Dr Mahnaz Ilkhani Dclinp, AONC, BCCN
Transcript of Dr Mahnaz Ilkhani Dclinp, AONC, BCCN
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Symptom management:Pain
Dr Mahnaz Ilkhani
Dclinp, AONC, BCCN
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What is pain?
درد یک احساس و تجربه هیجانی ناخوشایند است
به همراه صدمه واقعی یا احتمالی به بافت
International Association for the Study of Pain (2012)
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Pathophysiology of pain
Release of pain producing
chemicals such as bradykinin,
substance P and prostaglandins
As part of the inflammatory
response
Pain results from the activation of nociceptors (pain
receptors)
By actual or potential tissue
damage
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Spinal cord
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Pathophysiology of pain
سیگنال ها به مغز توسط
nociceptors (no-si-sep-tors).
nociceptor یک عکس العمل
(.heat, pressure, etc)به محرک
By sending nerve signals to the spinal cord and brain.
This process, called nociception (no-si-sep-shun), is the feeling of pain.
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These neurons are carried through the ascending pathway
The spinothalamic
tract
The thalamus
cortex
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: عللPhysical:
•Somatic, visceral or bone injury
Nociceptive pain caused
by;
•Nerve damageNeuropathic pain caused
by:
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Causes
2. Non-physical:
• Anger
• Anxieties
• Fears
• Sadness
• Helplessness
• Spiritual
• Social and family distress
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Pain assessment
The first stage in successful management of pain
A comprehensive assessment
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Principles of pain management
Medication: by mouth if possible
By the clock, analgesia must be given regularly, not on a PRN basis
By the ladder
Continual review
All patients taking opioids should prescribed laxative
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Step 1: Non opioid /Mild pain
• Paracetamol: NSAID
Oral or rectal (500mg-1g)
برای هر نوع دردی مناسب است
.در نارسایی قلب منع استعمال دارد
حفاظت از مشکلات معده ای دارد
• Ibuprofen (200-400 mg/TDS or QDS)
• Diclofenac (75 mg BD/oral, SUPP 100-150mg/d)
• Naproxen (500 mg/ BD)
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Step 1: Non opioid /Mild pain
Starts with a non-opioid such as Aspirin
A non-steroidal anti-inflammatory drug (NSAIDs) such as ibuprofen; paracetamol.
تمامی این داروها خاصیت ضد التهابی
دارند
ممانعت از سنتز پروستا گلاندین می
.کنند
کاهش تحریک نوسی سپتورها
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Step 1: Non opioid /Mild pain
Useful in controlling pain from
Bone or soft tissue
damage
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Step 2/weak opioids
• Included:
The codeine-based drugs such as:
Co-codamol
Co-dydramol
The non-codeine based tramadol
کدئین در کبد به مرفین تبدیل شده و دارای اثرات ضد دردی می باشد•
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Step 2/weak opioids
• Weak opioids can be prescribed with:
NSAIDs
Adjuvant analgesics
Paracetamol (if the weak opioid does not contain paracetamol).
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در صورت درمان ترکیبی همه این اثرات ضد دردی با مسیر های
.مختلف باعث بیشترین تاثیر می گردد
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Step 2/weak opioids
• Codeine 30 mg with paracetamol/ QD
• Tramadol 50-100 mg QD
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Step 3 /Strong opioids
The use of strong opioids
مهمترین انتخاب در درمان درد در بیماری های پیشرفته
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Morphine
The rescue dose is 1/6 of the
total amount of morphine taken
in 24 h.
A starting dose of 20–30 mg daily in the preparation
It is important, to have
immediate release
morphine
(NICE, 2012).
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• The PRN dose for any pain experienced is 1/6 of the total 24-h dose of morphine.
• If a patient is receiving 60mg MST BD.
• The total 24 h dose is 120mg The PRN dose will be 120/6 = 20mg oromorph.
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Case 1
ه کرده ساله مبتلا به سرطان پیشرفته تخمدان با درد مداوم ناحیه زیر شکم مراجع76یک خانم co-codamolبیمار قبلا قرص . است 30/500 QDS دریافت کرده است اما دیگر تاثیری.ندارد
. دفع بیمار طبیعی است و هیچ گونه علایم ادراری ندارد
.در معاینه شکم نرم است و در ربع تحتانی کمی تندر است
.شما تصمیم می گیرد دوز داروهای بیمار را بیشتر کنید
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Case 1
با توجه به دریافت منظم اپوئید توسط بیمار، ضد درد بیمار به •
• Release morphine e.g. MST – starting dose would be 10-20mg MST BD.
oramoprhیا • 5-10mg QDSدر هنگام تثبیت وضعیت بیمار
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Breakthrough Pain
.همه بیماران باید در ابتدا با مرفین درمان شوند•
oramorph:دو فرم• (liquid) or sevradol (tablets)است .
• a sixth of the 24 hour morphine dose. In this case the breakthrough dose would be 5mg
• Standard strength oramorph is 10mg/5mls.
. ساعت نیاز به تجویز دارد4ساعت است بنا بر این معمولا هر 4اثر مرفین برای •
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Adjuvant analgesics
The WHO ladder
اغلب به رژیم های ضد درد که به مسکن های معمول مثل مرفین جواب نمی دهد
اضافه می شوند
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Bone pain
Palliative radiotherapy
NSAIDs may be effective
Infusion of bisphosphonate (breast cancer, prostate cancer, metastasis to bone)
Referral for orthopedic surgery
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Abdominal pain
Constipation is a common cause
For colic use anticholinergic (sc Hyoscine 20-120 mg/24 by syringe driver.
