Download - Pain management in palliative care
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Pain Management in Palliative Care
Dr.Raman Swathy VamanDistrict Programme Manager
National Health MissionAarogyakeralam Kasaragod
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WHY AM I HERE TODAY ?????
NOT FOR THIS
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"Pain is a more terrible Lord of Mankind than even
Death itself"
Albert Schweitzer (1875-1965)
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Dr.Robert Twycross
Pain is what the patient says Hurts....
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Evolution of Pain theories
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Rene Descartes Dr. Henry Beecher
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Ronald Melzack Patrick Wall
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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"
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Pathophysiology
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Types of pain
• Acute• Chronic
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Pain
NeuropathicNociceptive
Sympathetic
Capsular Soft TissueBoneCardiac
CentralPeripheralSomaticVisceral
Bowel
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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
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Causes of pain in C/c illness
Debility RelatedConstipationPressure soresBladder spasmStiff JointsPost Herpetic neuralgia
Co MorbiditiesSystemic IllnessesArthritisTrauma
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Total Pain
Psychosocial Distress Physical Distress
Spiritual Distress
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Assessment of Pain
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1) Visual Analogue Scales (VAS)
2) CategoricalVerbal Rating Scales (VRS)
3) Categorical Numerical Rating Scales (NRS)
For Adult Paients
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VAS
NO PAIN WORST PAIN
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VRS
None
Mild
Moderate
Severe
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NRS
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For Childrens
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McGill Pain Questionnaire
Brief Pain Inventory
The Abbey Pain Scale
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Management of Nociceptive pain
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WHO Analgesic Ladder
Continued Psycho Social Support
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Non Opioids• Paracetamol• Aspirin• NSAIDs
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Weak Opioids
• Tramadol• Codeine• Dihydrocodeine• Dextropropoxephene• Pentazocin
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Strong Opioids
• Morphine• Pethidine• Buprenorphine• Fentanyl• Methadone• Oxycodone
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Adjuvants / Co-Analgesics • Anti emetics• Anti depressants• Anti convulsants• Anti spasmodics• Anti biotics• Muscle relaxant• Anxiolytics• Sedatives• PPI/ Antacids• Bisphosphonates
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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
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Practical Guidelines
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Practical aspects of using strong Narcotics
• 1st Line -- Morphine
• 2nd line -- Oxycodone , Fentanyl, Hydromorphone
• 3rd Line -- Methadone
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Morphine Trial
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ADDICTIONADDICTION TERMINAL STAGETERMINAL STAGE
COPDCOPD
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By the MouthBy the Clock
By the LadderFor the IndividualAttention to detail
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REVIEW, REVIEW,REVIEW
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Common Opioid Side effects
Drowsiness & Cognitive ImpairmentHallucinations or DeliriumMyoclonusConstipationNausea & VomitingPruritusOpioid withdrawal symptomsOpioid induced increase in generalised
pain
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Warning Signs of Morphine toxicity
DrowsinessConfusionHallucinationVomitingMyoclonusPinpoint pupilUrinary retention
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Opioid Resistant Cancer Pain
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Opioid Conversion Rules
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Management of Neuropathic Pain
1st LineWHO Analgesics/ OpioidsAntidepressantsAnticonvulsantsCorticosteroidsRadiotherapyChemotherapy
2nd LineKetamineLignocaine infusionSpinal analgesiaTENSNeurolytic proceduresCaspaicin
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Non Pharmacological management
Complementary therapiesAcupunctureReflexologyTouch therapyAroma therapyArt therapyMusic therapyHypno therapy
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Other non pharmacological interventions
PositioningReassuranceGood communicationDiversional therapyPsychological supportRelaxation therapyJoint mobility- Passive and ActiveSpiritual Counselling
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Break through pain
End of Dose Pain
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Any Questions
?
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Lets bring the smiles back on their faces.......
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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