7 Delirium and nursesNurses are in an optimal position to detect fluctuating symptoms of deliriumAgar et al. Palliative Medicine. September, 2011.
8 Delirium and nursesSilent, unspoken piece of nursing practice, impacting on workloadNurses deal with the unpredictable and fluctuating condition of delirious patients, which may be a signal of impending ‘chaos’Agar et al. Palliative Medicine. September, 2011.
9 Delirium and nursesUnder-detection of delirium relates to a lack of knowledge of the criteria for identifying delirium…failure to relay or communicate detected symptoms at onset…Agar et al. Palliative Medicine. September, 2011.
10 What is delirium ? Global cerebral dysfunction “Brain Failure” Early signs often mistaken asanger, anxiety, depression, psychosis10
11 Dsm-iv criteriaA) Change in consciousness with reduced ability to focus, sustain or shift attentionB) Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia11
12 Dsm-iv criteria C) Abrupt onset (hours to days) with fluctuation D) Evidence of medical condition judged to be etiologically related to disturbance12
13 Dsm-iv criteria…a disturbance in consciousness with inattention and problems in cognition and/or a disturbance in perception that develop over hours to days with organic causes.13
15 Delirium vs dementia Delirium Abrupt onset Decreased LOC Sleep/wake cycle DementiaInsidious, progressiveAlert, LOC intactMinimal
16 Delirium vs dementia Reversible? PREVENTABLE? Delirium Dementia Irreversible
17 Delirium is reversible In up to 50 % of patients with advanced cancer, delirium can be reversedKang JH et al. “Comprehensive approaches to managing delirium in patients with advanced cancer.” Cancer Treat Rev(2012)
18 Reversed vs non-reversed Lawlor P, Gagnon B, Mancini I, Pereira J, et al. Arch Intern Med 200019
19 Delirium sub-types Hypoactive confusion, somnolence, alertness Hyperactiveagitation, hallucinations, aggressionMixed (>60%)features of both
20 Delirium sub-typesLawlor P, Gagnon B, Mancini I, Pereira J, et al. Arch Intern Med 2000
21 Prevalence/incidence 80 % in medical intensive care units (ICU)28 % in patients following hip fracture22 % in general medical inpatientsPartridge et al. “The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this?” Int J Ger Psych. October 2012 (online)21
22 Incidence/prevalence Most frequent neuropsychiatric complication in patients with advanced CAUp to 85 % of patients delirious prior to deathBruera et al. JPSM 2010; 39;2:
23 Incidence/prevalence ~ 42% patients in PC program delirious on admission50% of episodes reversible“Terminal delirium” in 88 %Lawlor et al. Arch Intern Med 2000; 160:786
24 Impact Palliative sedation requests Delirium/terminal restlessness (55%)Dyspnea (27%)Pain (18%)Nausea/vomiting (4%)Eisenchlas. Current Opinion in Supportive and Palliative Care 2007, 1:207–212
25 Impact Palliative sedation requests Delirium number one reason for requestsFainsinger RL et al. “A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients.” Palliat Med 2000;14:257–65.
