Palliative Care And Pain

Management In Anesthesia
KyU
Anesthesia Lecture Series
James Nderitu

©2024
What Is Palliative Care?
• The active total care aimed at improving quality of life of
terminally ill patients whose disease is not responsive to curative
treatment (life-threatening illness), including control of pain, other
symptoms, and psychological, social, and spiritual problems.
• May be given any time during the patient’s illness.
• Can be:
– Curative – eliminates the disease
– Therapeutic – extends life
– Palliative – provides comfort
Palliative Care
•Symptom Management
•Key concept: -Taking care of all the needs of a patient
 Physical
 Psychological
 Social
 Spiritual
 Legal
Hospice Care
• You can offer palliation to someone without hospice care

• Hospice is end of life care

• Patients with terminal illness

• Estimated prognosis of six months or less.

Living Wills
• What does it mean? -
• aka advance directive.
• Its a written legal document that directs/spells out medical treatments
one would or would not want to be used to keep them alive, as well as
their preferences for other medical decisions, such as pain management
or organ donation in the event of incapacitation/unable to communicate
their wishes.
• Clarification of wishes is the key
• Be specific if needed
Living Wills
• Key aspects:
– Who has medical power of attoney
– Legally next of kin without documentation
– Anyone can be chosen with appropriate documentation
– This person must be aware of the patient’s wishes
• Do Not Resuscitate (DNR): In hospital or out of hospital
CANCER

PAIN / DYSPNEA
 CANCER

MEANINGLESSNESS
ANGER
RELIGIOUS GUILT

GRIEF
PAIN / DYSPNEA

CHILDHOOD
FEARS CONFLICTS WITH ALCOHOL ABUSE

CHILDREN
Symptom Management

This constitute the main role of the physician/clinician

in end of life care:
Nausea
• Causes include:
– Narcotics
– Constipation/bowel obstruction
– Disease process
• Treat reversible causes
• Drug therapies:
– Prokinetic agents
– Steroids
– Haloperidol
– Anticholinergics such as Hyoscyamine
Cachexia/Anorexia
• Loss of body weight
• Usually more concerning for the loved ones than the patient
• In terminally ill patients the goal is symptom management not
nutrition.
• Drug therapy:
– Megestrol (Megace) – improves appetite, but not weight
– Dronabinol (Marinol) – improves appetite, N&V but not weight
– Steroids – improves appetite, and a sense of well being..
Hydration

• Frequently very difficult discussion

• Loved ones (and almost all lay people) believe it is inhumane to
let someone die of thirst
• Little correlation between thirst and hydration in a dying patient
• At the very end of life, hydration can worsen pain and swelling
• More difficult decision is hydration with patients not near death
Hydration
• Decreases delirium and sedation in some patients
– Improves electrolyte abnormalities
– Improves drug clearance
• Small retrospective series have shown a benefit in appropriate
patients
– Can be given IV
– SQ (Hypodermoclysis)
– PR (proctoclysis)
– Total fluid requirements are less – 1.0-1.5L/day
 Delirium
• Most common neuropsychiatric complication. Most patients die with delirium.
• Prevention is key, early recognition and treatment of reversible causes if able.
• Treatment
– Non-pharmacological
• Providing support and orientation: clear, simple, firm, slow-paced language; avoid abstract ideas/
language; engage in familiar topic such as hobbies/profession; provide a calender, clock, in the room;
• Maintain competence: early mobilization, encourage indipendence in self-care, eliminate catheters at
the earliest, etc.
– Pharmacological
• Antipsychotics: Haloperidol, Droperidol, Chlorpromazine, Olanzapine, Loxapine etc
• Benzodiazepines: Midazolam, Lorazepam etc.
• Cholinesterase inhibitors: Physostigmine, Rivastigmine, Donepezil etc.
• Others: Ketamine
Dyspnea
• Uncomfortable awareness of difficult or labored breathing
• Very common symptom in all patients.
• Treat underlying cause if possible
• Assess by symptoms, not signs
• Medical intervention
– Oxygen
– Cool moving air
– Opioids
Last Hours
• Progressive unresponsiveness
• Purposeless movements, facial expressions
• Noisy breathing, death rattle
• Periods of awareness
– Rally day
• Last interventions
• What to do after death
Pain

