1. -Anuja

3. Infusion  Infusion therapy involves the administration of medication through a needle or catheter.  It is prescribed when a patient’s condition cannot be treated effectively by oral medications.  When to start: o Loss of gut function o Sublingual morphine will not control breakthrough pain of patients on mega doses o Requires rapid onset of analgesia o Requires very high doses

4. Infusion devices  Syringe drivers are defined as power driven devices that drive the plunger of a syringe at an accurately controlled rate to deliver medications  Use pumping action to infuse fluids, medication or nutrients into patient  Suitable for intravenous, subcutaneous, enteral and epidural infusions  Provide accurate and controllable flow over a prescribed period or on demand  Two basic types :  Syringe pumps  Volumetric pumps

5. SYRINGE PUMPS: Generally used for low volume, low flow rate infusions Good short term accuracy Long start up time at low flow rates: Prime and purge line before connecting to patient Alarms: End/near end of infusion; drive disengaged, occlusion, battery low Specialised syringe pumps for ambulatory use, PCA, sedation, insulin etc VOLUMETRIC PUMPS: Preferred for medium and high flow rates and large volumes Generally not suitable for rates < 5ml/h Variable short term accuracy Alarms: Latch/door open, set out, occlusion, battery low, air-in-line Specialised volumetric pumps for ambulatory use, epidural infusions etc.

6. SYRINGE PUMPS VOLUMETRIC PUMPS

7. Equipment guidelines  The syringe driver should be used for the delivery of drugs over a 24 hour period, reducing the risk of errors in setting up the device  It is the length of the solution within the syringe—not the volume—that will determine the rate, i.e. the syringe driver delivery rate is a measure of distance, not a measure of volume administered  It is important to always measure the syringe prior to determining the rate each time the syringe driver is set up  A Luer-Lock® syringe6 is recommended to prevent accidental disconnection of the tubing from the syringe  10 ml syringes are recommended unless there are drug concentration and/or volume issues. A 10 ml syringe rests securely in the device, whereas a 30 ml syringe is more difficult to secure firmly onto the syringe driver  Consider using a tamper-proof ‘lock-box’6 if there is a possibility of the patient or others tampering with the device, or using the boost facility  Employ an aseptic technique when changing the device  When changing the extension set and/or cannula, prime the line after drawing up the prescribed medications to the appropriate length in the syringe. After priming the line, measure the syringe and document the line change and the time the syringe is calculated to finish  Ensure that the patient and the family have received a full explanation of how the syringe driver works, and its indications for use

8.  Selection : o Using an area with a good depth of subcutaneous fat o Using a site that is not near a joint o Selecting a site that is easily accessible—such as the chest or the abdomen  Longevity : 1–14 days ( depends on medication, type of cannula, etc)  Select and use sites on a rotating basis  Form a loop of tubing to prevent dislodgement, use a transparent, semiocclusive dressing to cover the site to permit inspection of the site  Factors that cause site reactions include: the tonicity of the medication, the pH of the solution, infection and prolonged presence of a foreign body  Site selection will be influenced by whether the patient is ambulatory, agitated and/or distressed  The chest or abdomen are the preferred sites, specifically the upper, anterior chest wall above the breast, away from the axilla. If the patient is cachectic, the abdomen is a preferred site  The site should be inspected regularly (4 hourly, or more frequently if indicated) o Check for: tenderness at the site; presence of a haematoma and leaking at the insertion site The selection, preparation and maintenance of the site

10.  Inappropriate sites:  Lymphoedematous areas  Areas where there is broken skin  Skin sites that have recently been irradiated  Sites of infection  Bony prominences  In close proximity to a joint  Sites of tumour  Skin folds  Inflamed skin areas  Wherever ascites or pitting oedema are present  Where scarring is present The selection, preparation and maintenance of the site  Reducing site irritation:  Factors: tonicity of the medication, pH, infection, foreign body, drugs (cyclizine, levomepromazine, methadone, promethazine, morphine tartrate, ketamine)  Techniques to minimise :  Changing syringe 12hrly, site in 2-3 days  Plastic cannulas  Diluting ( larger syringe size)  Using NS (0.9%) if applicable  Adding 1 mg of dexamethasone to the syringe, 1% hydrocort LA  The use of Teflon® or Vialon® cannulas

