Nurse-based monitoring and management of breakthrough pain in an acute pain relief and palliative care unit.

OBJECTIVES: To assess the nurses' performance in assessing, treating, and documenting breakthrough pain (BTP) in a palliative care unit where traditionally there is continuous training. METHODS: The study was performed in an acute palliative care unit. Once a week, a research nurse examined the documentation regarding all the episodes of BTP registered in a specific pain chart, designed by the institutional nurse board, as part of the routine nurse activity. RESULTS: The charts of 50 consecutive eligible patients (32 M/18 F), were analysed. The mean number of episodes/patient was 3.3 (SD 1.61; range 1-7). 166 episodes occurred. The main BTP pain intensity was 7.06 (SD 0.82). In 7 episodes, pain intensity was not evaluated at T0. The pain intensity after 15 minutes after BTP medication was 3.01 (SD1.19). In 28 episodes, pain intensity was not evaluated at T15. The change in pain intensity was highly significant (P < 0.0005). BTP episodes were distributed normally through different day intervals. No relevant adverse event attributable to BTP medication was reported in the nurse diary. CONCLUSION: Training in a research environment allows a good nurse capability in evaluating and treating BTP, and above all, providing documentation for each BTP episode. The theoretical work and recommendations around BTP need to be translated into day-to-day clinical practice.

Frequency and Indications of Parenteral Nutrition in an Acute Palliative Care Unit.

The aim of this study was to estimate the use of parenteral nutrition (PN) in advanced cancer patients enrolled in an acute pain relief and palliative care unit of a comprehensive cancer center and the appropriateness of the criteria to select patients for PN. Fourteen out of 750 patients (1.8%) admitted to an acute palliative care unit were administered PN. Patients were referred from various settings. The mean age was 58 yr (range 37-79), and 9 were males. The mean hospital stay was 7.7 days (range 3-14), and the mean Karnofsky level was 35 (range 10-50). The principal indication was bowel obstruction. Ten patients (71%) were already receiving PN before admission, and 2 of them discontinued the treatment during admission. Four patients (29%) started PN during hospital admission as decided by the staff. Twelve patients (85%) were discharged on PN. One week after hospital discharge, 9 patients were still receiving PN, 4 patients died, and no data were available for 1 patient. One month after hospital discharge only 2 patients of these were still on PN, 2 patients discontinued PN, and 5 patients died. This study shows that decisions to start or to stop PN were individually based on multiple considerations, not only clinical. Goals may vary from expected clinical benefits to compassionate use. The administration of PN should be assessed carefully and individually approached.

Intranasal fentanyl versus fentanyl pectin nasal spray for the management of breakthrough cancer pain in doses proportional to basal opioid regimen.

UNLABELLED: The aim of this randomized, crossover, comparison study was to assess the analgesic and adverse effects of 2 nasal preparations, intranasal fentanyl (INFS) and fentanyl pectin nasal spray (FPNS), for breakthrough pain, given in doses proportional to opioid basal regimen. Each patient randomly received INFS or FPNS in doses proportional to opioid dosages used for background analgesia for 2 pairs of episodes. For each episode of breakthrough pain, pain intensity and adverse effects intensity were recorded just before starting the INFS or FPNS (T0) and 5 minutes (T5), 10 minutes (T10), and 20 minutes (T20) after the administration of the nasal drugs. Sixty-nine patients were studied. The mean age was 63.4 years, and 37 patients were males. For the present analysis, 188 episodes were considered. A statistical decrease in pain intensity was observed with both nasal drugs after 5, 10, and 20 minutes. A decrease in pain intensity of >33% was observed in 16, 102, and 159 treated episodes at T5, T10, and T20, respectively. Adverse effects were of mild nature in most cases or were preexistent because of basal opioid therapy. No differences were found in summed pain intensity difference 20 minutes after dosing. Most of patients did not find substantial preferences. INFS and FPNS were effective and well-tolerated treatments for breakthrough pain management. Both delivery systems, in doses proportional to the basal opioid regimen, provided significant analgesia within 10 minutes, without producing relevant adverse effects. PERSPECTIVE: This article showed that INFS and FPNS in doses proportional to basal opioid regimen are equally safe and effective for the management of breakthrough pain in cancer patients. These data provide new insights on the use of nasal preparations of fentanyl.

Changes of QTc interval after opioid switching to oral methadone.

A consecutive sample of patients who were switched from strong opioids to methadone in a period of 1 year was surveyed. QTc was assessed before switching (T0) and after achieving adequate analgesia and an acceptable level of adverse effects (Ts). Twenty-eight of 33 patients were switched to methadone successfully. The mean initial methadone doses at T0 were 67.1 mg/day (SD ±80.2, range 12-390). The mean QTc interval at T0 was 400 ms (SD ±30, range 330-450). The mean QTc interval at Ts (median 5 days) was 430 ms (SD ±26, range 390-500). The difference (7.7 %) was significant (p < 0.0005). Only two patients had a QTc of 500 ms. No serious arrhythmia was observed. At the linear regression analysis, there was no significant association between mean opioid doses expressed as oral morphine equivalents and QTc at T0 (p = 0.428), nor between mean methadone doses and QTc at Ts (p = 0.315). No age differences were found with previous opioid doses (p = 0.917), methadone doses (p = 0.613), QTc at T0 (p = 0.173), QTc at Ts (p = 0.297), and final opioid-methadone conversion ratio (p = 0.064). While methadone used for opioids switching seems to be an optimal choice to improve the opioid response in patients poorly responsive to the previous opioid, the possible QTc prolongation should be of concern despite not producing clinical consequences in this group of patients. A larger number of patients should be assessed to quantify the risk of serious arrhythmia.

