Palliative care tips: Commonly administered sub-cutaneous medications in palliative care
Palliative Care; Terminal Care; Analgesics; Antiemetics; Morphine; Narcotics; Opioid; "Hypnotics and Sedatives"; Pharmaceutical Preparations
2002
Bielech M; Turnbull K; Watanabe S
2002
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Journal Article
Pharmacokinetics of methadone in children and adolescents in the perioperative period
Child; Analgesics; Methadone; Narcotics; adolescent; Opioid; Antitussive Agents; Biological Transport; Kinetics; Perioperative Care; Pharmacokinetics
Introduction Previous studies by Gourlay and coworkers1-3 have demonstrated that in adults undergoing surgery, methadone has slow elimination and a very long duration of effective analgesia. For children, intramuscular injections are a major source of distress in the peri-operative period. If methadone behaves in children as it does for adults, then use of methadone intravenously should provide a steady analgesic effect. For these reasons, we have undertaken studies of methadone in children and adolescents undergoing major surgery. Methods Fifteen children and adolescents, ages 1-18 years were enrolled with informed parental and patient consent according to procedures approved by the institutional Human Studies committee. Enrollment was restricted to patients requiring prolonged surgery (greater than 3 hours) and placement of arterial cannulae or multiple venous cannulae. Included in the studey were 3 one-year olds, 2 two-year olds and 2 three-year olds. Following tracheal intubation and line placement, methadone (0.2 mg/kg) was administered via rapid intravenous bolus. Heparinized plasma samples for methadone assay were obtained at approzimately 1, 2, 3, 4, 7, 10, and 30 minutes and 1, 3, 6, 12, 18, 24, 48, and 72 hours. Methadone assay (gas-liquid chromatography with mass spectrometry) yielded a lower detection limit of 5 ng/ml; for several patients the final 1-4 points fell below the detection limit and were excluded from analysis. Concentration versus time curves were fitted to a bioexponential equation using nonlinear least-squares. Results Kinetic parameters are summarized in Table 1. It is apparent that in children and adolescents ages 1 to 18 years, methadone has very prolonged elimination and a low clearance rate. For this population, regression analysis showed no dependence of half-lives or normalized volumes and clearances on patient age or weight. Areas under the concentration-versus-time curves from the equation parameters and from the trapezoid rule (model-independent) agreed to within 4%. Discussion Methadone has not been studied previously for post-operative pain in children. Observation of the patients in this study and of 16 additional children suggests that methadone provides prolonged analgesia; many children remained comfortable and required no analgesia for 12-36 hours post-operatively. Studies in progress are directed at testing these impressions via double-blinded administration and formal pain assessment scales. If these studies confirm that methadone's dynamics as well as kinetics are similar in children and adults, then peri-operative administration would be a safe, inexpensive and convenient means for providing prolonged analgesia and decreasing the use of painful intramuscular narcotic injections in children following major surgery. In adults ages 29-69 years, there was a positive correlation between age and beta half life. In the present study, we found no dependence of elimination half-life or normalized clearance on age for patients ages 1-18. The mean value for elimination half-life in the present study, 19.2 hours, is indistinguishable from that of the youngest adults in the previous study. As with adults, there is substantial variability among children in the rates and volumes of methadone distribution and elimination. It therefore seems prudent to follow an approach similar to that used in adults with titration to clinical effect. To date, at least 40 children have received methadone (via blinded or unblinded administration) in this fashion without requiring naloxone or assisted ventilation postoperatively. Further study is required before these conclusions can be extrapolated to newborns and very young infants.
1987
Berde CB; Sethna NF; Holzman RS; Reidy P; Gondek EJ
Anesthesiology
1987
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Journal Article
<a href="http://doi.org/10.1097/00000542-198709001-00519" target="_blank" rel="noreferrer">10.1097/00000542-198709001-00519</a>
Pain medication during terminal care of children with cancer
Palliative Care; Terminal Care; Analgesics; Pain; Morphine; Analgesia; Narcotics; Palliative treatment; Children; Administration; Oral; Neoplasms; Opioid
The purpose of this study was to evaluate the need for pain medication and the adequacy or inadequacy of the analgesia achieved, in children with cancer who died while in terminal care. Of the 100 pediatric patients with cancer treated at the Children's Hospital, University of Helsinki, Finland, who died during 1987-1992, 70 died while in terminal care. The underlying diseases were leukemia (N=25), solid tumors (N=24), and brain tumors (N=21). Of these children, 60% were treated at home, 29% at hospital, and 11% at both. The assessment of pain during terminal care was retrospective and included analysis of the patients' records and a structured interview of the two parents separately. In total, 62 children (89%) received regular pain medication, with a mean duration of 17 days in children with leukemia, 58 days in those with solid tumors, and 66 days in those with brain tumors. Medication was usually started with anti-inflammatory drugs, then changed to oral opioids when deemed necessary, and finally to parenteral opioids. Parenteral morphine was administered to 40 children, to 30 as a continuous infusion through a central venous line. The dose of morphine was 0.8 mg/kg/day at the start and was increased to 4.9 (range, 0.2-55) mg/kg/day. Of the 62 children who received regular pain medication, the majority (81%) had adequate analgesia. In 19%, analgesia had been suboptimal. In conclusion, the vast majority of children with cancer need regular pain medication while in terminal care. This can be administered adequately at home, even if continuous intravenous infusions are required.
