Burt. Symptom Management 11/7/2016. Always looking for lowest dose to achieve symptom management to limit side effects

Transcription

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 1

2 Pain Assessment History 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 Non-opioid +/- adjuvant Mild Pain Moderate Pain Opioid +/- Non-opioid +/- Adjuvant Opioid +/- Non-opioid +/- Adjuvant Severe Pain WHO Analgesia ladder 2

3 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 3

4 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 4

5 Opioids in Renal Failure Not Recommended Morphine Codeine Use with Caution Hydromoprhone Oxycodone Hydrocodone Safest Fentanyl Methadone Nausea Definition A feeling of sickness with an inclination to vomit Dictionary.com Nausea A: Anxiety/Anticipation V: Vestibular O: Obstructive M: Meds/Metabolic I: Infection/Inflammation T: Toxins Basic and Clinical Pharmacology 5

6 Nausea Mechanism Drugs Good For Use In Notes Serotonin Antagonist Ondansetron (Zofran) Chemotherapy Granisetron (Kytril) Radiation Dolasetron (Anzemet) Dopamine Antagonist Haldol Medication related Chlorpromazine (Thorazine) Metabolic related Prochlorperazine (Compazine) Olanzapine (Zyprexa) Anti-histamine Diphenhydramine (Benadryl) Vestibular Hydroxizine (Vistaril) Gut receptor Promethazine (Phenergan) Pro-kinetic Agents Metaclopramide (Reglan) Gastric Stasis GI dysmotility Corticosteroids Dexamethazone Increased ICP (unknown mechanism) Prednisone Multiple NK-1 Receptor Aprepitant (Emend) Delayed chemotherapy Antagonist induced Cannabinoid Receptor Dronabinol (Merinol) Blocker Benzodiazepines Lorazepam (Ativan) Anticipatory Diazepam (Valium) Anxiety Can cause dystonia Can prolong QTc Caution in elderly Both dopamine and 5- HT3 antagonist activity Beware of long term side effects Poor evidence for efficacy 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 6

7 Constipation Causes: Inadequate fiber intake Inadequate fluid intake Altered bowel habits Lack of physical activity Medications: Opioids NSAIDs Tricyclic antidepressants 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 Pharmacotherapy Category Agents Notes Stimulant Laxative Senna - Increases enteric muscle contraction/ GI motility Bisacodyl - Stimulate mesenteric plexus Osmotic Laxatives Non-absorbable sugar molecules: - Limited intestinal absorption increase in - Polyethelyne glycol colonic intra-luminal water through oncotic - Lactulose pressure. - Sorbitol -With increased intra-luminal volume and Poorly absorbed salt-based molecules: distension, reflex peristalsis subsequently occurs. - Milk of magnesia -The increase in intra-luminal water also leads to - Magnesium citrate 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 Peripheral mu-receptor antagonist Methylnaltrexone -Bisacodyl: Stimulate rectosigmoid -Glycerin: Lubricant and osmotic agent -Enema: Soften stool and flush it out - Refractory opioid inducted constipation 7

8 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 8

9 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) 9

10 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 Chemical Causes (Hypercapnia and Hypoxia) Oxygen= FUEL Carbon Dioxide= WASTE 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 10

11 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 11

12 Dyspnea: Correctable Abnormalities B: 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 Treating for respiratory distress Tachypnea Nasal flaring Retractions Grunting Respiratory depression follows sedation, unlikely if patient is arousable Careful with naloxone: Completely blocks opioid receptors No studies demonstrate a superior agent 12

13 Dyspnea: Anxiolytics Opioids remain first line Worsened Panic Worsened Dyspnea Trigger Causing Dyspnea Quick Shallow Breathing Panic 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 patient and family Anticholinergics Glycopyrrolate Atropine drops Scopolamine 13

14 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 14

15 Delirium: Management Treat reversible causes if it aligns with patient goals Critical Can be dangerous to patients and caregivers (increased mortality) Emotionally disturbing Non-Pharmalogical Strategies Reorientation and cognitive stimulation Vision and hearing assessment Removal of unecessary lines, catheters, restraints Proper sleep/wake cysles Relaxation techniques Pharmalogical Strategies Common Psychtropics Haldol Quetipine Olanzapine Risperidone Valproic Acid Always think of uncontrolled pain In hyperactive delirium may have to add a benzodiazepine Music Address psychosocial and spiritual concerns Change environment or bring familiar objects In hypoactive delirium may consider a stimulant In refractory terminal delirium, may consider palliative sedation 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 15

16 Fatigue Energy banking, Exercise, Education regarding realistic goals Drug Therapy Stimulants Methylphenidate Modafanil Steroids 16