How do I manage pain and agitation? Kate Warburton June 08

Pain

Pain ladder Paracetamol +/- NSAID +/- other Adjuvant Weak Opioid + Paracetamol +/- NSAID +/- other Adjuvant Strong Opioid + Paracetamol +/- NSAID +/- other Adjuvant Remember laxative +/- anti-emetic

Pain ‘rules’ Breakthrough dose 1/6th total dose Breakthrough pain different from incident pain Increasing analgesia Increase by 30% or as per prn dose

Adjuvant analgesia NSAID: bone/ liver/ soft tissue pain. Amitriptyline/ Gabapentin: nerve pain. Steroid: nerve pain/ raised intracranial pressure/ liver capsule pain. TENS Radiotherapy Bisphosphonate

Pain Assessment Severe and overwhelming? What is it like? What is cause of pain? Specific type of pain? Other contributing factors?

Approximate conversions Codeine/ Dihydrocodeine 60mg Morphine 6mg (oral) Tramadol 50mg Morphine 10mg (oral) Morphine 5mg (subcut) Morphine 20mg (oral) Oxycodone 10mg (oral) Morphine 60-90mg (oral) Fentanyl 25mcg (patch) Morphine 30mg (oral) Alfentanil 1mg (subcut) Oxycodone 5mg (subcut) Fentanyl 12mcg (patch)

When to use naloxone? Life threatening respiratory distress caused by opiate. Not to be used if someone actively dying or for opiate induced drowsiness/ delerium. If less severe opiate toxicity omit next dose and review dose- Usually reduce dose by 30%. Ensure adequate hydration. Try adjuvants if still sore but opiate toxic or consider change to different preparation.

When to use oxycodone? If pain opioid-responsive but unable to tolerate morphine in adequate dose because of side effects. If drug sensitivity to morphine. Some indication for nerve pain. ?Renal failure- but will also accumulate but to a lesser extent.

When to use alfentanil? CKD 4 & 5: subcut alfentanil 100-250mcg hourly. Very good for incident pain- Give 5minutes prior to event which will cause pain. When on stable subcut infusion can convert to fentanyl.

Terminal pain Subcut prn Syringe driver Don’t stop fentanyl patch

Ketamine Lidocaine Methadone Local anaesthesia

Agitation

Assessment Cause Is it reversible Prognosis Is investigation appropriate

Cause Opiate toxicity Physical causes (Eg.Pain, Urine retention, Constipation) Infection Hypoxia Hypercalcaemia/ Abnormal glucose/ Uraemia Psychological distress Alcohol/ Nicotine withdrawal

Management Maintain hydration Quiet room, reorientation, similar staff. Minimal sedation, oral if possible- Haloperidol

Terminal agitation Midazolam 20- 30mg/ 24hrs in driver Prn 5mg Levomepromazine 12.5mg prn subcut

Thanks