26 Impact “We’d rather see dad dead than like this.” “S/he would be horrified by this.”
27 impact 73/99 patients (74%) remembered delirious episode Of these, 81 % recalled experience as distressingFamily stress > patients’ recalled stressBruera et al. JPSM 2010; 39;2:
28 impact Interferes with Sx assessment and Tx Increases morbidity and mortalityHinders communication within familiesBruera et al. JPSM 2010; 39;2:
29 Sx difficulty and distress Pain Dyspnea Delirium29
30 Sx difficulty and distress Ax/Tx ChallengesWorsening Delirium30
31 pathophysiologyDelirium mediated by failure in central cholinergic transmission?Acetylcholine final common neurotransmitter pathway leading to delirium?White et. al. “First Do no Harm…” JPM. 10 (2); 2007:
32 pathophysiologyRelative acetylcholine deficiency and dopamine excess could mediate the characteristic symptoms of deliriumDelirium can be evoked by dopamine agonists and anticholinergic medicationsMoyer. American Journal of Hospice and Palliative Medicine 28(1),Kang JH et al. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev(2012)
33 pathophysiology Dopamine/acetylcholine inverse relationship Haloperidol first line treatment for deliriumHaloperidol D2 antagonist:? Haloperidol increase levels acetylcholine?White et. al. “First Do no Harm…” JPM. 10 (2); 2007:Kang JH et al. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev(2012)
34 pathophysiologySometimes successfully treated with dopamine receptor antagonists and possibly by cholinesterase inhibitorsHigh serum anticholinergic activity inpatients with deliriumMoyer. American Journal of Hospice and Palliative Medicine 28(1),
35 pathophysiologyΥ-aminobutyric acid (GABA)-ergic benzodiazepines seem to cause deliriumNeuroinflammatory processes drives up-regulation of GABA receptorsGABA receptor versus microglial activation versus apoptosisC.G. Hughes et al. “Future Directions in Delirium Management and Research.” Best Practice & Research Clinical Anaesthesiology. 26 (2012) 395–405
49 Prevention? Prophylactic haldol Prophylactic olanzepine Prohylactic cholinesterase inhib.sNo conclusive literature on meds prophylactically, especially in palliative care, but certain basic “no-brainers.”Gagnon et al. Psycho‐Oncology 21: 187–194 (2012)
50 Prevention? Maintain sensorium: hearing aids, eye glasses Orientation (clocks, calendars, conversation)No conclusive literature on meds prophylactically, especially in palliative care, but certain basic “no-brainers.”Gagnon et al. Psycho‐Oncology 21: 187–194 (2012)
51 Prevention?No good evidence for benefit from screening hospitalized patientsNo conclusive literature on meds prophylactically, especially in palliative care, but certain basic “no-brainers.”Greer N et al. Delirium: screening, prevention, and diagnosis – a systematic review of the evidence 2011 Internet.
52 Prevention?“Cured yesterday of her disease, she died last night of her doctor.”paraphrasing Jonathon Swift(you know, Gulliver’s Travels)No conclusive literature on meds prophylactically, especially in palliative care, but certain basic “no-brainers.”
53 Dr. Dr. Drugs drugsMedication sole precipitant of delirium in 12 – 39 % healthy patientsAlagiakrishnan et al. Postgrad Med J, 2004; 88:53
54 Drugs Drugs drugs Drug toxicity, drug withdrawal Start low, go slow Very often, less is more
55 Prevention? Analgesics: Uncontrolled pain is risk factor for delirium “Rome wasn’t built in a day”Balance pain against doseTitrate gently
56 Prevention?Analgesics: Titrate gentlyDon’t be afraid to decrease
57 Sx difficulty and distress Ax/Tx ChallengesWorsening Delirium57
58 Prevention? Sedatives: “A benzodiazepine will never help your thinking.”Dr. Mike Harlos
59 Prevention?Lorazepam is an independent risk factor for delirium, increasing risk by ~ 20 % (not to mention falls, etc.)Hold the benzos!Panpharpande et al. Anesthesiology. 2006; 104:21Kang JH et al. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev(2012)
60 Prevention? Sedatives: Try not to be the one who starts bzd, but don’t be the one who abruptly stops itBetter a tired patient in AM than a delirious patient in AM
61 Prevention?“Anxiety,” “restlessness?” -- how about company? Going for a walk-about?More staff, fewer sedatives, less delirium?Drugs cheap, one-on-one expensiveValue?
62 hydration? Does vigorous hydration decrease delirium incidence? Hyd’n reversed or improved 30 – 70 % delirium casesThomson et al. Current Op Supp Pal Care. 2009; 3:72-78
64 DELIRIUM Name it! “A little fluffy” “Loopy” “A little off” “Not quite right”“Fruit-cake”DELIRIUM
65 Name it MMSE? CAM? Intuition? Do something; Name it…. When we hear about fluffy patients, assess concentration. Can they name the months of the year backwards? Can they attend to a short conversation? If not, consider them, if not delirious, at high risk of becoming so, and do something…..
66 Name itChange in consciousness with reduced ability to focus, sustain or shift attentionDisturbance of consciousness with reduced ability to focus, sustain, or shift attention.
67 Concentrate, focus? Engage in conversation? Months of year backward? Clinical suspicionDisturbance of consciousness with reduced ability to focus, sustain, or shift attention.