What is Pain?
Pain
Pain
• Definition (Intl. Association for the Study of Pain)
 Complex unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described
in terms of such damage.
 Consists of a physiological and a psychological response to a noxious
stimulus that influences an organism to withdraw from (potentially/)
harmful stimuli.
 Pain is always a personal experience influenced to varying degrees by
biological, psychological, social, cultural, cognitive and genetic
factors.
 Its subjective and difficult to quantify because it has both an affective
Total pain (Cicely Saunders 1964)

Physical Emotional
Symptoms Psychological
Problems

Pain
Pt’s Experience
Pain

with Pain

Spiritual
Social
Existential
Concerns
Distress
Physiology of pain
• Primary afferent nociceptors
– Nerves that respond to painful stimuli
– Can respond to many different types of stimuli
• Sensitization
– Intense, repeated or prolonged stimuli
– Threshold for activating nerves is lowered
– Inflammatory mediators such as bradykinin, prostaglandins
and leukotrienes are at play
Physiology of pain
• Central pathways
– Axons of primary nociceptors enter the spinal cord via
the dorsal root
– Transmit pain signal to brain sites
– Axon of each primary afferent contacts many spinal
neurons
– Each spinal neuron receives convergent input from
many primary afferents
Referred Pain
• All spinal neurons receive
input from viscera and skin
• Convergence patterns are
determined by the spinal
segment of the dorsal root
ganglion
• For example both the
diaphragm and the skin of
the shoulder have same
dorsal root
Nociception
• Nociception is the sensory nervous system’s process of encoding
noxious stimuli.
• Effected through a series of events and processes required for an
organism to receive a painful stimulus, convert it to a molecular
signal, and recognize and characterize the signal to trigger an
appropriate defense response.
• Involves:
– Activation of receptors in peripheral pain pathways
– Transmission and processing of information in the brain
– Leads to pain perception
Basic Steps in Pain Processing
• Transduction – process by which nociceptors respond to noxious
stimuli. Noxious stimulation carried by A-delta and C-fibres
• Transmission – Process by which impulses are relayed to the dorsal
horn of the spinal cord and brain via primary afferents.
• Modulation – The process of changing or inhibiting pain impulses
in the spinal cord.
• Perception – Conscious, multidimensional experience of pain
resulting from interaction of transduction, transmission, and
modulation. Dependent on the psychological state of the
individual.
Classification Of Pain
• Broadly classified as Acute or Chronic
• Physiologic
– Nociceptive
• Somatic – skin, soft tissue, bone
• Visceral - organ
– Neuropathic – Pain due to damaged or dysfunctional nerves
– Mixed – Experiencing both nociceptive and neuropathic pain
• Most common in advanced illnesses
Types of Pain
Somatic
• Nociceptors in cutaneous or deep tissues
• Dull or aching but well-localized pain
Visceral
• Nociceptors from involvement of the viscera
• Poorly localized and described as deep, squeezing, and pressure-like. Can
be associated with nausea or sweating
Neuropathic
• Injury to peripheral or central nervous system
• Often severe and described as burning or shock-like
Acute Pain
• Well-defined temporal pattern of onset.
• Associated with subjective and objective physical signs
• Hyperactivity of the autonomic nervous system
• Usually self-limited
• Responds to analgesics and treatment of the underlying cause
Two types
• Subacute comes on over several days with
increasing intensity
• Episodic occurs during confined periods of time
Chronic Pain
• Persistence of pain for more than 3 months
• Autonomic nervous system adapts
• Patients lack objective signs of pain
• Leads to changes in personality, lifestyle and functional
ability
• Treatment requires control of pain and its
multidimensional aspects
 Chronic Pain
• Causes are multiple
– Trauma, surgery
– Cancer, medical conditions
• Baseline pain
– Average pain intensity for 12 or more hours in a 24 hour period
within a duration of six months or more
• Breakthrough pain
– Transient flare of pain from any cause happening even though
one is on regular analgesics which are effective for chronic pain.
 Chronic Pain
• Change over time

• Constant

• Breakthrough

• Intermittent
acute
Measurement of Pain
• Important to determine but hard to define
• Many scales are used
– Mild, moderate, severe, excruciating
– Numeric scales 1 (no pain) 10 (worst possible pain)
– Visual analog scales faces, 10cm line
– All of these are validated instruments
Measurement of Pain