11. Drugs and Diluents  Wide variety with different combinations  Common drugs- morphine sulphate, haloperidol, midazolam, metoclopramide, hyoscine, dexamethasone, clonazepam, fentanyl, hydromorphone  Relatively irritant- diclofenac, ketamine, ketorolac, levomepromazine, methadone, octreotide, ondansetron, phenobarb, promethazine  Contraindicated- prochlorperazine, diazepam, chlorpromazine  More drugs- greater risk of precipitation  2-3 drugs can be mixed (occasionally upto 4)  Stability info - checked before mixing drugs  Boost not recommended- not enough analgesia and risk of overdosing  Diluents: Water for injection Adv: less chance of incompatibility (more compatibility data available) Disadv: hypotonic: infusion site pain and reactions 0.9% SalineIsotonic, less infusion site pain and reactions Less compatibility data available; Risk of incompatibility at high conc.

12.  Factors which may affect stability and compatibility: o Drug concentrations o Diluent o Time interval o Temperature of surroundings o Exposure to light o Order of mixing o Delivery system material Drugs and Diluents

13. Setting up a syringe driver  Insert battery and perform initial safety checks and remove  Fill syringe with drugs and dilute  Aseptic technique, adequate mixing, clear solution  Dexamethasone- added last  Label- contents  Rate setting (standard delivery length of 48 mm)  Connect the line and prime  Fit the syringe into the syringe driver and strap  Attach the syringe to the line/ butterfly cannula  Reinsert the battery. Press and release start button. Alarm sounds when  Syringe is empty  Line is blocked  Start/ test button is held- 5 secs (MS16A)/ 10 secs (MS26)

14.  Light on front of the driver- starts flashing  Plastic cover / lock box to be placed around the syringe driver  Protect syringe from excess heat/ sunlight  Changed prescription- new syringe and line(discard previous), consider stat doses for immediate effect  Do not add drugs to already placed syringe/ increase rate once infusion is started  To stop- remove battery, disconnect line from patient before removing the syringe Setting up a syringe driver(cont…)

15. SC syringe driver CHECKLIST IF FAST (<30 mins) 1. Check the rate setting is correct 2. Change entire for a new one, send for servicing 3. Inform doctor if patients clinical condition worsens IF SLOW (>30 mins) 1. Check the rate setting is correct 2. Check syringe driver light is flashing 3. Check that syringe is inserted correctly in the pump 4. Check battery, change if voltage is low 5. Check if syringe driver has been stopped and then restarted 6. Check for crystallisation (in syringe and line) 7. Check for needle site reactions 8. Inform doctor if patients clinical condition worsens NEXT 4 HOURLY CHECK 1. To check for all the above FOR SETTING UP A NEW DRIVER ALWAYS CHECK 1. Battery voltage and the rate set

16. Parenteral Morphine  Conversion : PO:SC = 2:1 ; PO:IV = 3:1  Breakthrough dose= 1/6 th of total dose  Peak effects: 30- 60 min IM, 5-90 min SC  Time to peak plasma conc. : 10-20 min IM/SC  Plasma half life: 1.5 hrs  Duration of action: 3-6 hrs  Preparations:  Injection morphine sulphate 10, 15, 20, 30 mg/ml available as 1 ml and 2ml amp

17. IV morphine trial for severe pain Rapid titration of morphine dose in opioid-naïve patients SequenceIVSC Dose1 mg/ min up to 10 mg2 mg q5min up to 10 mg Pause5 min10 min Dose1 mg/ min up to 10 mg2 mg q5min up to 10 mg Pause5 min10 min Dose1 mg/ min up to 10 mg (review cause after inadequate relief after 30 mg) 2 mg q5min up to 10 mg (review cause after inadequate relief after 30 mg) based on practice at Cleveland Clinic, Ohio, USA  Obtain venous access with a butterfly cannula  Give Metoclopramide 10mg IV routinely  Dilute the contents of 10mg morphine ampoule in a 10ml syringe  Inject 1 ml every 5-10min until the patient is pain-free complains of undue sedation  If patients experience nausea, give additional Metoclopramide 5mg IV