68 Claim it Drs. cause delirium? Can Drs/nurses prevent it, reverse it, or reduce its impact?Who better?
69 Tame it Two simultaneous pathways Seek and treat cause (thus reverse?) Manage behaviours (“supportive care”)Human intervention better than pharmacological
70 Tame it Supportive measures Investigations Hydrate? Avoid restraints MobilizeReduce noise, etc.OrientReassureOne-on-oneMEDICATION REVIEWBloodworkU/AImaging
71 Tame it Meds: Eliminate any psychoactive med possible: Metoclopramide, cipro? Baclofen? Ranitidine? Lasix? others?
72 Tame it Meds: Analgesia: Good pain control? Consider dose reduction? Sub-optimal pain control? Opioid rotation
73 Tame itIf investigations reveal pathology that can reasonably be thought to be causing delirium; and if the pathology can be treated; and if it is in keeping with goals of care; trial treatment
74 Tame itDoes patient behaviour compromise care, or put patient, staff, or others at risk?If “yes,” can a bedside sitter safely help?If “no,” low-dose neuroleptic and/or low-dose bzd
75 Medical management Haloperidol remains standard of care Powerful Oral and parenteralLimited anti-cholinergic, sedative propertiesWhite et. al. “First Do no Harm…” JPM. 10 (2); 2007:
76 Medical managementNo significant differences in response in double-blind RCT comparing risperidone and haloperidolSimilar evidence finding minimal differences in efficacy between olanzapine and risperidoneBourne et. al. “Drug Treatment of Delirium.” Journal Psychosomatic Research. 65; 2008:Kang JH et al. “Comprehensive approaches to managing delirium in patients with advanced cancer.” Cancer Treat Rev(2012)
77 hypoactiveMethylphenidate can improve cognitive and psychomotor function in hypoactive deliriumMethylphenidate can cause agitation, aggravation, psychosisBourne et. al. “Drug Treatment of Delirium.” Journal Psychosomatic Research. 65; 2008:
78 Recap Delirium is bad Hard on patients, families, staff Often preventable, often iatrogenicNurses optimally locatedOccasionally reversible
81 objectives At the end of this session, you will Understand the importance of context in the interpretation of painAppreciate at a basic level the physiology of pain and some principles of analgesiaHave an approach to pain management that always bears in mind the above points
85 Who definitionPalliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
86 Who the prevention and relief of suffering….. …by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
87 Loeser, JD. “Perspectives on Pain Loeser, JD. “Perspectives on Pain.” Clinical Pharmacology and Therapeutics. Padgham, ed. Baltimore: University Park Press p 314
88 Loeser, JD. “Perspectives on Pain Loeser, JD. “Perspectives on Pain.” Clinical Pharmacology and Therapeutics. Padgham, ed. Baltimore: University Park Press p 314
93 What is pain?“…an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.
94 What is pain?“…what ever the experiencing person says it is, existing whenever s/he says it does.”Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.Pain is subjective. It’s what the person experiencing it says it is.Pain confers a survival benefit; we are “hard-wired” to experience it
95 Symptoms in Advanced Cancer Bruera 1992 “Why Do We Care?” Conference; Memorial Sloan-Kettering
96 Seow H et al. “Trajectory of performance status and symptom scores for patients with cancer during the last six months of life.” J Clin Oncol 2011; 29:1151.
97 Pain is not a diagnosis Pain Classification Nociceptive Neuropathic visceralsomaticneuralgicdysestheticsuperficialdeephyperalgesiabonyAdapted from Jovey R, 2002
103 NP Descriptors“Pins and needles,” tingling, numb
104 Tx of Neuropathic Pain Pharmacologic treatment Anticonvulsants – gabapentin, pregabalinTCAs (esp. if depression)NMDA receptor antagonists: ketamine, dextromethorphan, methadoneSteroidsOpioids
105 Up to 90% of patients with cancer pain could have their pain alleviated by following the treatment guidelines of the WHO analgesic ladderFitzgibbon et al. “Parenteral Ketamine as an Analgesic Adjuvant for Severe Pain.” J Pall. Med. 8(1) 2005
106 Adjuvant Rx may be added at any step WHO AnalgesicLadderStrong opioid+ Step 2Weak opioid+ Step 1Severe(7-10)Acetaminophen& NSAIDsModerate(4-6)Mild pain(0-3)By the clockBy the ladder
107 Adjuvant Rx may be added at any step WHO AnalgesicLadderStrong opioid+ Step 2Weak opioid+ Step 1Severe(7-10)Acetaminophen& NSAIDsModerate(4-6)Mild pain(0-3)By the clockBy the ladder
108 Pharmacology Review TOXIC Serum [ drug ] Therapeutic Sub-therapeutic Single dose, prn usageSub-therapeuticTime
118 Poor pain control?Think about drug, dose, route
119 Deteriorating condition Steady decline at homeAccelerated deterioration begins,pain worsening, pt. admitted,medications changedRapid decline due to illness progression with diminished reservesWhat’s the best approach? Proactive, tell them that of course you wondered about the meds, of course you’ve reviewed med changes, med usage. HOPEFULLY, you’ve pre-emptively given them a bit of warning that the meds may precipitate somnolence, and, more importantly, that there likely will be fairly significant deterioration to come. Then they’re not so surprised, ambushed. But don’t be defensive. Consider adjusting meds further?Family thinking what?
