5. PainManagement:OpiateTolerant
โข Need to convert existing PO doses of opiate analgesics to IV/SC equivalent
โข Breakthrough should be charted as 1
12
to 1
6
of calculated equivalence
Opioid Parenteral Oral
morphine 10 mg IV/SC 30 mg
oxycodone 10 mg IV/SC 20 mg
hydromorphone 1.5 to 2 mg IV/SC 6 mg
fentanyl 100 to 150 micrograms IV/SC โ
methadone Discuss with palliative care
buprenorphine 400 micrograms IV/SC 800 micrograms sublingual
codeine โ 240 mg
tapentadol โ 100 mg
tramadol 100 mg intravenous 150 mg
6. PainManagement:OpiateTolerant
Patient is on Oxycodone 60mg BD
โข Daily dose = 120mg
โข Equivalent = Morphine 180mg PO
โข SC equivalent = 60mg in 24hrs
โข PRN range 1
12
to 1
6
= 5mg to 10mg morphine SC PRN
Opioid Parenteral Oral
morphine 10 mg IV/SC 30 mg
oxycodone 10 mg IV/SC 20 mg
7. PainManagement
โข Re-review analgesic use in 24 hours (if still in EDโฆ) to recalculate requirements
โข Donโt forget adjuncts!
โข Paracetamol
โข NSAIDs
9. DyspnoeaandSecretions
โข Opiate or benzos
โข Sit patient up, or in desired position for comfort
โข High flow oxygen (even in the absence of hypoxia)
โข Humidified air
โข Permit patient to hold mask to face rather than securing to minimize claustrophobia
โข Secretions: buscopan 20mg q1h SC PRN โ max 80mg
10. BladderandBowelCare
โข Consider catheterization/urodome if patient is unable to mobilize to the toilet
โข Remember, the Lotus room does not have facilities or readily accessible nursing staff!
โข Patients without family/NOK present do not qualify for use of the lotus room
โข If not imminently dying, consider laxatives for management of constipation secondary to
opiate use
11. Nauseaand Vomiting
โข Metoclopramide
โข Shouldnโt be used if pro-kinetic effect can worsen symptoms, i.e. bowel obstruction
โข Haloperidol
โข Ondansetron
โข If intracranial cause, consider dexamethasone 4-8mg PO/SC OD
โข Refractory nausea with multiple multimodal agents
โข Dexamethasone 4mg PO OD
12. OtherComplications
โข Seizures โ midazolam
โข Acute airway obstruction/stridor
โข Dexamethasone 16mg PO/IV/SC stat
โข Adrenaline nebs
โข SVC obstruction or spinal cord compression
โข Dexamethasone 16mg PO/IV/SC stat
13. AcuteHaemorrhage
โข If active treatment is appropriate, treat as usual
โข If catastrophic bleeding secondary to a terminal event (i.e. arterial erosion), active treatment
and medications unlikely to be administered in time
โข Remain with the patient to provide the comfort of physical presence
โข If not for active treatment, but not imminently dying
โข Morphine and midazolam
15. BitsandPieces
โข Palliative care consultation available 24hrs
โข After hours = pall care consultant (theyโre really nice!)
โข Flags patient for PC follow up
โข Need to liaise with PC, if lotus room is desired
โข Nobody should have to die alone
โข Comfort from physical presence should not be underestimated
โข Pre-empt dealing with the aftermath
โข Liaise with SW early
โข Have difficult discussions/breaking bad news with other
team members present to reiterate and explain