18. Monitoring and titrating opioid infusions Opioid naïve patient  Start infusion at 1 mg/hr  With initiation of therapy, a bolus dose of 2 mg is appropriate  If a patient requires 2 or more bolus doses in an hour, the infusion rate should be increased to the next rate according to the titration chart  An increase should not occur more frequently than once per hour  Each time the basal infusion is increased, the bolus dose may need to be increased  Once the patient’s symptoms have been controlled, maintain the current effective infusion rate

19. Opioid Dose Escalation Always increase by a percentage of the present dose based upon patient’s pain rating and current assessment Mild pain 1-3/10 25% increase Moderate pain 4-6/10 25-50% increase Severe pain 7-10/10 50-100% increase

20. Opioid-naïve patient- Morphine Infusion RatePRN Bolus Doses 1 mg/hr2 mg every 15 minutes 2 mg/hr2 mg every 15 minutes 3 mg/hr2 mg every 15 minutes 5 mg/hr3 mg every 15 minutes 8 mg/hr4 mg every 15 minutes 12 mg/hr6 mg every 15 minutes 16 mg/hr6 mg every 15 minutes 20 mg/hr10 mg every 15 minutes 26 mg/hr10 mg every 15 minutes 32 mg/hr10 mg every 15 minutes 40 mg/hr10 mg every 15 minutes

21. Opioid-naïve patient- Fentanyl Infusion RatePRN Bolus Doses 10 mcg/hr20 mcg every 15 minutes 20 mcg/hr20 mcg every 15 minutes 30 mcg/hr20 mcg every 15 minutes 50 mcg/hr30 mcg every 15 minutes 80 mcg/hr40 mcg every 15 minutes 120 mcg/hr60 mcg every 15 minutes 160 mcg/hr60 mcg every 15 minutes 200 mcg/hr100 mcg every 15 minutes 260 mcg/hr100 mcg every 15 minutes 320 mcg/hr100 mcg every 15 minutes 400 mcg/hr100 mcg every 15 minutes

22. Why these doses???  Basal infusion rate o Going from 1 to 2mg/hr is a 100% increase o Going from 10 to 11 mg/hr is a 10% increase o Doses are usually increased by 25 to 100% depending on the severity of the Pain  Breakthrough pain doses o Patient receiving 2 mg/hr receives 2 mg bolus (100%). o If patient is receiving 20 mg/hr and the bolus dose remained at 2 mg, bolus dose is only 10% of basal o Patient will not receive relief from bolus if not 25 to 100% of basal

23. Opioid-tolerant patient  Calculate the 24 hour dose of the currently used opioid (conversion table)  Convert to an equianalgesic dose IV morphine and divide by 24 to calculate starting hourly rate  If the patient requires 2 or more boluses in an hour, the infusion rate should be increased to the next infusion rate on the titration chart  Do not increase basal rate more than once an hour  Each time the basal infusion is increased, the bolus dose may need to be increased  Once the patient’s symptoms have been controlled, maintain the current effective basal infusion rate

24. Opioid-tolerant patients- Morphine Infusion RatePRN Bolus Doses 1 mg/hr2 mg every 15 minutes 2 mg/hr2 mg every 15 minutes 3 mg/hr2 mg every 15 minutes 5 mg/hr4 mg every 15 minutes 8 mg/hr4 mg every 15 minutes 12 mg/hr8 mg every 15 minutes 16 mg/hr8 mg every 15 minutes 20 mg/hr10 mg every 15 minutes 26 mg/hr15 mg every 15 minutes 32 mg/hr20 mg every 15 minutes 40 mg/hr20 mg every 15 minutes

25. Opioid-tolerant patients- Fentanyl Infusion RatePRN Bolus Doses 10 mcg/hr20 mcg every 15 minutes 20 mcg/hr20 mcg every 15 minutes 30 mcg/hr20 mcg every 15 minutes 50 mcg/hr40 mcg every 15 minutes 80 mcg/hr40 mcg every 15 minutes 120 mcg/hr80 mcg every 15 minutes 160 mcg/hr80 mcg every 15 minutes 200 mcg/hr100 mcg every 15 minutes 260 mcg/hr150 mcg every 15 minutes 320 mcg/hr200 mcg every 15 minutes 400 mcg/hr200 mcg every 15 minutes

