Pain Management and Antiemetic Therapy in Hematologic Disorders

Published on 04/03/2015 by admin

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Last modified 04/03/2015

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Chapter 43 Pain Management and Antiemetic Therapy in Hematologic Disorders

Kathy J. Selvaggi, Bridget Fowler Scullion, Craig D. Blinderman, Janet L. Abrahm

Table 43-1 Common Pain Syndromes in Hematologic Malignancies

Table 43-2 Classification of Pain Syndromes in Sickle Cell Disease

Adapted from Ballas SK. Pain management of sickle cell disease. Hematol Oncol Clin North Am 19:785, 2005.

Figure 43-1 STRATEGY FOR PHARMACOLOGIC MANAGEMENT OF PAIN USING THE WORLD HEALTH ORGANIZATION (WHO) ANALGESIC LADDER.

Multiagent therapy is usually required for optimal pain management. Patients with mild pain should be started on a nonopioid analgesic, and those with moderate pain should be started on a step 2 opioid. Many patients can benefit from the addition of a nonopioid to the opioid (e.g., for bone pain) or an adjuvant agent to the opioid (e.g., for neuropathic pain). If this combination does not produce adequate relief or the patient presents with severe pain, step 3 opioids should be begun initially. Toradol (Ketorolac) is a nonsteroidal antiinflammatory drug (NSAID) with the pain-relieving potency of a step 3 opioid. Many patients can benefit from the addition of nonopioid analgesics or adjuvants, if indicated. ASA, Aspirin; *, oxycodone in combination with products.

Management of Severe Pain

Opioid therapy is the cornerstone of management of patients presenting with severe pain. Our practice is to begin with reassurance of patients and their families. We tell them that to relieve the pain as quickly as possible, we will initiate the use of intravenous opioid medications immediately but that we will begin oral pain medication as soon as the pain is well controlled. Without this explanation, patients have misinterpreted a “morphine drip” as an indication that they were considered terminal.

The starting dose is calculated from the patient’s current opioid dose (10% of their 24-hour opioid requirement) or weight (e.g., 0.05 mg/kg/hr of morphine). After the opioid bolus dose is administered, the patient should be monitored continuously during dose titration. If the patient was on standing opioid medication, the medication is continued when possible or converted to a continuous infusion if necessary. Pain is reassessed 20 minutes after the patient receives a bolus dose. If the pain remains severe (7, 8, or 9 of 10), a subsequent bolus dose is administered at double the dose. If the pain has decreased to moderate (4, 5, or 6), another bolus at the same dose as the immediately previous dose is used. If the pain score is below 4, the patient is carefully monitored. At 4 to 8 hours, either a continuous infusion is begun or the ongoing infusion rate is adjusted upward based on the amount of opioid taken as boluses during that period. There is no maximal opioid dose; we give whatever is required to relieve the pain. If the patient falls asleep, this is usually an indication that pain relief has been achieved, not that the dose should be lowered. We lower the dose if the respiratory rate falls to below 10 to 12 breaths/min or if there are signs or symptoms of neurotoxicity (e.g., myoclonus).

Agents to prevent side effects are begun along with the opioid. All patients are given a stool softener and an irritant agent such as senna (one or two tablets orally daily to twice daily, up to a maximum of 8 pills per day). If a more laxative effect is needed, lactulose (15-30 mL) or polyethylene glycol (17 g) is added. In opioid-naive patients, prochlorperazine (Compazine 10 mg taken orally two or three times daily) is ordered as needed to treat nausea. In patients with bone or nerve pain, appropriate adjuvants are added.

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