Symptom Management in Patients with Stage 5 CKD Opting for Conservative Management
Abstract
:1. Introduction
2. Conservative Management
3. Pain
- For those already on background oral opioids but unable to swallow, convert to a continuous subcutaneous syringe driver infusion (the use of which must be thoroughly discussed with patients and their families) using Table 3 below:
Table 3. Conversion chart for commonly used opioids (* denotes the trade name of drug). Codeine
24 h Oral Dose (mg)Tramadol
24 h Oral/IV Dose (mg)BuTrans* Patch
(mcg/h) WeeklyTranstec * Patch
(mcg/h)
Twice WeeklyFentanyl * Patch
(mcg/h)
Every 3 DaysOxycodone
24 h Oral Dose (mg)Oxycodone
24 h Subcutaneous Dose (mg)Alfentanil
24 h Subcutaneous Dose (mg)60 120 50–100 10 7.5 5 0.5 240 150 20 12 15 7.5 1 200 35 12 20 10 1.5 200–400 35 25 30 15 2 52.5 25 45 20 3 70 37 60 30 4 37 75 35 5 50 90 45 6 62 105 50 7 62 120 60 8 75 150 75 10 100 180 90 12 125 225 110 15 150 270 135 18 175 315 155 21 200 360 180 24 250 450 225 30 500 900 450 60
3.1. Analgesia
- If the patient is opioid naïve and unable to take regular oral medication:
- ○
- Commence 5–10 mg/24 h morphine sulphate SC via syringe driver.
- ○
- Anticipatory prescribing for opioid naive patients: Morphine 2.5–5 mg s/c prn.
- ○
- If known to have renal impairment/renal failure/morphine not tolerated, use: Oxycodone 1.25–2.5 mg s/c prn.
- Most patients require at least low dose opioid analgesia for discomfort in the terminal phase. However if the patient appears comfortable and has not previously required analgesia, prescribe appropriate opioid prn and review regularly. Only start a syringe driver if they are uncomfortable or have required two or more SC doses in the previous 24 h.
- If the patient is taking analgesia via a patch (Fentanyl, Buprenorphine) leave the patch on and add a syringe driver with any extra analgesia required. Contact the Palliative Medicine Team for advice.
3.2. Agitation
- Terminal restlessness and agitation is a common symptom at the end of life, studies. Symptoms may include inability to relax, picking at clothing or sheets, confusion and agitation, and trying to climb out of bed.
- Consider potentially reversible causes of agitation:
- ○
- Pain
- ○
- Urinary retention
- ○
- Full rectum
- ○
- Nausea
- ○
- Temperature
- ○
- Cerebral irritability
- ○
- Side effects of medication (especially steroids)
- Medication
- 1st Line, Midazolam 10–30 mg SC/24 h via syringe driver PLUS 2.5 mg–5 mg SC prn.
- 2nd Line, Levomepromazine 12.5–50 mg via syringe driver PLUS 1.5 mg prn and contact the palliative care team.
3.3. Respiratory Secretions
- The noise is often distressing for the patient’s family—reassure them that the secretions are not distressing the patient.
- Reposition patient and stop parenteral fluids—if unsuccessful consider drug treatment.
3.4. Nausea/Vomiting
- A PRN anti-emetic should always be prescribed as above for a dying patient even if not previously required as symptoms can vary.
- ○
- Haloperidol 1.5 mg SC/po max 10 mg/24 h (antiemetic and anxiolytic).
- ○
- If patient has Parkinson’s, use levomepromazine 6.25 mg SC prn instead of haloperidol.
- ○
- Cyclizine 50 mg s/c tds prn max 150 mg/24 h (if likely cause drug induced/bowel obstruction/metabolic or intracranial cause).
- ○
- OR Metoclopramide 10 mg s/c tds prn max 60 mg/24 h (if likely cause gastric outflow obstruction/gastric stasis).
- ○
- If above ineffective, prescribe Levomepromazine 6.25 mg s/c tds prn.Caution—cyclizine may precipitate in a syringe driver when combined with hyoscine butylbromide, if this occurs, switch to alternative antiemetic.
- If nausea/vomiting continue please contact the Palliative Care Team.
3.5. Dyspnoea
- Opioids or Midazolam can be effective for dyspnoea.
- Start a syringe driver with morphine sulphate 10 mg SC/24 h.
- If distressed, consider Midazolam 10 mg SC/24 h.