26. Morphine >40 mg/hr Infusion RatePRN Bolus Doses 40 mg/hr20 mg every 15 minutes 50 mg/hr20 mg every 15 minutes 60 mg/hr25 mg every 15 minutes 75 mg/hr30 mg every 15 minutes 90 mg/hr30 mg every 15 minutes 110 mg/hr40 mg every 15 minutes 135 mg/hr40 mg every 15 minutes 165 mg/hr50 mg every 15 minutes 200 mg/hr50 mg every 15 minutes 240 mg/hr50 mg every 15 minutes 280 mg/hr80 mg every 15 minutes 340 mg/hr80 mg every 15 minutes 400 mg/hr80 mg every 15 minutes

27. Fentanyl >400 mcg/hr Infusion RatePRN Bolus Doses 400 mcg/hr200 mcg every 15 minutes 500 mcg/hr200 mcg every 15 minutes 600 mcg/hr250 mcg every 15 minutes 750 mcg/hr300 mcg every 15 minutes 900 mcg/hr300 mcg every 15 minutes 1100 mcg/hr400 mcg every 15 minutes 1350 mcg/hr400 mcg every 15 minutes 1650 mcg/hr500 mcg every 15 minutes 2000 mcg/hr500 mcg every 15 minutes 2400 mcg/hr500 mcg every 15 minutes 2800 mcg/hr800 mcg every 15 minutes 3400 mcg/hr800 mcg every 15 minutes 4000 mcg/hr800 mcg every 15 minutes

28. Monitoring recommendations  The frequency, intensity, duration, and nature of monitoring (sedation levels and respiratory status and technology- supported monitoring) – individualized  Monitoring practices- defined by institutional policies and procedures – aligned with published EBM guidelines and expert opinion  Serial sedation and respiratory assessments are recommended  Include regular sedation and respiratory assessments during wakefulness and sleep  Acceptable sedation scales  Unintended advancing sedation from opioids- patient may be at higher risk for respiratory depression  Resp. rate counted for a full minute/ rhythm and depth- while the patient is in a restful/ sleep state  Patients should not be transferred American Society for Pain management and Nursing Guidelines on monitoring of opioid induced sedation and respiratory depression

29.  Patients found to have signs of respiratory depression (e.g., rate <8 or <10 breaths per minute and/or paradoxic rhythm with little chest excursion), evidence of advancing sedation, poor respiratory effort or quality, snoring or other noisy respiration, or desaturation should be aroused immediately and instructed to take deep breaths  Technology-supported monitoring (e.g., continuous pulse oximetry and capnography) - for the patient at high risk for unintended advancing sedation and respiratory depression  At risk : preexisting conditions, response to therapy, overall clinical status, practice environment, and concurrent medication administration  Capnography - postoperative period - useful indicator for respiratory depression in high- risk patients  Technology monitoring systems may interfere with individualizing analgesic therapy or effective analgesia  More vigilant monitoring of sedation and respiratory status- performed when patients may be at greater risk for adverse events, such as at peak medication effect, during the first 24 hours after surgery, after an increase in the dose of an opioid, coinciding with aggressive titration of opioids, recent or rapid change in end-organ function (specifically hepatic, renal, and/or pulmonary) or when moving from one opioid to another or one route of administration to another Monitoring recommendations American Society for Pain management and Nursing Guidelines on monitoring of opioid induced sedation and respiratory depression

31. Monitoring the opioid infusions  Sedation, respiratory rate and heart rate: 1 hourly until the opioid infusion is ceased  Pain score: 1 hourly while awake  Vomiting: 1 hourly for the first 12hrs, then 4 hourly as indicated  Pulse oximetry: if indicated  Observations following a bolus of opioid infusion: o Respiratory rate and sedation: every 5 minutes for 15 minutes o Pulse oximetry: if indicated