4 - 5th Vital Sign = Pain Severity

Clinical Assessment
• Believe the patient's complaint of pain – “Pain is whatever the
patient says it is”.
• Take a careful pain history
• Evaluate the patients psychological state
• Perform a careful medical and neurological examination
• Order appropriate diagnostic studies
• Treat the pain
• Reassess response to therapy
Pain History
• Description of site of pain
• Quality of pain
• Exacerbating and relieving factors
• Temporal pattern
• Associated symptoms and signs
• Interference with activities of daily living (ADLs)
• Effect on psychological state
• Response to previous and current therapies
 2

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.Warden V, Hurley AC, Volicer V. J Am Med Dir Assoc, 2003; 4 :9-15

Three-step Analgesic Ladder (WHO)
1. Paracetamol and/or NSAID +/-
Adjuvants

2. Codeine, Dihydrocodeine,
Tramadol +/- Adjuvants

3. Morphine, Fentanyl,
Methadone, Oxycodone +/-
Adjuvants
Management
• Modalities
– Analgesics
– Rehabilitation
– Psychotherapy
– Cognitive
– Surgical
• Individualized treatment plan
Non-opioids Analgesics
• Acetaminophen (Paracetamol)
– Main serious side effect is liver toxicity
– Counsel patients on all Paracetamol-containing drugs
• Non-steroid anti-inflammatory drugs (NSAIDs)
– Main serious side effect is GI ulcers
– Risk factors: steroid use, advanced age, higher doses, history of ulcer disease
– Most inhibit platelets
• Analgesia limited by a ceiling effect
• Tolerance and physical dependence do not occur
• Mechanism of action is inhibiting prostaglandins.
Opioid Drugs
• Morphine is the prototype
• Vary in potency, efficacy, and adverse effects
• Produce analgesia by binding to discrete opiate receptors in the
peripheral and central nervous systems
• Do not have a ceiling effect, but care is needed to balance
analgesia vs side effects
– SE: Respiratory depression, nausea, mental clouding, sedation,
constipation, tolerance, physical dependence, and myoclonus
Principles of Opioid Therapy
• Start with a specific drug for a specific type of pain
• Know the equianalgesic dose of the drug and its route of
administration
• Administer analgesics regularly after initial titration
• Tailor the route of administration to the patients needs
• Use a combination of drugs
• Anticipate and treat side effects
Points
• Morphine is the prototype
drug
• Oxycodone has street value
• Hydromorphone has poor
oral availability
• Methadone is a great drug,
but
– Negative pre-conceived
notions
– Unpredictable, long half-life
• Pethidine not a good drug for
pain as its inactive
metabolite can cause seizures
• Fentanyl only comes in a
patch
– Great for patients who cannot
take po
– Hard to titrate
Side Effects
• Sedation • Nausea
– Discontinue all other drugs that can – Medullary chemoreceptor trigger zone
cause this – Tolerance develops
– Use drug with shorter ½ life – Switching drugs can help
– Methylphenidate (Ritalin), caffeine • Constipation
or an amphetamine can help
– START REGULAR BOWEL
• Respiratory depression REGIMEN!!
– Occurs with other CNS symptoms – Senna and colace most useful
– Tolerance develops – Never gets better
– Can reverse with Naloxone • Pruritis
– Tolerance develops
– Use H1 blockers
Tolerance
• Effectiveness of analgesia diminishes over time
– Increase dose of drug
– Cross tolerance not complete so can change drugs
• Taper drugs slowly
– Withdrawal agitation, tremors, insomnia, fear,
hyperexcitability, and pain
– Tapering the drug slowly can prevent these symptoms
Adjuvant Drugs
• Enhances analgesia esp. • Steroids
neuropathic pain – Improves mood and appetite
• Antidepressants – Helpful in bone and tumor pain
– Tricyclic • Other
• Enhance serotonin activity – Benzodiazepines
– Paroxetine (Paxil) - (SSRI) – Neuroleptics e.g., Haloperidol,
• Anticonvulsants Fluphenazine, Olanzapine.
– Stabilize membranes and alter – Bisphosphonates
Na+ & Ca2+ influx – LA nerve blocks
– Phenytoin, Gabapentin, Tegretol. – Intrathecal opioids
Other Techniques
• Physical therapy - heat/cold packs,massage, hydrotherapy,
exercise etc.
• Psychological therapy - cognitive behavioral therapy,
relaxation technique, meditation etc.
• Mind and body technique - e.g. acupuncture
• Community support groups
…

GRATIAS