124 “it’s the drugs”Popular misconception held by families, lay public, and professionalsThey’re grasping at straws.
125 “it’s the drugs”“’By the way, palliative care shortens your life,’ [xxxx] suggested.”They’re grasping at straws.
126 “it’s the drugs”“Increasing overall opioid dosage was associated with improved survival compared with no change or decreasing overall dosage (mean survival days versus versus , days respectively, P 5 .01).”They’re grasping at straws.Azoulay et al. “Opioids, Survival, and Advanced Cancerin the Hospice Setting.” J Am Med Dir Assoc. Feb. 2011; 12:
127 “it’s the drugs”“Opioid usage, even at high dosages, had no effect on survival among advanced cancer patientsin a hospice setting.”They’re grasping at straws.Azoulay et al. “Opioids, Survival, and Advanced Cancerin the Hospice Setting.” J Am Med Dir Assoc. Feb. 2011; 12:
128 “it’s the drugs”“Among patients with metastatic non–small-cell lung cancer…, As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.”They’re grasping at straws.Temel et al. “Early Palliative Care for Patients withMetastatic Non–Small-Cell Lung Cancer.” N Engl J Med. 2010; 363:
129 Bruera et al. J Pain Symptom Manage. 1990; 5:341-344 Sub-Q MorphineBruera et al. J Pain Symptom Manage. 1990; 5:
130 A Patient 64 woman resents to ED with “severe” pain; Hydromorph Contin 24 mg PO bid;Hydromorphone IR 6 mg Q1H prn, taking “several” times daily;“Confused” per family
131 A Patient Pain “everywhere”; Poor historian, “muddled,” family report fairly rapid escalation of opioids past 3-4/7;O/E: vitals unremarkable, dry MM, decreased BS R>L, no adventitia, normal HS. Very tender over R rib cage (without compressing), abdo benign, DTR unremarkable, no tremors or twitches;
132 A patientACP “M”;B/W shows creatinine increased from previous, at 195, dry, corrected Calcium 2.5;U/A benign;CXR no obvious rib fractures;AXR abundant stool, no a/f levels, no free air
133 A few red flags…. Pain “everywhere” (pathophysiology?); Family report fairly rapid escalation of opioids past 3-4/7;Poor historian, “muddled”;Creatinine up
136 Normal Renal Fcn Renal Insufficiency Osborne et al. “The Pharmacokinetics of morphine and morphine glucuronides in Kidney Failure.” Clin Pharmacol Ther 54: , 1993
137 Misinterpreted as Pain Misinterpreted as Disease-Related Pain Opioid-Induced Neurotoxicity (OIN)Opioid toleranceMild myoclonus (eg. with sleeping)Severe myoclonusSeizures, DeathDeliriumAgitationMisinterpreted as PainOpioids IncreasedHyperalgesiaMisinterpreted as Disease-Related PainOpioids IncreasedWe should be more clear with our definitions.
145 Objectives At the end of the session, you will Have a basic understanding of respirationBe aware of the complex mechanisms underlying dyspneaHave an approach to the management of dyspneic patients145
146 Dyspnea“Subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”Under normal circumstances, we are not aware of our breathingAmerican Thoracic Society. “Dyspnea: Mechanisms, Assessment, and Management, a Consensus Statement.” Am J Respir Crit Care Med. 1999; 159:146
150 Dyspnea“Subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”Under normal circumstances, we are not aware of our breathingAmerican Thoracic Society. “Dyspnea: Mechanisms, Assessment, and Management, a Consensus Statement.” Am J Respir Crit Care Med. 1999; 159:150
151 Time till death Without eating Months Without drinking Days Without breathingMonthsDaysMinutesWe can go a long time without eating, a fairly long time without drinking, but a very short time without breathing. Therefore, if our bodies perceive threats in any of these domains, there will be a proportional response. Deranged blood gases, and/or perceptions that the current respiratory status is unsustainable, will lead to very significant “concern” on the part of the organism.151
152 DyspneaDyspnea, like pain, is protective. As pain alerts us to actual or impending tissue damage, dyspnea alerts us to threat.“Hardwired” to protect152
153 Dyspnea 60 % lung Ca patients Nearly 90 % once near death 50 % described dyspnea as severeMuers MF, Round CE. “Palliation of symptoms in non-small cell lung cancer: a study by the Yorkshire Regional Cancer Organization thoracic group.” Thorax 1993;48:339– 43.
