Torment Management Paul Rozynes, M.D. Medicinal Director Vitas BrowardSlide 2
Pain—Definition is based upon our own encounters with torment. Torment is subjective and affected by our experience and passionate status.Slide 3
Somatic Pain Tumor weight upon inward organs, aggravation of tissues, or traumatic wounds.Slide 4
Neuropathic Pain Effect nerve or nerve buildings. Shingles, post herpetic neuralgia, diabetic fringe neuropathy, nerve pressure from tumor.Slide 5
Pain scale:1 to 10. 1 to 3—gentle agony. 4 to 6 - moderate torment 7 to 10—extreme torment Pain versus torment and aggravation.Slide 6
Choice of Analgesic Depends Upon: Severity of Pain Location of torment Pain sort i.e. Neuropathic versus Somatic torment versus blended neuropathic substantial Individual Physician Preference Cost and medication accessibility. Method of organization.Slide 7
Step 1 Over the counter analgesics: Tylenol-pain relieving impact yet is not a calming and is not a NSAID. Mitigating and pain relieving impact - The non steroidal calming drugs(NSAIDS): Disalsid, motrin, aleve, naprosyn, advil. Utilized as a rule for gentle torment or joint agony of a mellow to direct nature.Slide 8
All NSAIDS can bring about gastritis and peptic ulcers with the exception of disalsid which is invested in the small digestive system. Ensure the GI tract on the off chance that you utilize NSAIDS aside from disalsid for any noteworthy timeframe. Use zantac, pepsid, or prilosec. Alert—There is a medication cooperation between all NSAIDS and coumadin. This incorporates disalsid. Keep in mind, Tylenol is not a NSAID and can be securely utilized with coumadin.Slide 9
Step 2 Mild to direct agony. Moderate quality opiates. Percocet, vicodin, Tylenol#3.Slide 10
Can be utilized if step 1 doesn\'t work. Meds are blocking—dependably arrange a purgative. Can likewise bring about queasiness—consider compazine prn.Slide 11
Step 3 Moderate to extreme agony. More grounded opiates. Morphine-the highest quality level.Slide 12
Long acting-Kadian—once per day or twice per day. Can open container and give by means of g-tube. Advantageous, enhances consistence, costly, can\'t be given rectally. MS Contin-twice every day. Duragesic—A patch. Connected once every 3 days(72 hours). Exceptionally costly. Misuse potential. At specific times duragesic can be utilized—not able to take po, or has serious queasiness or regurgitating ie. can\'t hold meds down.Slide 13
Methadone Long acting. Advantageous. Powerful. Extremely financially savvy. Begin low measurement then work up gradually. Generally don\'t have a state of mind issue as you see with morphine. Most likely not utilized as regularly as it ought to be. Has total impact. Increment dosage gradually.Slide 14
Dilaudid Short acting. Obliges 3 to 4 hour dosing. Misuse potential. Can be given through subcutaneous pump as consistent trickle.Slide 15
All progression 3s are exceptionally blocking—dependably arrange a purgative and entrail prep.Slide 16
The idea of "achievement" or salvage in agony administration: All long acting analgesics have impediments in torment control ie. the dosage might be too low, or the interim decided for dosing the medication may not be sufficiently short to completely control the torment for the period of time coveted. A short acting opiate is requested on a prn premise in the occasion more analgesics are required.Slide 17
Roxanol or short acting fluid morphine: Dosed generally at regular intervals prn leap forward torment. Regularly given at regular intervals all day and all night with a leap forward dosage like clockwork prn. Simple to take po. Can be given sublingual. Can be utilized as an achievement for kadian and duragesic. Can likewise be utilized for respiratory trouble.Slide 18
Choices for achievement relies on long acting medication ie. use methadone as leap forward for methadone - make an effort not to blend diverse opiates.Slide 19
Concepts: Dosing. Expanding the dosage. Transformations. Half life.Slide 20
Special medications for agony administration: Prednisone—phenomenal for joint and bone torment. Likewise can animate the hunger. Can bring about peptic ulcers and gastritis. Secure GI tract with zantac or prilosec. Additionally not sheltered to use with coumadin. Elavil—raises torment limit. Useful for neuropathic torment ie shingles or fringe neuropathy notwithstanding opiate. Elavil is a stimulant however particularly impacts the torment limit. Ativan, xanax, or paxil and prozac if tension as well as wretchedness is a variable.Slide 21
Examples of Medications Discussed & Dosing: Morphine (Roxanol) Start with 5 mg po q 4 h ATC with 5mg po q2h prn BT (leap forward). On the off chance that patient uses 2 or 3 BT in 24 hours, increment measurement to 10 mg po q4h ATC with 10 mg po q2h prn BT. Continue changing measurements until torment is controlled with minmum requirement for BT as the objective.Slide 22
Kadian Start with 30mg po qd with Roxanol 5mg po q4h prn BT. Increment Kadian to 50mg po qd with Roxanol 10mg po q4h prn BT if understanding had required regular BT dosing.Slide 23
Duragesic Start with 25mcg patch q 72h with Roxanol 5mg po q4h prn BT. In the event that successive dosing of BT is required following 48 to 72 hours, increment Duragesic to 50 mcg q 72h with Roxanol 10 mg po q4h prn BTSlide 24