For liver capsule pain: dexamthasone (4-8 mg/d) combine with opioids
For upper abdominal tumour coeliac plexus block
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Rectal pain
Exclude constipation
Tenesmus and deep pelvic pain may use amitriptyline
Local or systemic steroids
Muscle spasm: cap nifedipine 10-20 mg
Benzodiazepines 2-10mg• Local radiotherapy
• Never block
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Neuropathic pain
Opioid
Amitriptyline 10-25mg
Antiepileptic
Gabapentine 300mg/d
Carbamazepine 200-1200 mg/d
Clonazepam 500mcg
Dex 4-8mg/d
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Adjuvant analgesics
Anxiolytics
کاهش درد های اسپاسمتیک
باعث تسکین سفتی و تنشن عضلات می شود
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Adjuvant analgesics
Antispasmodics:
کاهش اسپاسم و سفتی عضلات
Corticosteroids
برای کاهش التهاب
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SYRINGE DRIVER/ PUMPS IN PALLIATIVE CARE
• It is a portable battery operated device
• Used to deliver a continuous subcutaneous infusion of medication
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Case 2
. ساله با سرطان پستان است68یک خانم
.می گیرند ولی به شدت خواب آلوده هستند 90mg MST BDروزانه
بیشتر در تختخواب هستند و فقط کمی مایعات می خورند
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Case 2
ه نظر با توجه به این که گرفتن خوراکی داروهای ضد درد به نظر برای بیمار مشکل ب•. می رسد بنابر این پمپ سرنگی پیشنهاد می گردد
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Syringe Driver Prescription
: مثال•
• 60mg diamorphine/24 hours or 90mg morphine/24 hours
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Prescription of Anticipatory Medications
• Other anticipatory meds:
Haloperidol
Midazolam
Buscopan
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First Line Anticipatory Medications
Nausea and Vomiting – Haloperidol 1.5-3mg (max dose in 24 hours = 10mg)
Respiratory Tract Secretions – Buscopan 20mg (max dose in 24 hours = 120mg)
Aggitation – Midazolam 2.5-5mg (normally give an initial max dose of 25mg/24 hours)
Dyspneoa – morphine/diamorphine as above
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Syringe Drivers
برای کنترل علایم می تواند استفاده شود•
چون چندین ساعت برای شروع تاثیر پمپ ها به طول می انجامد بنا بر این یک•
در ابتدا لازم است bolusدوز
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SYRINGE DRIVER/ PUMPS IN PALLIATIVE CARE
• 3 models of syringe driver / pump use:
• Graseby MS26
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SYRINGE DRIVER/ PUMPS IN PALLIATIVE CARE
• Micrel MP Daily
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SYRINGE DRIVER/ PUMPS IN PALLIATIVE CARE
• McKinley T34
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SYRINGE DRIVER/ PUMPS IN PALLIATIVE CARE
باشد Luer lok سرنگ
.ساعت باید تعویض شوند24سرنگ هر
.توصیه می شود 20ml syringe حداقل
The extension lines should be avoided as they produce an increase in “dead space”
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SYRINGE DRIVER/ PUMPS IN PALLIATIVE CARE
در صورت نیاز به تجویز داروهای زیر جلدی می توان از سوزن های پروانه ای •.استفاده کرد( اسکالپ وین)
.قبل از استفاده از سوزن پروانه ای باید با یک دوز از دارو یا سرم هواگیری شود•
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SYRINGE DRIVER/ PUMPS IN PALLIATIVE CARE
• All syringes should have labels
• Name of patient.
• Name(s) of drug(s) in syringe.
• Dose(s) of each drug.
• Name of diluent (if used).
• Date and time syringe driver / pump commenced
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The following checks should be made
• Presence or absence of site reactions.
• Length of fluid remaining in the syringe.
• Clarity of solution in syringe.
• Battery check.
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.ساعت انجام و گزارش شود4کنترل ها باید هر •
.روز باید عوض شود3محل سوزن سرنگ پمپ هر •
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.رقیق شوند %0.9داروها باید در سرم نمکی •
از آب استریل برای •
•cyclizine and diamorphine > 40mg/ml
.استفاده می شود
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The following drugs should be used in a syringe driver/pump as single agents
Dexamethasone.
Diclofenac.
Ketorolac.
Phenobarbital
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از ترکیب
cyclizine plus hyoscine butylbromide
در یک سرنگ اجتناب شود چون ممکن است .باعث کریستال شدن گردد
در صورت کریستال شدن یا کدر شدن انفوزیون متوقف و محتوای سرنگ دور ریخته
.شود
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Palliative radio/chemo therapy for pain management
A patient with cancer may receive palliative radio or chemotherapy as
part of pain management
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Non-pharmacological pain relief
• Biological therapies:
dietary supplements such as glucosamine, chondroitin (for joint pain) and vitamins.
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Non-pharmacological pain relief
Mind-body medicine:
Distraction , prayer, relaxation, guided imagery, meditation,
creative therapies, hypnosis and cognitive behavioural therapies
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Non-pharmacological pain relief
Manipulative and body-
based practice:
Physiotherapy, occupational
therapy, osteopathy, chiropractic techniques,
massage and acupuncture.
Energy medicine:
Therapeutic touch, reikiand healing
touch.
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