

• Morphine hydrochloride
• Substance
• Sevredol tabl. 10- 20mg short acting
• Vendal
• Morphinum sulphate 10,30,60,100mg
• M-Eslon
• MST-Continuous
• Doltard
• Kapanol

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Rp.

• Morphini hydrochlorici 4,0Aquae
  destillatae ad 400,0 mlM.f.
  SolutioD.s. ½ ml q4h
• 600, 1000, 1400, 1800, 2200, ( 200 )

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Fentanyl

• Pure agonist ?
• Fentanyl is 150 x ? than MF
• Lipophilic ( peripheral side effects are not so
  strong as MF)

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Pethidine

• Agonist ?
• Action time 2-3 h
• Ceiling effect 600mg/24h
• Toxic methabolite norpethidine
• Siede effects myoclonus, dysphoria,
• Indications acute pain, not use longer than 48
  h,
• Contraidications renal failure

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Sensitization

• PERIPHERAL
• activation of sleeping receptors
• inflammatory soup
• CENTRAL activation of the NMDA receptor-channel
  complex

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Wind-up

• Chronic irritation of C-fibers , which are
  proliferated in posterior horns of medullae
  spinalis and are responsible for potencialization
  of the impulses ( allodynia)

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Methadone

• Agonist ?-receptor and ?-receptor
• Racemic forms L- i D
• NMDA receptor antagonist
• The plasma halflife ranges 8-80 h
• Bioavailibility 80 (parenteral)
• Lipophilic
• Eliminated by alimentary tract in 80 (in renal
  failure may be used)
• 5-10 x ? than MF, 3-5mg start dose

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Receptor NMDA
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Opioid Rotation

• Non effective, toxic
• Because- of different types of opioid receptors
• Differences in pharmacocinetics and methabolizm
  of opioids
• Be careful in equivalent dose
• supports of tolerance metadon ma wieksza
  wewnetrzna aktywnosc niz MF

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Muscle spasm

• Miorelaxants
• Baclofen (GABA- agonist) tabl. 10 i 25mg
  3 x 5-10 mg
• Tyzanidine
• Benzodiazepins Midazolam 7,5 15 mg p.o.
  Clonazepam 0,5 mg /nocte Diazepam 5-20 mg
  p.o.

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Adverse effects of opioids

• Constipation 100
• Nausea and vomiting 50
• Drowsiness 100
• unsteadiness, confusion initial
• Stop urination be careful !!
• Central depressant effects
• Psychological dependence
• Physical dependence
• Occasional dry mouth, inflammation of mouth,
  candidiasis, sweating, myoclonus

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Never say

• I have tried everything...
• There is nothing more I can do ...