32.  COMPLICATIONS  IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:  CEASE the opioid infusion  CEASE all other infusions that could be contributing to sedation  Attempt to rouse the patient  If apnoeic: administer bag & mask ventilation with 100% oxygen  If breathing: maintain airway, monitor oxygen saturation and administer oxygen via face mask at 8 L/min  Check circulation. If pulseless: commence chest compressions  Administer naloxone if opioid toxicity is suspected  Ceasing the opioid infusion  Oral/rectal opioids may be administered immediately after the opioid infusion is ceased  The date and time of ceasing the opioid infusion must be recorded on the opioid infusion attachment chart.  Any remaining opioid infusion must be disposed off properly Monitoring the opioid infusions

33. Naloxone Administration- Respiratory Depression  DETERMINE- respiratory depression/sedation unresponsive to arousal measures AND application of O2(Sp02<90%)  RR< 8, cyanosed AND unable to arouse AND SpO2 <90% on 6-10 litres O2 - STOP opioid infusion and other sedative-maintain IV access  CALL code blue.  REMAIN with the patient and continue attempting to awaken him/her  INSTRUCT a colleague to bring prepare the naloxone for you  PREPARE naloxone: (400 mcg amp in 10ml 0.9% NS)  Opioid overdose: 0.4 – 2 mg/kg (max 10 mg); no response repeat every 2-3 min  Respiratory depression: 0.1-0.2 mg IV; if no response, repeat 0.1 mg every 2 min  IDENTIFY patient  ADMINISTER initial dose slowly IV push over 30 seconds and flush IV site with normal saline at same rate Naloxone Drug Monograph, Parenteral Drug Manual, 2003-04-01.

34.  OBSERVE patient response and monitor RR, HR, BP and Sp02 every minute until ventilation and alertness is achieved with an arousal score less than 3  The patient should be able to open his/her eyes within 1-2 minutes. If the patient doesn't respond, REPEAT dose as above  DOCUMENT in appropriate record(s)  date and time  amount of naloxone administered  patient's response to naloxone  vital signs (RR, BP, and HR), pulse oximetry, arousal score  any other pertinent actions or observations  CONTINUE to monitor and record RR, HR, BP, Sp02, arousal score and pain score every 15 minutes for 2 hours, then every 30 minutes for the next 4 hours.  Nurse should REMAIN with the patient until evaluated by a physician  REPORT adverse drug events  NOTIFY - need to immediately evaluate the patient and discuss pain management plan Naloxone Administration- Respiratory Depression (cont…)

35. Compatibility charts

38. Compatibility when using Parenteral Morphine - General Compatible Not Compatible Use with caution Not applicable ? No data

39. Compatible Not Compatible Use with caution Not applicable ? No data Compatibility when using Parenteral Morphine - Specific

41. Indications  Systemic opioid intolerence  Pathological # in patient close to death  Refractory neuropathic pain (effective ≥ 50%)  Caution: spinal deformity, incipient SCC, myelosuppressive CT  C/I: uncorrected coagulopathy, systemic/local infections, raised ICP  Preferred route and delivery device: Likely duration of useRoute and deviceComments </= 3 weeksExternal ED device, reusable Fewer initial complications than IT, less headache 3 wks to 3 monthsExternal IT device, reusable Fewer later complications than ED, less catheter occlusion >/= 3 monthsImplantable IT deviceMore expensive initially, lower running costs, cost effective in long- term

42. Neuraxial analgesia IntrathecalEpidural  Higher longterm success rate  Easy confirmation of space  Rapid onset of effects  Complete coverage of all nerve trunks (fewer failures)  Able to use much lower drug doses and volumes (practical/cost)  More selective  Easy to get higher dermatomes  Less potential motor / sensory block  Less invasive: reduced  Neurotoxicity  Infection  trauma

44. Intraspinal treatment algorithm Comprehensive Consensus Based Guidelines on Intrathecal Drug Delivery Systems in the Treatment of Pain Caused by Cancer Pain. Pain Physician 2011; 14:E283-E312 ISSN 2150-1149

45. Drugs and dosages DrugIT doseED dose Morphine0.4-1 mg 1/100 of 24 hr SC dose 2-5 mg bolus Infusion rate 0.3-0.9 mg/ hr 1/10 of 24 hr SC dose Fentanyl15-25 mcg50-100 mcg bolus Infusion rate 10-50 mcg/ hr Sufentanyl10 mcg20-50 mcg bolus 10-25 mcg/ hr Clonidine15-30 mcg/24 hr150-300 mcg/24 hr dexmedetomidine3-5 mcg1 mcg/kg Baclofen25-200 mcg/day Ziconotide2.4 mcg/day titrated max 19.2 mcg/day Calcitonin100 IU Adeosine500-2000 mcg

