Common Symptoms at the End-of-Life and Management :PAIN. พญ.ป ยพร ท สยากร ศ นย ช วาภ บาล โรงพยาบาลจ ฬาลงกรณ 3 rd NPHC Conference
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1 Common Symptoms at the End-of-Life and Management :PAIN พญ.ป ยพร ท สยากร ศ นย ช วาภ บาล โรงพยาบาลจ ฬาลงกรณ 3 rd NPHC Conference
2 Pain ความปวด ความปวด ค อ ประสบการณ ท ไม สบายท งทางด านความร ส กและ อารมณ ซ งเก ดร วมก บการท าลายหร อม ศ กยภาพท จะท าลายเน อเย อ ร างกาย หร อถ กบรรยายประมาณหน งว าม การท าลายของเน อเย อน น (ส ระ บ ณยะร ตเวช)
3 Total Pain
4 Type of Pain Temporal (time-oriented) approach Acute pain เฉ ยบพล น Chronic pain เร อร ง Mechanism-based approach Nociceptive pain ความปวดท เก ดจากการบาดเจ บโดยตรงหร อจากการท าลาย ของเน อเย อ Somatic pain ความปวดของโครงสร างของร างกายท ไม ใช อว ยวะภายใน, ช ดเจน Visceral pain ความปวดของอว ยวะภายใจ, ต อๆ บอกต าแหน งยาก Neuropathic pain ความปวดท เก ดจากม กระแสประสาทท ผ ดปกต เป นผลให เก ด ขบวนการร บร ท ผ ดไป Neuralgia ปวดเหม อนเข มท ม แสบร อน เหม อนไฟช อต, ปวดตลอดหร อเป นพ กๆ Dysesthetic Hyperalgesia ปวดมากกว าปกต Allodynia ปวดเม อได ร บส งกระต นท ปกต ไม ท าให ปวด
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6 Pain Assessment History taking Gold standard = self report Problem & Severity Onset Location Severity Characteristic Intermittent or continuous Radiating Aggravating/alleviating factors Impact or disability index Associated symptoms Prior/current treatment Others: past medical history, social history Mechanism? Cause: disease itself, its treatment and comorbid illness? Physical Examination Investigations
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8 Management Regular, around the clock As needed regimen Start low, Go slow Minimized medication regimen Delicate instruction
9 WHO Analgesic Ladder Nonpharmacological Non Opioids Acetaminophen NSAIDs Weak Opioids Codeine Tramadol Strong Opioids Morphine Oxycodone Fentanyl Methadone Adjuvants Anticonvulsants Antidepressants Corticosteroids
10 Non Opioid Analgesics Acetaminophen Limited total dose < 4 g/day Hepatic toxicity NSAIDs Anti-inflammatory, nociceptive pain eg. Bone pain Side effects: GI irritation, plt dysfunction CI: kidney disease, heart disease Ibuprofen, diclofenac, naproxen, celecoxib, etoricoxib
11 Weak Opioids Codeine Metabolized into morphine by CYP2D6 5-10% lack of enzyme metabolized codeine to morphine Not recommended in renal failure Dose: mg q4h (maximum 240 mg/day) Tramadol Synthetic opioid, weak opioid Conversion to a active metabolite by CYP2D6 Serotonin-NE reuptake inhibitor neuropathic pain Dose: mg q6-8h (maximum 400 mg/day)
12 Strong Opioids No ceiling effect (no maximum dose) Morphine, oxycodone, fentanyl, pethidine, methadone Adverse effects: nauseated, ileus, constipation, urinary retention, itchiness, confusion, sedation, respiratory depression, and dependence Equianalgesic table
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14 Morphine Metabolized at liver, eliminate by kidney Use with caution when CrCl < 30 For opioid naïve, consider low dose (morphine 2.5-5mg routine or prn), and increase by 25-50% every hrs
15 Morphine Preparations and administration Immediate release ออกฤทธ 4 ชม Morphine liquid (syrup) 2 mg/ml Immediate release tablet (MIR) 10 mg Sustained release Tablet ออกฤทธ 12 ชม. Morphine slow release tablet (MST), MS contin 10 mg, 30 mg Capsule ออกฤทธ 24 ชม. Kapanol 20 mg, 50 mg IV injection (10 mg/ml)
16 Fentanyl Lipid soluble, synthetic Metabolized at liver (CYP3A4) to inactive metabolite, eliminate by kidney Preparations Transdermal (Duragesic ) ออกฤทธ 72 ชม. 12, 25, 50 mcg/hr Reach therapeutic blood level in hr Continue to be effective for hr after removed IV injection (50 mg/ml)
17 Oxycodone Metabolize at liver, elimination by kidney Long half-life in renal failure and liver failure Less hallucinations and nausea Preparation Slow release tablet Oxycontin ออกฤทธ 12 ชม. Oxycodone naloxone tablet Targin Less constipation
18 Methadone µ receptor agonist NMDA receptor antagonist neuropathic pain Metabolized at liver (CYP450) Half-life varies hrs Associated with QTc prolongation and torsade de pointes
19 Adjuvant Medications Anticonvulsant Gabapentin, pregabalin, carbamazepine Antidepressant TCA: amitriptyline, nortriptyline SNRI: duloxetine, velafaxine Anxiolytic Benzodiazepine: clonazepam Corticosteroid Dexamethasone, prednisolone
20 Non-pharmacological treatment Acupuncture, acupressure TENs Psychotherapy: Cognitive Behavioral Therapy Address anxiety and provide reassurance Discuss the need for companionship and spiritual support Discuss the meaning of symptoms Relaxation intervention Presence of caregivers
21 Subcutaneous Route Dose Equivalent Dose conversion ratios between IV and SQ route for opioids are not well established For morphine, the ratio appeared to be close to 1 mg IV = 1 mg SQ Subcutaneous tissue can absorb up to 3 ml/hr
22 Palliative Medication Commonly Administered Subcutaneously Atropine Dexamethasone Fentanyl Citrate Furosemide Glycopyrrolate Haloperidol lactate Hydromorphone Hyoscine butylbromide Ketamine ketololac Metoclopramide Midazolam Morphine sulfate Naloxone Octreotide omeprazole Ondansetron Phenobarbitone Ranitidine
23 Administration Use 25 or 27G butterfly needle - 45 angle Place on the upper arm, shoulder, abdomen or thigh Avoid chest wall to prevent iatrogenic pneumothorax during needle insertion Rate gravity driven
24 Subcutaneous Infusion Advantages Smaller needle/iv catheter Less pain More site of injection/infusion Less frequent site change Avoid infusion reactions Systemic infection less common Administration at home Less cost Limitations Contraindicate in patients with generalized edema or major coagulopathy Limited volume Local skin irritation Most common Managed by a needle site change Other toxicity Itching Site bleeding infection
25 Thank You 3 rd NPHC Conference
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