Cancer pain management in an oncological ward in a comprehensive cancer center with an established palliative care unit.

BACKGROUND: This survey was performed to draw information on pain prevalence, intensity, and management from a sample of patients who were admitted to an oncologic center where a palliative care unit (PCU) has been established for 13 years. METHODS: Cross-sectional survey in an oncological department performed 1 day per month for six consecutive months. RESULTS: Of the 385 patients, 69.1, 19.2, 8.6, and 3.1 % had no pain, mild, moderate, and severe pain, respectively. Inpatients and patients with a low Karnofsky score showed higher levels of pain intensity (p < 0.0005). One hundred twenty-eight patients with pain or receiving analgesics were analyzed for pain management index (PMI). Only a minority of patients had negative PMI score, which was statistically associated with inpatient admission (p = 0.011). Fifty of these 128 patients had breakthrough pain (BTP), and all of them were receiving some medication for BTP. CONCLUSION: It is likely that the presence of PCU team providing consultation, advices, and cultural pressure, other than offering admissions for difficult cases had a positive impact on the use of analgesics, as compared with previous similar surveys performed in oncological setting, where a PCU was unavailable. This information confirms the need of the presence of a PCU in a high volume oncological department.

The use of sublingual fentanyl for breakthrough pain by using doses proportional to opioid basal regimen.

OBJECTIVE: The aim of this study was to prospectively assess the efficacy and safety of sublingual fentanyl (SLF) in doses proportional to opioid doses used for background analgesia for the treatment of BTP of cancer patients. METHODS: A sample of patients admitted to an acute palliative care unit, presenting breakthrough pain (BTP) episodes and receiving stable doses of opioids for background pain was selected to assess the efficacy and safety of SLF used in doses proportional to the basal opioid regimen used for the management of BTP. For each patient, data from four consecutive episodes were collected. For each episode, nurses collected changes in pain intensity and adverse effects when pain got severe (T0), and 5, 10, and 15 minutes after SLF was given (T15). RESULTS: Seventy patients were recruited for the study. The mean age was 61.7 (±11.5). Forty-one patients were males. A total of 173 episodes of BTP were recorded (mean 2.5 episodes/patient). In 19 events, documentation regarding changes in pain intensity was incomplete. Of the 154 evaluable episodes, 143 were successfully treated (92%). Mean doses of SLF were 637 µg (SD 786), and 51 patients (72.8%) received SLF doses ≥800 µg. When compared to younger adult patients, older patients received significantly lower doses of SLF (p < 0.0005) [DOSAGE ERROR CORRECTED], similarly to their lower basal opioid regimen. Pain intensity significantly decreased at T5, 10 and T15 (p < 0.0005). The number of patients with a pain reduction of more than 33% at T5, T10, and T15 were 11, 79, and 137, respectively, and the number of patients with a reduction in pain intensity of more than 50% were 1, 21, 114 at the same intervals, respectively. No differences in changes in pain intensity for gender (p < 0.9) or age (p < 0.85) were observed. No significant changes in the number of patients reporting adverse effects of mild-moderate intensity were reported after SLF administration in comparison with baseline, and no adverse effects severe enough in intensity to require medical intervention were observed. Limitations of this study are represented by the uncontrolled design. CONCLUSION: This study suggests that SLF given in doses proportional to the basal opioid regimen for the management of BTP is safe and effective in clinical practice.

Opioid use and effectiveness of its prescription at discharge in an acute pain relief and palliative care unit.

The aim of this study was to present how opioids are used in an acute pain relief and palliative care unit (APRPCU), where many patients with difficult pain conditions are admitted from GPs, home palliative care programs, oncology departments, other hospitals or emergency units, and other regional places. From a consecutive sample of cancer patients admitted to an APRPCU for a period of 6 months, patients who had been administered opioids were included in this survey. Basic information was collected as well as opioid therapy prescribed at admission and, subsequently, during admission and at time of discharge. Patients were discharged once stabilization of pain and symptoms were obtained and the treatment was considered to be optimized. One week after being discharged, patients or relatives were contacted by phone to gather information about the availability of opioids at dosages prescribed at time of discharge. One hundred eighty six of 231 patients were specifically admitted for uncontrolled pain, with a mean pain intensity of 6.8 (SD 2.5). The mean dose of oral morphine equivalents in patients receiving opioids before admission was 45 mg/day (range 10-500 mg). One hundred seventy five patients (75.7 %) were prescribed around the clock opioids at admission. About one third of patients changed treatment (opioid or route). Forty two of 175 (24 %), 27/58 (46.5 %), 10/22 (45.4 %), and 2/4 (50 %) patients were receiving more than 200 mg of oral morphine equivalents, as maximum dose of the first, second, third, and fourth opioid prescriptions, respectively. The pattern of opioids changed, with the highest doses administered with subsequent line options. The mean final dose of opioids, expressed as oral morphine equivalents, for all patients was 318 mg/day (SD 798), that is more than six times the doses of pre-admission opioid doses. One hundred eighty six patients (80.5 %) were prescribed a breakthrough cancer pain (BTcP) medication at admission. Sixty five patients changed their BTcP prescription, and further 27 patients changed again. Finally, eight patients were prescribed a fourth BTcP medication. Of 46 patients available for interview, the majority of them (n = 39, 84 %) did not have problems with their GPs, who facilitated prescription and availability of opioids at the dosages prescribed at discharge. For patients with severe distress, APRPCUs may guarantee a high-level support to optimize pain and symptom intensities providing intensive approach and resolving highly distressing situations in a short time by optimizing the use of opioids.