pain management in palliative care
TRANSCRIPT
Pain Management in Palliative Care
Dr.Raman Swathy VamanDistrict Programme Manager
National Health MissionAarogyakeralam Kasaragod
WHY AM I HERE TODAY ?????
NOT FOR THIS
"Pain is a more terrible Lord of Mankind than even
Death itself"
Albert Schweitzer (1875-1965)
Dr.Robert Twycross
Pain is what the patient says Hurts....
Evolution of Pain theories
Rene Descartes Dr. Henry Beecher
Ronald Melzack Patrick Wall
IASP Definition
"Pain is an Unpleasant, Subjective, Sensory and Emotional experience associated with actual or potential tissue damage or described in terms of
such damage"
Pathophysiology
Types of pain
• Acute• Chronic
Pain
NeuropathicNociceptive
Sympathetic
Capsular Soft TissueBoneCardiac
CentralPeripheralSomaticVisceral
Bowel
Causes of pain in C/c illness
Disease Related
Soft tissue infiltrationVisceralNerve compression / InfiltrationBone spreadMuscle spasmLymphoedemaRaised ICT
Treatment Related
Post op Scars and adhesionsRadiotherapy FibrosisChemotherapy neuropathy
Causes of pain in C/c illness
Debility RelatedConstipationPressure soresBladder spasmStiff JointsPost Herpetic neuralgia
Co MorbiditiesSystemic IllnessesArthritisTrauma
Total Pain
Psychosocial Distress Physical Distress
Spiritual Distress
Assessment of Pain
1) Visual Analogue Scales (VAS)
2) CategoricalVerbal Rating Scales (VRS)
3) Categorical Numerical Rating Scales (NRS)
For Adult Paients
VAS
NO PAIN WORST PAIN
VRS
None
Mild
Moderate
Severe
NRS
For Childrens
McGill Pain Questionnaire
Brief Pain Inventory
The Abbey Pain Scale
Management of Nociceptive pain
WHO Analgesic Ladder
Continued Psycho Social Support
Non Opioids• Paracetamol• Aspirin• NSAIDs
Weak Opioids
• Tramadol• Codeine• Dihydrocodeine• Dextropropoxephene• Pentazocin
Strong Opioids
• Morphine• Pethidine• Buprenorphine• Fentanyl• Methadone• Oxycodone
Adjuvants / Co-Analgesics • Anti emetics• Anti depressants• Anti convulsants• Anti spasmodics• Anti biotics• Muscle relaxant• Anxiolytics• Sedatives• PPI/ Antacids• Bisphosphonates
Clinical Situation Adjuvant
Headache due to Cerebral edema Dexamethasone
Painful wounds Antibiotics
Liver Capsule pain Dexamethasone
Gastric mucosa irritation PPI
Gastric distension Dimethicone+Metoclopramide
Skeletal muscle spasm Diazepam, baclofen
Cardiac pain Nitrates, Nifedipine
Oesophagealspasm Nitrates, Nifedipine
Intestinal Colic Hyoscine
Practical Guidelines
Practical aspects of using strong Narcotics
• 1st Line -- Morphine
• 2nd line -- Oxycodone , Fentanyl, Hydromorphone
• 3rd Line -- Methadone
Morphine Trial
ADDICTIONADDICTION TERMINAL STAGETERMINAL STAGE
COPDCOPD
By the MouthBy the Clock
By the LadderFor the IndividualAttention to detail
REVIEW, REVIEW,REVIEW
Common Opioid Side effects
Drowsiness & Cognitive ImpairmentHallucinations or DeliriumMyoclonusConstipationNausea & VomitingPruritusOpioid withdrawal symptomsOpioid induced increase in generalised
pain
Warning Signs of Morphine toxicity
DrowsinessConfusionHallucinationVomitingMyoclonusPinpoint pupilUrinary retention
Opioid Resistant Cancer Pain
Opioid Conversion Rules
Management of Neuropathic Pain
1st LineWHO Analgesics/ OpioidsAntidepressantsAnticonvulsantsCorticosteroidsRadiotherapyChemotherapy
2nd LineKetamineLignocaine infusionSpinal analgesiaTENSNeurolytic proceduresCaspaicin
Non Pharmacological management
Complementary therapiesAcupunctureReflexologyTouch therapyAroma therapyArt therapyMusic therapyHypno therapy
Other non pharmacological interventions
PositioningReassuranceGood communicationDiversional therapyPsychological supportRelaxation therapyJoint mobility- Passive and ActiveSpiritual Counselling
Break through pain
End of Dose Pain
Any Questions
?
Lets bring the smiles back on their faces.......
Wishing you a l l the very BEST** in your Personal , Profess iona l & Academic facets o f l i f e . . . . . . . . . . . . . . . .
Thanking You . . . . . . . . . . . . .
BEST - - B es t Extent in the S i tuat ion and T ime frame