154 DyspneaReuben DB, Mor V. “Dyspnea in terminally ill cancer patients.” Chest. 1986; 89(2):
155 DyspneaAbnormality of blood gases, especially hypercapnia (PaCO2 > 50 mmHg) and, to a lesser extent, hypoxia (PaO2 < 60 mmHg);Amount of work that must be performed by respiratory muscles to provide adequate ventilation;State of mind.Guyton and Hall. Textbook of Medical Physiology. 491
156 DyspneaUnder normal circumstances, we are not aware of our breathing
157 Mahler. “Understanding Mechanisms …Dyspnea Mahler. “Understanding Mechanisms …Dyspnea.” Current Opinion in Supportive and PalliativeCare .2011, 5:71–76
158 CNS Integrates information about: Degree of effort required Mechanical response achievedO2/CO2 pH statusIn order to answer two questions:
159 CNSIs the mechanical response normal relative to the degree of effort expended?Is the current effort sustainable?If not, dyspnea
160 DyspneaDyspnea occurs when there is a mismatch between ventilation and the demand set by chemical driveUnder normal circumstances, we are not aware of our breathingBuchanan and Richerson. “Role of Chemoreceptors in Mediating Dyspnea.” Respiratory Physiology and Neurobiology. 2009; 167: 9 – 19
169 Complex monitoringWith each heartbeat the blood passes through the medulla, where molecular watchmen pay attention to the various gases.
170 Complex monitoringIf O2 drops, or CO2 rises, the watchmen hit the alarm bell, telling the organism to breathe harder, deeper, and to be afraid, to panic
171 A dyspneic patient Tachypneic? Hypoxic? Anxious/afraid? Diaphoretic? Unconscious?
172 Dyspnea“Subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”Under normal circumstances, we are not aware of our breathingAmerican Thoracic Society. “Dyspnea: Mechanisms, Assessment, and Management, a Consensus Statement.” Am J Respir Crit Care Med. 1999; 159:172
173 Approach to Dyspnea Assess the symptom Determine the cause Treat the causeTreat the symptom
174 As is the case with all sx, here is an algorithm
175 Assess the symptom Remember: Tachypnea is not dyspnea; Assess distress, not just apparent intensity
176 Determine the cause Thoracic Extra-thoracic Non-malignant Malignant ParamalignantExtra-thoracicCachexia;Anemia;Ascites;Hepatomegaly‘Lyte derangement
177 Treat the cause Anti-tumour: chemo/RT, etc. Infection CHF SVCO Pleural effusionPulmonary embolismAirway obstruction
178 Treat the Symptom Goal of interventions: Minimize production of symptom (pre-medicate, energy mgmt., breathing techniques)Diminish perception of symptom (meds, fan, distraction)
179 Treat the Symptom Goal of interventions: Modify the experience of the symptom (address meaning, help with mood/fear/anxiety)
182 Oxygen?Bruera 199314 dyspneic, hypoxic (SaO2 < 90%) cancer inpatientsRCT, 2 x blind, placebo, crossover5 L/min air by NP vs O2no ∆ in VAS from baseline with air, significant improvement with O2Bruera et al. Lancet. 1993; 342:
183 Oxygen?Bruera 1993Conclusion: O2 substantial benefit in hypoxic dyspneic cancer patientsBruera et al. Lancet. 1993; 342:
184 Oxygen? Bruera 2003 33 dyspneic, non-hypoxic cancer pts RCT, single blind, placebo, cross-over5 l/min air vs O2 for 6 MW testNo difference in dyspnea, fatigue, or distance walkedBruera et al. Pall Med. 2003; 17:
185 Oxygen?Bruera 2003Conclusion: O2 of no benefit over air to exercising non-hypoxic cancer ptsBruera et al. Pall Med. 2003; 17:
186 Oxygen? O2 no better than air in non-hypoxic patient O2 better than air if hypoxic
187 Oxygen in COPD? Normal COPD O2 CO2 Resp. Drive O2 CO2 Resp. Drive Under normal circumstances, our respiratory drive is controlled by CO2. As CO2 rises, so does our drive to breathe,O CO2 Resp. DriveO CO2 Resp. Drive