Dilaudid Start with 2mg. Can give ATC or prn and provided that this is true, give q3h. If not successful, increment to 4mg.Slide 25
Methadone Start with 2.5mg po q 12h ATC with 2.5mg q6h prn BT. On the off chance that various BT are obliged, change to 5mg po q12h ATC. The BT measurements may need to stay at 2.5mg because of the total way of methadone. Measurements ought to be expanded gradually and all the more warily.Slide 26
Suggested Methadone Conversion Protocol Calculate add up to every day measurements of methadone Stop current opioid Start methadone, separating complete dosage into 3 q 8 hr measurements Breakthrough measurement is 10% of aggregate day by day measurement given q 3-4 hrs prn Adjust dosage just q 3 – 5 days Watch nearly for indications of expanding medication level: sedationSlide 27
Morphine/24hrs MS: methadone <100 mg = 4:1 100-300 mg = 8:1 301-600 mg = 12:1 601-799 mg = 15:1 >800 mg = 20:1Slide 28
Percocet or Vicodin 1 or 2 tablets either ATC or PRNSlide 29
MS Contin Start with 30mg po q 12h ATC With MS IR (prompt discharge) 15mg po q4h prn BT. On the off chance that BT utilized regularly, increment MS Contin to 60 mg po q12h ATC and MSIR to 30mg q4h prn BT.Slide 30
The DripsSlide 31
When do we utilize IV or Subcu pain relieving trickles? Understanding not able to take PO analgesics Nausea Vomiting Intestinal hindrance Pain pharmaceutical not powerful by mouth or by patch in spite of high doses of solution. Stay away from utilization of various analgesics when one is not successfulSlide 32
Patient and of family demand in a moral setting. Port of IV site promptly available. Patient can control sum and time of prescription organization.Slide 33
PCA=PATIENT CONTROLLED ANALGESICS PCA is a little, lightweight, battery-worked pump connected to a syringe loaded with torment medicine. The syringe is snared to an IV tube. A catheter is put IV or SQ and the IV tube is conned to this. A "basal rate" is the measure of pharmaceutical which mixes at a consistent rate.Slide 34
A catch is pushed to permit a leap forward measurement of pain relieving to be given at the patient\'s circumspection after an altered time interim. The patient is constrained in recurrence of organization at the altered sum. On the off chance that the patient endeavors more successive measurements, there will be no extra pharmaceutical given in light of the fact that the pump is modified to give the pain relieving in a settled time interim. This time interim is known as the "lock out" period.Slide 35
What do we usually utilize? Morphine and Dilaudid Effective Can change over from PO to Parenteral (other than oral or GI course) Can utilize IV or Subcutaneous Can be given by means of persistent trickle pump with patient, family or Nurse controlled achievement organization (PCA).Slide 36
Problems with the Drips: Difficult to manage at home Need Continous Care Need RN acquainted with pumps and patient controlled gadgets if the opiate is given IV. IV may turn out and RN should have the capacity to reinsert. Can utilize IV affirmed LPN if the opiate is given SQ.Slide 37
Must work with mixture organization to give the opiate, pump and set up starting settings. Modification are made by a RN with Physician\'s request and supervision by the implantation organization drug specialist (for the most part by telephone). In the event that conceivable use SQ course particularly if port not accessible Easier to keep in place Easier to embed and re-embed Easier to staff Continuous CareSlide 38
Examples: Morphine Patient is on PO Morphine at 60 mg q4h. The patient must be changed to subqu Morphine because of obstinate spewing. 60 mg PO q4h = 5 mg SQ qh by means of constant trickle (see transformation ruler) Choose a leap forward i.e. 25 to half of the hourly dosage which is 2mg for this situation and regulate like clockwork by means of patient or parental figure control.Slide 39
Dilaudid Patient is on PO Dilaudid at 16 mg q3h. The patient is not getting alleviation of his manifestations and can\'t endure any more PO analgesics. 16 mg PO q3h = 0.8 mg SQ qh through consistent trickle (see change ruler) Choose a leap forward 0.2mg for this situation and direct at regular intervals by means of patient or parental figure control prnSlide 40
If the patient uses incessant achievement, increment the nonstop dribble dosage as indicated by the measure of leap forward.Slide 41
Hypodermoclysis: Objectives Familiarize with this time-respected method. This can be utilized as a part of the Inpatient Units and at Home without hardly lifting a finger! Likewise to advance its utilization amongst our Physicians, as a contrasting option to tx got dried out patients, a treatment for insanity and to manage pharmaceuticals when po is not down to earth.Slide 42
Hypodermoclysis: Safe and Simple Subcutaneous imbuement of liquids Under-perceived and under-utilized! Safe, no genuine results Suitable for the elderly, Cancer patients with phlebosclerosis for the treatment of moderate or serious drying out and as a contrasting option to control solutions (other than intravenous).Slide 43
Hypodermoclysis Fluids to be mixed are isotonic : NSS, D5/N
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