BUMC Basics.pdf - Anesthesia Home

80
17-20 hrs and takes the same to be eliminated once
removed. Titrate doses every 48 hrs but no sooner.
• Methadone is often an effective opioid when other
opioids are not working. However, it is easily mis-dosed
and carries some increased risks. Involve a physician,
nurse, or pharmacist member of the palliative care team
when starting and titrating methadone.
• There is no “ceiling” for the amount of opioids that a
patient can have, but side effects may eventually become
limiting and alternatives (like Ketamine, for opiod-sparing
effect) may have to be explored. Undesirable effects to
monitor for are 1.) respiratory depression 2.) over-sedation
3.) delirium 4.) hyperalgesia 5.) myoclonus
• Stimulants such as Ritalin (10 mg upon arising then 10
mg 4-6 hrs later), Dexedrene, and Provigil can offer
periods of improved alertness by combating the sedation
of opioids during the day or more specifically for planned
family time or visits. Avoid doses late in the day to avoid
insomnia.
• For dyspnea/air hunger, consider morphine 1-2 mg IV
every 1-2 hours PRN in an opioid naieve patient. Patients
tolerant of opioids may need higher doses for air hunger
managment.
• Saturate the opioid receptors to achieve sedation before
adding benzodiazepines because you want patients to be
comfortable, not just look comfortable. Benzodiazepines
can mask pain despite a patient’s appearance.
• Always be open to adjuvant therapies such as TENs
unit, heat, trigger point maneuvers (injections, ball in
sock), myorelaxants, neuropathic agents (TCAs,
Neurontin, Lyrica), relaxation/complimentary therapy,
nerve blockade, NSAIDs, palliative radiation,
bisphosphonates, glucocorticoids, anti-emetics, and
scopolamine for control of secretions
• Don’t forget other potentiators of pain such as
emotional, spiritual, or relational distress.
Useful resources
• Hopkins opioid calculator for PDA or on the web at
http://www.hopweb.org/hop/login.cfm; you then create a
user name and password for free to gain access.
• Palliative Care “Fast Facts” available at
http://www.eperc.mcw.edu/ff_index.htm
• CPR Outcomes and Counseling Guidelines tri-fold
brochure