46. Compatibility data At room temperatureAt body temperature Morphine sulphate with bupivacaine or clonidine 2 monthsMorphine sulphate with clonidine +/- bupivacaine </= 3 months Clonidine with bupivacaine 2 weeks

47. Undesirable effects Drug relatedMedicalDelivery system Early onset Opioids : 1.Diarrhea and intestinal colic d/t withdrawal of systemic opioids 2.Nausea vomiting (33%) 3.Pruritis (15%) 4.Urinary retention (8-43%) 5.Respiratory (0.1-2%) depression Bupivacaine: 1.Motor or sensory disturbance (dose dependent) (4-13%) 2.Urinary retention 3.Respiratory depression 4.Cardiovascular compromise Clonidine: Cardiovascular compromise (5-20%) Late onset Opioids: 1.Decreased libido / disturbed menstruation (70-95%) 2.Hypocorticalis m or GH deficieny (15%) 3.Oedema (6- 18%) 4.Immunomodu lation (?) Traumatic catheter placement: 1.CSF leakage (</= 25%) 2.ED hematoma (rare) 3.Neurological tissue damage (rare) Infections: 1.Local site infection (</=6%) 2.ED abscess (</=8%) 3.Meningitis (</= 3%) 1.All device related complications (8- 27%) 2.Catheter related (#/ kinking/ displacement/ withdrawal) 3.Catheter tip granulomas (0.04%) 4.Pump failure (battery failure/ mechanical failure/ programming or refilling errors)

48. Management of adverse effects ComplicationManagement Respiratory depression (emergency) Sitting position/ stop infusion/ O2 / IV access RR<8 / barely arousable / cyanosed- Naloxone 20 mcg/ 2min till recovers; Arrest- CPR Hypotension (emergency) systolic<80mmHg Lay flat/ stop infusion/ O2 / HR<40- treat bradycardia No fluid overload- IV fluid challenge- no response- ephedrine 6 mg IV; Examine for bleeding; Arrest- CPR Bradycardia (emergency)Stop infusion/ O2 /IV access/ ECG monitor/ atropine (0.6 mg bolus IV upto 3 mg)- ineffective –ephedrine 6 mg IV Arrest- CPR Opioid discontinuationStop laxatives, prn dosing, reduction of prn dosing by 25% Opioid induced pruritisConcurrent bupivacaine/ NSAIDs/ ondansetron/ opioidswitching/ opioid antagonists( naloxone/ natrexone) Urinary retentionTransient/ remove catheter after 3-4 days InfectionsCSF culture- appropriate antibiotics Neurological impairementEvaluate for cause- MRI Exacerbation of painEvaluate device related cause; Prn opioids PO/SC- not responding- ketamine 10-25 mg PO/SC prn

50. MOAContraindications  Analgesic, antihyperalgesic, and antiinflammatory  Na+ channel blockade (attenuation of peripheral nociceptors sensitisation and CNS hyperexcitability)  Inhibition of G protein– coupled receptors and NMDA receptors  In sub-anesthetic dose- blocks spontaneous ectopic discharge of the injured nerve without blocking normal nerve conduction  Heart block, second or third degree (without pacemaker)  Severe sinoatrial block (without pacemaker)  Serious adverse drug reaction to amide local anaesthetics  Concurrent treatment with quinidine, flecainide, disopyramide, procainamide (Class I agents)  Prior use of Amiodarone hydrochloride  Hypotension  Accelerated idioventricular rhythm  Pacemaker  Porphyria, especially acute porphyria (AIP)

51. Systemic lignocaine for neuropathic pain  Benefit in: o Trigeminal neuralgia o Post herpetic neuralgia o Diabetic neuropathy o Lumbosacral radiculopathy o Post stroke pain o Chronic post surgery/ post trauma pain o Spinal cord injury pain o CRPS  Not of benefit: o Cancer related neuropathy o HIV-neuropathy

