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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Part III: Corticosteroids in Pain Management

    Corticosteroids in Pain Management Topical Analgesia in Pain Management
    Anesthesia, Neurosurgery in Pain Management
    Opioid Adverse Effects

    Corticosteroids in Pain Management

    Uses of Corticosteroids

    • Corticosteroids are frequently helpful and commonly used in advanced illness
    • They may be useful for a variety of symptoms, including:
      • Acute nerve compression
      • Increased intracranial pressure
      • Bone pain
      • Visceral pain (obstruction of a viscous and/or capsular distention)
      • Anorexia
      • Nausea
      • Depressed mood


    Drug and Dosage Recommendations

    • Dexamethasone is the drug of choice due to its:
      • Long half-life (>36 hours)
      • Minimal mineralocorticoid effect
    • It can be administered once a day in doses of 2 to 20 mg or more


    Adverse Effects

    • Steroid psychosis should be considered if an agitated delirium ensues
    • Other toxicities that are possible with long-term use but are seldom a problem in the setting of advanced disease include:
      • Proximal myopathy
      • Oral candidiasis
      • Bone loss


    Problem Solving: Case Example Involving Corticosteroids (Case 9)

    David is a 67-year-old farmer with colon cancer metastatic to liver. He has complained of increasing right upper quadrant pain. Examination reveals a tender liver, but no shifting dullness to percussion of his abdomen. How would you manage David’s pain?

    Click here for the Answer


    Topical Analgesia in Pain Management

    • Even simple procedures such as venipuncture may be painful
      • Topical anesthetic creams should always be considered

      • If trained, patients can always apply these analgesics in advance of office visits
    • Open wounds may also be a source of considerable pain, particularly during dressing changes or debridement
      • If incident pain is significant, consider topical analgesics such as 10% lidocaine endotracheal spray or nitrous oxide puffers


    Anesthesia, Neurosurgery in Pain Management

    • For difficult to manage, persistent pain, anesthesia or neurosurgical colleagues may be able to provide considerable pain relief through:
      • Nerve blocks
      • Unilateral cordotomies
      • Other selective procedures
    • Consider referring patients with:
      • Upper abdominal pain due to pancreatic disease
      • Lower body pain
      • Pain localized to 1 limb
      • Unilateral pain
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