Related Subjects:
|Analgesia and Pain management
|Sedation and Analgesia on ITU
|Neuropathic Pain Management
|Codeine
|Dihydrocodeine
|Diamorphine
|Morphine
|Paracetamol (Acetaminophen)
About
Nausea and vomiting
- Nausea is common due to uraemia and comorbidity or side effect of other drugs.
- Antiemetics for nausea and vomiting that occurs with opioid therapy are usually only needed for the first four or five days.
- Good mouth care (eg, keeping the mouth clean with foam sticks and saline) is needed for those who are unable to drink.
- Removal of stimuli (eg, sights, smells and certain fatty, spicy or salted foods), relaxation, distraction and massage.
- Acupuncture and ginger have been shown to be effective for chemotherapy-induced emesis and anticipatory nausea
| Name | Starting Dose | Frequency | Route |
|---|
| Haloperidol | 0.5 mg to 1.0 mg | 8-hourly PRN or regularly | SC/IV/PO |
| Levomepromazine | 2.5 mg to 5 mg PRN or regularly | 12-hourly | SC
|
| Cyclizine (raised ICP) | 50 mg PRN or regularly | 8-hourly | SC, IV, PO
|
| Metoclopramide (prokinetic) | 10 mg PRN or regularly | 8-hourly | SC, PO, IV
|
| Domperidone (elderly) | 10 mg PRN or regularly | 8-hourly | PO
|
Raised intracranial pressure
- Dexamethasone 8 mg od (bd if severe symptoms) for 5 days titrating down according to symptoms/response.
Discuss with Oncologist radiotherapy.
- Consider gastroprotection; steroids alone do not significantly increase risk of GI bleed but do by around a factor of 4 when given with NSAIDs
- Initiate anticonvulsants after first seizure; Levatiracetam 250mg od starting dose is recommended-consider specialist neurological advice
Breathlessness
- This at the stage where time is short and diagnosis such as PE or Pneumonia often not being pursued
- Discuss with patient and those important to patient
- Breathless consider it may be due to pulmonary oedema, acidosis, anxiety or lung disease
- In some cases removing fluid from a large pleural effusion may give some temporary relief but weigh up risks.
- In others fluid restriction will help pulmonary oedema.
- When all options unreasonable manage symptoms with opiates
- A fan blowing air may help. Oxygen may occasionally be useful if hypoxic
- Anxiety component so consider Diazepam and Midazolam
- Bronchodilators e.g. salbutamol may help wheeze
- Prednisolone 60 mg OD for SVC or tumour obstruction +/- stenting
- Anticoagulation where felt to be in best interest if suspected PE
- Suffering may be less if Opiates started rather than specific causes explored
Terminal Breathlessness (for opioid naive patient) titrate dose to symptoms Doses for breathlessness tend to be less than for pain
| Name | Starting Dose | Frequency | Route |
|---|
| Morphine (Oramorph) | 2 mg | 4-hourly PRN | PO |
| Morphine (Modified release) | 5 mg | 12-hourly | PO |
| Diazepam | 2-5 mg | at night | PO |
| Midazolam | 2-5 mg | 6-hourly | SC |
| Morphine | 1-2 mg | 4 hrly | SC |
| Morphine | 10 mg | Over 24 hrs | Syringe driver SC |
| Diamorphine | 1.25-2.5 mg | 4 hrly | SC |
| Diamorphine | 5 mg | Over 24 hrs | Syringe driver SC |
| Buprenorphine | standard dose | | Used in renal failure |
| Alfentanil | 0.5 to 1 mg | Over 24 hrs | Used in stage 4/5 renal failure. Syringe driver SC |
| Alfentanil | 0.1 mg | Used for breakthrough | Used in stage 4/5 renal failure. S/C |
Analgesia: Mild - Moderate Pain
| Name | Starting Dose | Frequency | Route |
|---|
| Paracetamol | 500 mg - 1 g | 6-hourly PRN | PO |
| Codeine | 30-60 mg | 6-hourly | PO |
| Ibuprofen | 400 mg | 8-hourly | PO |
Moderate to Severe Pain (for opioid naive patient) titrate to symptoms
| Name | Starting Dose | Frequency | Route |
|---|
| Morphine (Oramorph) | 5 mg | 4-hourly PRN | PO |
| Morphine (Modified release) | 10 mg | 12-hourly | PO |
| Morphine | 2-5 mg | 4 hrly | SC |
| Morphine | 20 mg | Over 24 hrs | Syringe driver SC |
| Diamorphine | 1.25-2.5 mg | 4 hrly | SC |
| Diamorphine | 10 mg | Over 24 hrs | Syringe driver SC |
| Buprenorphine | standard dose | | Used in renal failure |
| Alfentanil | 0.5 to 1 mg | Over 24 hrs | Used in stage 4/5 renal failure. Syringe driver SC |
| Alfentanil | 0.1 mg | Used for breakthrough | Used in stage 4/5 renal failure. S/C |
Hepatic distension syndrome (liver capsule pain):
- First line: follow WHO analgesic ladder; usually responds well to opioids.
- If pain uncontrolled,consider Dexamethasone under specialist advice.
Palliation : Respiratory secretions
- This at the stage where time is short and diagnosis such as PE or Pneumonia often not being pursued
- Discuss with patient and those important to patient
Assessment
Dose range: titrate to symptoms. Doses for breathlessness tend to be less than for pain
| Name | Starting Dose | Frequency | Route |
|---|
| Hyoscine butylbromide (Buscopan) | 20 mg | 1-hourly PRN | SC |
| Glycopyrronium bromide | 200 micrograms | 4-hourly | SC |
| Glycopyrronium bromide | 0.6-1.2 mg/24 hrs | Continuous | Syringe driver SC |
References