171■ Were appropriate analgesics given according to the World Health Organization (WHO) cancer pain ladder for adults? These include appropriate use of oral opioid and nonsteroidal anti-inflammatory drugs (NSAIDs), and use of adjuvant drugs as appropriate such as an anticonvulsant for neuropathic pain (WHO, 2016). The pain ladder could be applied to noncancer pain as well. ■ Was the pattern of taking pain medicines appropriate (e.g., around the clock)? ■ Were other noninvasive routes evaluated (e.g., transdermal)? ■ Was there an adequate trial of each intervention? ■ Were nonpharmacologic interventions included in the pain management plan? ■ Does the patient have: persistent gastrointestinal side effects (e.g., nausea and vomiting) associated with high doses of oral opioids; inability to take oral medications (e.g., dysphagia and obstruction); need for rapid titration of analgesics? Pain management, and infusion pain management in particular, is complex requiring significant knowledge on the part of the home care nurse. This chapter provides an overview of key issues. After reading this chapter, the reader will be able to: ■ 172Summarize patient selection criteria ■ Describe key aspects of analgesic administration ■ Summarize components of comprehensive care, assessment, and monitoring ■ Prepare a plan for patient education UNDERSTANDING PAIN MANAGEMENT: INFUSION ROUTE OPTIONS SC Route The SC route represents the standard of care for managing moderate to severe pain when the oral and rectal routes are not available or appropriate (Weissman, 2015a). Drugs that may be administered SC include morphine, hydromorphone, fentanyl, and sufentanil as either bolus doses or continuous SC infusion. Although clinicians believe that cachectic, febrile, or hypotensive patients will have difficulty with SC absorption, there are no data to support this (Weissman, 2015a). Infusion rates of 3 to 5 mL per hour are usually considered acceptable (Gorski et al., 2016). Some patients may tolerate higher infusion rates. Patient-controlled analgesia (PCA) can be used in conjunction with a basal rate. Information specific to SC infusion is included in Chapter 6. Advantages include: ■ Readily available; as vascular access is not required ■ Less costly and less complicated than IV route ■ Easy to initiate in the home setting ■ Patient/family can learn to rotate sites 173Limitations: ■ More difficult to titrate ■ Must use concentrated drug to keep infusion rates low IV Route IV infusions may be continuous, intermittent bolus, and/or PCA. Information specific to vascular access devices (VADs), care and maintenance, and potential complications are included in Chapters 4 and 5. The IV route allows for rapid titration of dose to achieve pain control. Intraspinal Route The intraspinal route allows for delivery of analgesic and adjuvant medications (e.g., anesthetics) via the epidural or intrathecal route. Intraspinal infusions may be used in carefully evaluated patients who have not achieved pain relief despite escalating analgesic doses or who have experienced excessive systemic side effects. There is less central nervous system (CNS) depression associated with intraspinal administration. Continuous infusions are most common in home care patients. PCA may be used with epidural catheters (Gordon & Schroeder, 2015). With epidural administration, the drug must pass through the dura mater to gain access to the cerebrospinal fluid (CSF; see Chapter 6). With intrathecal administration, the drug is administered directly into the CSF where it is immediately able to bind to opiate receptor sites in the dorsal horn, located all along the spinal cord. Pain impulses are intercepted before they are transmitted to the brain. Intrathecal drug doses are approximately 1/10th the dosage of an epidural infusion. Once the drug passes into the CSF, drug flows in two directions: primarily to the brain (rostral flow) and passively toward the base of the spine (minimal). Drug absorption is affected by: ■ Lipid solubility—lipid-soluble drugs (e.g., fentanyl) penetrate dura rapidly, have a more rapid onset of action, a shorter duration, have limited spread therefore effect is mainly in the area of catheter tip placement; water-soluble drugs (morphine) take longer to diffuse, have a longer duration, are more slowly cleared, and have a broader spread of analgesic effect ■ Molecular weight and volume—higher volume may have a wider effect ■ Specific receptor affinities (Sterns & Brant, 2015) 174Advantages to intraspinal pain management include less systemic effects, less drug requirement, and improved pain control/quality of life in patients unable to achieve pain control via less invasive methods. Limitations include higher cost, a more complex therapy requiring patient willingness, ability to manage, and, because of potential neurotoxicity, drugs must be preservative free. Information specific to epidural and intrathecal catheter placement, care and maintenance, and potential complications are addressed in Chapter 6. Refer to Table 12.1 for a list of analgesic medications used for infusion pain management. Pediatrics and Infusion Pain Management Home-administered opioid infusions can be administered in pediatric patients. Although there is limited research, a recent study documented the need for PCA opioid infusions for children during end-of-life and in advanced disease (Mherekumombe & Collins, 2015). This study from Australia identified 33 pediatric patients with diagnoses including metastatic bone disease, severe abdominal pain, and severe headaches. The most common infusion drugs administered were hydromorphone (more than 50%), fentanyl, morphine, and methadone with side effects that included itching, sedation, nausea, and urinary retention. The most common infusion route was via a central VAD (CVAD) and four patients received SC infusions. For 97% of the patients, the opioid infusions were continued at home until death. PATIENT SELECTION CONSIDERATIONS ■ The patient and family are motivated, willing, and capable of participating in self-infusion management. ■ There is a responsible family member or caregiver available and willing to participate in patient care and monitoring. ■ The patient is clinically stable on the intended analgesic infusion prior to hospital discharge and subsequent home care admission. 175Table 12.1 Analgesic Medications Used in Infusion Pain Management 176 Fast Facts in a Nutshell The Palliative Care Network of Wisconsin is the home of “Fast Facts for Palliative Care.” There are hundreds of concise, referenced, and easy-to-read guidelines including many related to pain management. Opioid conversion guides are available. An app is available for smart phones. The website is www.mypcnow.org/fast-facts. ■ For IV infusions, an appropriate infusion device is in place to administer infusion therapy. ■ The home environment is safe, clean, with adequate refrigeration space, and the patient has ready access to a telephone. ■ Reimbursement is verified. 178COMPREHENSIVE CARE, ASSESSMENT, AND MONITORING
Infusion analgesics are a continuous infusion administered using an infusion pump. This requires at least some level of patient or caregiver participation in infusion administration and monitoring.
The caregiver is available to troubleshoot problems in the event of adverse drug reactions, infusion pump problems, or deterioration in condition.
Patients taking oral or transdermal opioid drugs may be converted to a SC or IV analgesic infusion in the home setting; however, this requires a knowledgeable and committed patient and family. Oral or transdermal doses are converted to an equianalgesic infusion dose.
177Frequent assessment and ongoing monitoring of pain control and side effects by the nurse, and by the patient/family, are required when IV/SC analgesics are initiated in the home.
A short peripheral IV catheter is not indicated for chronic infusion pain management due to ongoing risk of dislodgement and interruptions in pain control.
A midline peripheral might be selected for infusion pain management when the duration of expected need is about 1 month or less.
For long-term needs, a CVAD such as a peripherally inserted central catheter (PICC), subcutaneously tunneled CVAD, or implanted port is appropriate.
Consider the possibility of SC analgesic infusion as preferred over IV as discussed previously.
Analgesic drugs and related supplies are generally delivered to the patient home on a weekly basis. Some drugs may require storage in the refrigerator.
Private third-party payers vary in coverage.
Continuous infusion of SC, IV, and epidural opioids may be covered under the durable medical equipment benefit for external infusion pumps under Part B of the Medicare program.
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