188 Oxygen in COPD? COPD O2 CO2 Resp. Drive In a certain percentage of COPD patients, their CO2 is chronically high, so their respiratory drive is controlled by dropping O2. That is, as O2 drops, resp. drive increases. In these patients, giving O2 can decrease resp. drive.O CO Resp. Drive
189 Oxygen in COPD?Giving pts. with COPD supplementary O2 can actually suppress their resp. drive (and kill them with kindness)
190 Anxiolytics?Anxiety is significantly correlated with intensity of dyspneaLimited evidence supporting BZD roleBruera, E. et al. “The Frequency and Correlates of Dyspnea in patients with Advanced Cancer.” J Pain Symptom Mgmt. 2000; 19:
192 Opioids? Used for analgesia for centuries Used since at least 19th century for breathlessnessNow a degree of reticence
193 Opioids? Naloxone versus saline in exercising COPD patients; Naloxone group more dyspnea;Endogenous opioids blunt dyspneaMahler DA, Murray JA, Waterman LA, Ward J, Kraemer WJ,Zhang X, Baird JC: “Endogenous opioids modify dyspnoeaduring treadmill exercise in patients with COPD.” Eur RespirJ 2009; 33:771.
194 Opioids?Cochrane:18 RDBPC crossover trials9 nebulized, 9 systemic, 14 single dosePrimarily COPDConclusion: significant benefit for systemic, but not for nebulized opioidsJennings et al. “Opioids for the Palliation of Breathlessness in Terminal Illness.” Cochrane. Database of Systemic Reviews. 2001
195 Opioids?Early use of opioids may prolong survival, by reducing physical and psychological distressTwycross, R. “Morphine and Dyspnea.” Pain Relief in Advanced Cancer. New York: Churchill Livingston,
196 Opioid mechanism?↓ Medullary sensitivity/response to hypercarbia/hypoxia↓ Cortical resp. awareness↓ Metabolic rate/ventilatory demandVasodilation (improved cardiac fcn)Analgesia: ↓ pain-induced resp. driveAnxiolysis
197 Opioid mechanism?With each heartbeat the blood passes through the medulla, where molecular watchmen pay attention to the various gases.
198 Opioid mechanism?If O2 drops, or CO2 rises, the watchmen hit the alarm bell, telling the organism to breathe harder, deeper, and to be afraid, to panic
199 Opioid mechanism?Opioids tell the watchmen to allow for broader derangements in the blood gases, and to hit the alarm bell with less force when they need to hit it
200 Opioids? Narrow therapeutic index Watch: Rate of dose change Previous exposure?Bruera, E. “Effects of Morphine on Dyspnea.” J Pain Symptom Mgmt. 1990; 5: 341-4
201 Excessive opioids Pinpoint pupils Gradual slowing of the respiratory rateBreathing is deep (though may be shallow) and regular
202 “it’s the drugs”“…fear has been shown to be largely unfounded. Examining changes in respiratory parameters…in dyspneic palliative care patients…demonstrated significant decrease in respiratory rate and improvement in dyspnea with titration with morphine or hydromorphone but no significant changes in other respiratory parameters, indicating no opioid-induced respiratory depression.”They’re grasping at straws.Kamal et al. “Dyspnea Review for the Palliative Care Professional.” J Pall Med. 2012; 15 (1):
203 “it’s the drugs”“…demonstrated benefits, and the lack of edvidence of accelerated death, have led the American College of Chest Physicians…to recommend that physicians titrate oral and/or parenteral opioids”They’re grasping at straws.Kamal et al. “Dyspnea Review for the Palliative Care Professional.” J Pall Med. 2012; 15 (1):
204 Bruera et al. J Pain Symptom Manage. 1990; 5:341-344 Sub-q morphineBruera et al. J Pain Symptom Manage. 1990; 5:
205 Recap Dyspnea can’t be measured, and often can’t be observed Oxygen is a drug; balance benefit vs cost ($ and other)Opioids work
206 If you want a wise answer, ask a reasonable questionGoetheWho questions much, shall learn much, and retain muchFrancis Bacon
207 Our solar system consists of one star, and some debris…. Carl Sagan