1998
Sirkia K; Hovi L; Pouttu J; Saarinen-Pihkala U
Journal Of Pain And Symptom Management
1998
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Journal Article
<a href="http://doi.org/10.1016/s0885-3924(98)00366-2" target="_blank" rel="noreferrer">10.1016/s0885-3924(98)00366-2</a>
Adequacy Of Palliative Care In A Single Tertiary Neonatal Unit
End Of Life Care; Palliative Care; Death; Neonatal; Perinatal Death; Infant; Parents; End Of Life Care; Child; Palliative Care; Narcotics; Hospice Care; Pediatrics
Aim: End-of-life care remains within the scope of practice of all neonatal units. There is a paucity of literature regarding the evidence-base for palliative care interventions in the perinatal or neonatal population (Balaguer).
Little is published regarding neonatal end-of-life care in Australia (Wilkinson). This study aimed to characterise the end-of-life care provided in an Australian tertiary neonatal centre, where paediatric palliative care was accessible via a consultative service.
Methods: This retrospective cohort study examined indicators of quality palliative care provided to forty-six infants born within a thirty-month period from January 2012 to June 2014. Included infants were liveborn, admitted to the Royal Brisbane and Women's Hospital at some time in their life and died prior to one year of age. Infants were excluded if there was no opportunity for palliative care. Indicators of quality palliative care assessed included communication, resuscitation planning, preferred location of death, symptom management, symptom management plan, multi-disciplinary team approach, caring for carers, memory making, spiritual care and bereavement care. Interventions were characterised using descriptive statistics.
Results: The most common causes of death were congenital abnormality (37%) and complications of extreme prematurity (22%). Very high proportions of infants and families had family meetings (100%), social worker involvement (100%), memory making opportunities (100%) and discussion of autopsy (91%). Opiates were prescribed to 78% in the last day of life; most (89%) were administered intravenously. For those prescribed opiates, the median parenteral morphine daily equivalent was 290 mcg/kg/day (interquartile range = 317) in the last 24 hours of life. Antenatal resuscitation planning for fetuses with a prenatal diagnosis (9%), discussion of preferred location of death (9%), communication with general practitioners (7%) and access to specialised bereavement care (3%) were infrequently provided. Palliative care consultation was sought infrequently (n = 4; 8%), precluding formal statistical comparison with the usual neonatal care cohort. The relative number of instances where indicators of quality palliative care were met was generally greater when palliative care was consulted.
Conclusions: At the time of this study, the neonatal unit was not meeting all of the end-of-life care needs of infants and their families. Care was more comprehensive when the palliative care service was consulted.
Gilmour D; Davies M; Herbert A
Journal Of Paediatrics And Child Health
2016
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<a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.13245_16">10.1111/jpc.13245_16</a>
Risk Stratification For Opioid Misuse In Children, Adolescents, And Young Adults: A Quality Improvement Project
Pediatrics; Drug Use; Narcotics; Young Adult; Teenagers; Children & Youth
BACKGROUND:
The Pediatric Palliative and Comfort Care Team (PACT) at Cincinnati Children's Hospital Medical Center (CCHMC) provides opioids to a large population of patients in the ambulatory setting. Before this project, PACT had no reliable system to risk stratify patients for opioid misuse.
METHODS:
The global aim was safe opioid prescribing by the palliative care team. The specific, measurable, achievable, realistic, and timely aim was as follows: "In patients who present for follow up with PACT, we will use the "opioid bundle" to increase risk stratification for opioid misuse from 0% to 90% over 5 months." The opioid bundle includes a urine drug screen, Ohio Automated Rx Reporting System report, pill count, and screening history for drug abuse and mental health disorders. The setting was multiple CCHMC ambulatory clinics. Participants included all PACT members.
RESULTS:
Since implementing the new system, we have increased risk stratification for opioid misuse among outpatients from 0% to >90%. Results have been sustained for 12 months. Key processes have become reliable: obtaining informed consent and controlled substance agreements for all new patients and obtaining the opioid bundle to enable risk stratification in a consistent and timely fashion. A total of 34% of patients have been stratified as high risk, and an additional 27% have been stratified as moderate risk.
CONCLUSIONS:
A system to ensure safe opioid prescribing practices to all patients is critical for providers. Identifying key processes and executing them reliably has enabled the palliative care team at CCHMC to risk stratify >90% of patients receiving opioids in the ambulatory setting for opioid misuse.
Thienprayoon R; Porter K; Tate M; Ashby M; Meyer M
Pediatrics
2016
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DOI: 10.1542/peds.2016-0258