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A Pilot study using a case study approach of the effectiveness and managebality of continuous subcutaneous infusion drug administration for patients with chronic malignant pain Beddard-Hyber, Elizabeth Anne
Abstract
The prevalence and complexity of unrelieved pain remains high among cancer patients, posing a challenge for health care providers to provide effective pain management. This becomes particularly challenging when the patient can no longer tolerate oral medications. Although continuous subcutaneous infusion (CSCI) via a low-technology syringe driver is commonly used as an alternative modality to oral administration in other countries, it has not been used much in Canada. The aim of this pilot study was to assess the feasibility of using a case study approach to gain insight into the decision to initiate CSCI via syringe driver and to test the effectiveness of CSCI related to pain and pain-related symptoms, and its comfort and manageability for use by patients who cannot tolerate oral medications and are experiencing severe or unstable pain. Both quantitative and qualitative approaches were used to gather information from the patient, family/caregiver, physician and community health care nurse. Data pertaining to levels of pain and pain-related symptoms were collected daily for two weeks and at a follow up point two weeks later using the Brief Pain Inventory and the Edmonton Symptom Assessment Scale plus questions related to frequency of breakthrough doses given and medication dosage. Questions were also asked about comfort and manageability in using CSCI via syringe driver. Although the plan was to include four case studies, only one case was included because of difficulty with recruitment of people who met the study criteria. In the case examined, CSCI via syringe driver was initiated after other modalities (transdermal fentanyl patch and intermittent subcutaneous injections) were found to be ineffective or labour intensive. Syringe drivers were accessible in the community where the study was conducted and health care providers were competent in their use. The patient's wife was willing and able to manage the modality and to assess her husband's pain accurately, provide bolus doses appropriately and report difficulties in administration of CSCI or in management of her husband's pain. In terms of effectiveness in managing pain, the administration of continuous and bolus doses of hydromorphone in increasing amounts was able to maintain the patient's average daily pain levels between 1 and 3.5 (on a numeric scale of 0-10). When pain levels reached a 4, the patient's wife administered a bolus dose. Least pain levels ranged from 0 and 0.5 daily, during the first two weeks. Two weeks following the main study period, the pain had increased considerably with average daily pain rated as 4 and worst pain rated as 9. Total hydromorphone administered increased from 114 mg to 204 mg during the first two weeks to a total of 378 mg per day (180 mg as continuous dose plus 11 breakthrough doses each of 18 mg) in the follow-up period. At that point, although better pain control would likely have been achieved by switching to methadone, switching would require patient hospitalization for medication adjustment. Neither the patient nor family wanted the patient to be hospitalized so the patient continued on CSCI at home until his death shortly after. In terms of pain-related symptoms, the main symptoms experienced related to elevated anxiety and tiredness. In terms of manageability, the patient's wife managed CSCI via syringe driver and the administration of bolus doses with relative ease and reported changes in her husband's condition when necessary. Although limitations pertain to the small sample and the use of proxy pain assessments by the wife, the findings suggest that CSCI via syringe driver is generally effective in administering an opioid that could be quickly titrated to meet the individual needs of the patient and easily managed in the home. A case study approach is appropriate and feasible. Implications for theory, practice, education and research are suggested.
Item Metadata
Title |
A Pilot study using a case study approach of the effectiveness and managebality of continuous subcutaneous infusion drug administration for patients with chronic malignant pain
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Creator | |
Publisher |
University of British Columbia
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Date Issued |
2004
|
Description |
The prevalence and complexity of unrelieved pain remains high among cancer
patients, posing a challenge for health care providers to provide effective pain management.
This becomes particularly challenging when the patient can no longer tolerate oral
medications. Although continuous subcutaneous infusion (CSCI) via a low-technology
syringe driver is commonly used as an alternative modality to oral administration in other
countries, it has not been used much in Canada. The aim of this pilot study was to assess the
feasibility of using a case study approach to gain insight into the decision to initiate CSCI via
syringe driver and to test the effectiveness of CSCI related to pain and pain-related
symptoms, and its comfort and manageability for use by patients who cannot tolerate oral
medications and are experiencing severe or unstable pain. Both quantitative and qualitative
approaches were used to gather information from the patient, family/caregiver, physician and
community health care nurse. Data pertaining to levels of pain and pain-related symptoms
were collected daily for two weeks and at a follow up point two weeks later using the Brief
Pain Inventory and the Edmonton Symptom Assessment Scale plus questions related to
frequency of breakthrough doses given and medication dosage. Questions were also asked
about comfort and manageability in using CSCI via syringe driver.
Although the plan was to include four case studies, only one case was included
because of difficulty with recruitment of people who met the study criteria. In the case
examined, CSCI via syringe driver was initiated after other modalities (transdermal fentanyl
patch and intermittent subcutaneous injections) were found to be ineffective or labour
intensive. Syringe drivers were accessible in the community where the study was conducted
and health care providers were competent in their use. The patient's wife was willing and able to manage the modality and to assess her husband's pain accurately, provide bolus doses
appropriately and report difficulties in administration of CSCI or in management of her
husband's pain. In terms of effectiveness in managing pain, the administration of continuous
and bolus doses of hydromorphone in increasing amounts was able to maintain the patient's
average daily pain levels between 1 and 3.5 (on a numeric scale of 0-10). When pain levels
reached a 4, the patient's wife administered a bolus dose. Least pain levels ranged from 0 and
0.5 daily, during the first two weeks. Two weeks following the main study period, the pain
had increased considerably with average daily pain rated as 4 and worst pain rated as 9. Total
hydromorphone administered increased from 114 mg to 204 mg during the first two weeks to
a total of 378 mg per day (180 mg as continuous dose plus 11 breakthrough doses each of 18
mg) in the follow-up period. At that point, although better pain control would likely have
been achieved by switching to methadone, switching would require patient hospitalization for
medication adjustment. Neither the patient nor family wanted the patient to be hospitalized so
the patient continued on CSCI at home until his death shortly after. In terms of pain-related
symptoms, the main symptoms experienced related to elevated anxiety and tiredness. In
terms of manageability, the patient's wife managed CSCI via syringe driver and the
administration of bolus doses with relative ease and reported changes in her husband's
condition when necessary.
Although limitations pertain to the small sample and the use of proxy pain
assessments by the wife, the findings suggest that CSCI via syringe driver is generally
effective in administering an opioid that could be quickly titrated to meet the individual
needs of the patient and easily managed in the home. A case study approach is appropriate
and feasible. Implications for theory, practice, education and research are suggested.
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Extent |
7365835 bytes
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Genre | |
Type | |
File Format |
application/pdf
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Language |
eng
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Date Available |
2009-11-24
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Provider |
Vancouver : University of British Columbia Library
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Rights |
For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use.
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DOI |
10.14288/1.0091492
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URI | |
Degree | |
Program | |
Affiliation | |
Degree Grantor |
University of British Columbia
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Graduation Date |
2004-11
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Campus | |
Scholarly Level |
Graduate
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Aggregated Source Repository |
DSpace
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Item Media
Item Citations and Data
Rights
For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use.