52. Lignocaine infusion Pre infusion assessment Complete history and physical examination Quantitative pain assessment Any history of allergy from lidocaine Any history of Heart or liver diseases ECG Lidocaine test Dose1-3 mg/kg (average 100 mg) Concentration: 8 mg/ml IV over 20-30 min. OR 40 mg/ml SC over 30-60 min (2-3 ml/hr) Monitor pain relief, vitals and side effects q15 min. 50% of the dose in elderly patients >70 year, patients with heart or liver disease Lidocaine infusionIf pain relief > 50% and no SE: Dose 0.5 -2 mg/kg/hr IV OR SC Monitor pain, V/S, SE after 15 min - 60 min - q 8 hr - prn Titrate up based on pain relief If any SE occurs, stop infusion, reassess after 30-60 min then resume with 20% Or last safe dose Home infusionMust have a caregiver, 24-hr supervision by a competent adult Must be visited by a registered nurse 2–7 times a week Provide with lidocaine patient information sheet Home MassagesLidocaine infusion is safe and effective intervention for operative and chronic pain Lidocaine infusion has narrow therapeutic index, it needs clear guidelines to demonstrate how we use it safely MonitoringSerum levels-Theraputic drug range: 1.5-5 mcg/ml; toxicity: >5 mcg/ml

53. Toxicity  Continuous infusion: accumulation of lignocaine and active metabolites- monoethylglycinexylidide and glycinexylidide  Caution in elderly >70 yrs  Light headedness, dizziness  Circumoral numbness  Tinnitus  Visual changes  Dysarthria  Muscle spasms  Seizures  Coma  Respiratory arrest

55. Ketamine  General anesthetic  Uses: induction and maintenance of anesthesia; pain unresponsive to standard treatment (post-op, neuropathic, inflammatory, ischemic limb, myofascial and procedure related  C/I: increased BP/ ICP, AIP  Caution:epilepsy, HTN, heart failure, IHD, CVA, plasma conc increased by diazepam  MOA: dissociatiev anesthetic, analgesic at sub anaesthetic doses. NMDA receptor blocker. Other actions- Ca++/ Na+ channels, dopamine receptors/ cholinergic transmission/ SNRI/ μδκ opioid like effects/ anti inflammatory and antidepressant effects  Bio-availability: 93% IM; 30% SL; 20% PO  Onset of action: 5 min IM; 15-30 min SC; 30 min PO  Half life: 1-3 hr IM; 3 hr PO  Duration of action: 30 min-2 hrs IM; 4-6 hr PO; generally given by CSCI

56. DOSE SC: 10-25 mg prn ; increase by 25-33 % if required CSCI: Dilute to largest volume; 0.9% NS – diluent Start 1-2.5 mg/kg/ 24hr Increase by 50-100 mg/24hr, max 3.6 gm/24hr Short term burst therapy: start with 100 mg/24 hr- not effective – after 24 hr- increase to 300 mg/24 hr- not effective – after 24 hr- increase to 500 mg/24 hr- stop 3 days after last dose increment Prophylactic diazepam/ midazolam/ haloperidol can be given IV: Cancer pain: 2.5-5mg For procedure: 0.5-1 mg/kg given over 1-2 min with midazolam 0.1 mg/kg to reduce emergent phenomenon Adverse effects Psychomimetic phenomenon: euphoria, dysphasia, blunted affect, psychomotor retardation, vivid dreams, nightmares, poor concentration, illusions, hallucinations, altered body image Delirium, dizziness, diplopia, blurred vision, nystagmus, altered hearing, HTN, tachycardia, erythema, pain at injection site At higher doses- tonic-clonic movements

57. Compatibility data 2-drug compatibility in 0.9% NSAlfentanyl, clonazepam, dexamethasone (low-dose), diamorphine, haloperidol, levomepromazine, midazolam, morphine sulphate, oxycodone 3-drug compatibility in 0.9% NSHaloperidol or midazolam with either diamorphine or morphine sulphate IncompatibilityPrecipitates with barbiturates and diazepam Preparations Inj ketamine hydrochloride: 5mg/ml, 20/10 ml vial Inj ketamine hydrochloride (preservative free): 5mg/ml. 5ml amp; 25 mg/ml, 2ml amp

58. Thank You….