3.6. Anticonvulsants
- A patient who was on a regular anticonvulsant and who is no longer able to swallow MUST be started on a syringe driver with Midazolam 20 mg SC/24 h. This can be titrated up to 60 mg.
- If a dying patient continues to fit despite Midazolam 60 mg add Phenobarbital 600 and titrate up to 1600 mg via a syringe driver. Give a loading dose of 200–1000 mg IV (give at a rate of 50 mg/min until fitting stops and call the palliative care team.
3.7. Nutrition and Hydration
- Oral hydration and nutrition should continue to be offered as tolerated.
- Risk feeding, where there is a risk of aspiration, is appropriate if the patient wishes/appears to enjoy it.
- Parenteral support may be considered where clinically appropriate.
- Always discuss plans where possible with the patient, and family, and clearly documented.
4. Conclusions
Conflicts of Interest
References
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Priority 1: Recognise: Clinical teams should recognise the possibility that patient may die in the coming days or hours and this is clearly communicated. This communication should include any decisions made and actions taken in accordance with the person’s needs and wishes. These should be reviewed regularly and updated accordingly. |
Priority 2 : Communicate: Ensure that sensitive communication takes place between staff and the patient and those people that are important to them, such as family, spouse, friends |
Priority 3: Involve: Ensure that the patient, and those more important to them, such as family, spouse, friends, are involved in all decisions about treatment and care to the extent that they want to be |
Priority 4: Support: Ensure that the needs of the patients’ families and others are identified as important to the patient are actively sought, respected and met as far as possible |
Priority 5: Plan and Do: Agree, co-ordinate and deliver an individualised care plan with the patient, which includes food and drink, symptoms control and psychological, social and spiritual support |
Prescribe prn: |
1. Analgesia (see below) 2. Anxiolytic/muscle relaxant Midazolam 2.5–5 mg SC prn maximum hourly 3. Antiemetic—depending on likely cause of nausea and /or vomiting Haloperidol 1.5 mg SC/po max 10 mg/24 h (antiemetic and anxiolytic) Cyclizine 50 mg s/c tds prn max 150 mg/24 h (if likely cause drug induced/bowel obstruction/metabolic or intracranial cause) OR Metoclopramide 10 mg s/c tds prn max 60 mg/24 h (if likely cause gastric outflow obstruction/gastric stasis) If above ineffective, prescribe Levomepromazine 6.25 mg s/c tds prn If patient has Parkinson’s, use levomepromazine 6.25 mg SC prn instead of haloperidol 4. Respiratory secretions Hyoscine Butylbromide (Buscopan) 20 mg prn maximum 180 mg/24 h Alternative antimuscarinics if above ineffective—Hyoscine hydrobromide 0.4 mg s/c qds prn OR Glycopyrronium 0.2–0.4 mg s/c qds prn |
Caution—Cyclizine may precipitate in a syringe driver when combined with other drugs, if this occurs, switch to alternative antiemetic |
These should be prescribed for all patients except in cases of known allergy to the above |
1st line | Hyoscine Butylbromide (Buscopan) 20 mg prn If secretions do not resolve with repositioning and PRN Buscopan, start Buscopan 60 mg SC/24 h in a syringe driver. The dose can be titrated up to max 180 mg in 24 h as needed. |
2nd line | If above ineffective, consider Hyoscine hydrobromide 0.4 mg s/c qds prn (this has some sedative effect). This can be used in a syringe driver dose 1.2–2.4 mg/24 h OR Glycopyrronium 0.2–0.4 mg s/c qds prn This can be used in a syringe driver dose 1.2–2.4 mg/24 h |
© 2016 by the author; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/).
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Johnston, S. Symptom Management in Patients with Stage 5 CKD Opting for Conservative Management. Healthcare 2016, 4, 72. https://doi.org/10.3390/healthcare4040072
Johnston S. Symptom Management in Patients with Stage 5 CKD Opting for Conservative Management. Healthcare. 2016; 4(4):72. https://doi.org/10.3390/healthcare4040072
Chicago/Turabian StyleJohnston, Sheila. 2016. "Symptom Management in Patients with Stage 5 CKD Opting for Conservative Management" Healthcare 4, no. 4: 72. https://doi.org/10.3390/healthcare4040072
APA StyleJohnston, S. (2016). Symptom Management in Patients with Stage 5 CKD Opting for Conservative Management. Healthcare, 4(4), 72. https://doi.org/10.3390/healthcare4040072