Continuous subcutaneous infusion for pain control in dying patients: experiences from a tertiary palliative care center

Continuous Ambulatory Delivery Device Use for Patients Managed by an Inpatient Palliative Care Team

BACKGROUND

The use of Patient Controlled Analgesia (PCA) via a Continuous Ambulatory Delivery Device (CADD) is a common and effective means of pain and symptom management for hospitalized patients with a malignancy. Studies exploring the indications for starting such a device for hospitalized inpatients referred to inpatient palliative care teams are limited.

AIM

This retrospective chart review aims to explore indications, timing of initiation, and barriers to the use of a CADD.

METHODS

Over a six month period, during daily inpatient palliative care consult team rounds, patients who required a CADD were enrolled in this study. Sixty-one adult patients were identified who required a pump for symptom control. The team's database sheets were used to capture patient demographics.

RESULTS

The main reasons for initiating a Continuous Ambulatory Delivery Device in the above setting included: lack of efficacy of oral opioids and to increase patient autonomy of their pain management. Approximately 20% of patients required transfer to another unit that could accommodate the CADD. The median length of stay for these patients was 13 days, with a median length of half a day for a pump to be started.

CONCLUSIONS

This initial study provides the Palliative Care Consult Team with information on the indications for the use of a CADD. The lack of universal access to a CADD in various areas of our hospital due to differences in departmental protocols may compromise good symptom management and patient safety. These results strengthen the argument that the existing hospital policy requires revamping to improve CADD access. A CADD has been shown to provide hospitalized patients, with a malignancy, with timely access to effective symptom management, and in turn, reducing their length of stay in hospital. These findings will help inform this organization's CADD policy and support the need to broaden access to this device.

Fentanyl titration for cancer pain: continuous subcutaneous injection and a once-daily transdermal patch - case series

OBJECTIVES

Continuous subcutaneous injection (CSCI) followed by a once-daily transdermal patch is a reasonable strategy for rapid titration of fentanyl in patients with cancer pain who are unable to take oral medication or have renal impairment, but the effectiveness and safety have not been demonstrated.

METHODS

Medical records of patients with moderate to severe cancer pain who underwent titration of fentanyl by CSCI between October 2019 and October 2021 at Kitano Hospital, Osaka, Japan, were retrospectively reviewed. The dose of fentanyl was increased to a maximum of 0.05 mg/hour. If the dose was inadequate, the fentanyl patch was added on CSCI. When pain relief was adequate, CSCI was completely converted to the patch.

RESULTS

Thirty-three patients were enrolled. Titration was completed successfully in 28 patients (85%) over a median of 2 days. The average Numeric Rating Scale for pain decreased by at least 66% in 22 patients (67%) and by at least 33% in 7 (21%). After conversion to the patch, two patients (6.1%) required to increase the dose of fentanyl within a week. Two patients (6.1%) experienced moderate drowsiness during titration.

CONCLUSIONS

Fentanyl titration by CSCI is an effective and safe method for achieving rapid pain control.

Improvement in Nurses' Knowledge of Subcutaneous Catheter Use for Pain Management

BACKGROUND

Nurses often have insufficient knowledge of subcutaneous catheter use for pain management. This quality improvement project evaluated implementation of an evidence-based subcutaneous catheter nursing policy with education to improve pain management for hospitalized patients.

METHOD

A convenience sample of nurses (N = 515) completed a posttest after online training on effective subcutaneous pain management. Patient pain ratings were assessed to evaluate whether they changed after nurses' training.

RESULTS

Posttest scores showed the online learning module effectively contributed to nurses' knowledge of subcutaneous catheter pain management. A statistically significant reduction occurred in patient pain ratings (p < .001) postintervention. The number of patients experiencing moderate or severe pain decreased by 58%, for a significant reduction in pain.

CONCLUSION

An online learning module was successful in educating nurses on pain medication administration through an indwelling subcutaneous catheter. [J Contin Educ Nurs. 2024;55(1):13-20.].

Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain

PURPOSE OF REVIEW

Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies.

RECENT FINDINGS

In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.

Providing End-of-Life Care in the Community: What Are the Challenges in Malaysia?

A 72-year-old woman with metastatic lung cancer to bone and brain and with left external iliac vein thrombosis was under the care of a community palliative care provider. She experienced an acute pain crisis due to acute limb ischemia of the left lower limb. Goals-of-care discussions were held with the patient and her family; she prioritized symptom control and end-of-life care at home. The family and patient were aware of her short prognosis. Her complex pain was managed by the community palliative team, and her family was empowered to give subcutaneous injections. We illustrate a case showing the importance of community health services with palliative care support in providing symptom management and support to patient and family caregivers throughout the course of a life-limiting illness. It also highlights family caregivers' potential psychological distress in delivering subcutaneous injections in terminal care for a patient at home.

The Use of Low-Dose Methadone as Add-On to Ongoing Opioid Treatment in Palliative Cancer Care—An Underrated Treatment?

The aim of this review is to summarize the current knowledge of low-dose methadone treatment in palliative cancer care. In Sweden, methadone is quite common in specialized palliative care, where almost a tenth of patients are prescribed this drug. Negative attitudes towards methadone do not seem to prevent it from being used for pain management, and by starting with low doses and then increasing slowly and gradually, methadone can apparently be introduced safely. It is still uncertain whether methadone has a better analgesic effect than other opioids. However, for pain relief in cancer patients with severe and complex cancer-related pain, NMDA receptor inhibition with methadone may, in selected cases, be an attractive alternative, especially in the form of low-dose supplements to other ongoing opioids. Due to long half-life and complex metabolism, the use of methadone requires an experienced physician and solid follow-up. Continuous administration of opioids, including low-dose methadone, has been proven effective and safe in reducing pain in dying patients without increasing the risk of confusion, regardless of age.