Tremors

Ok, so dumb question I think I know the answer but am looking for other options as well. ( actually not my patient but someone asked me and .........) If a patient is having tremors and is comatose ( end-of -life ) what other meds besides morphine, ativan , baclofen can be given?

Wondering what you mean by "tremors" do you mean myoclonic jerking? b/c that could be related to neurotoxicity from opioids.

If that is the case, the best course is to reduce and change opioids. Benzos (ativan) can be of some help too.

From EPERC's Fast Facts:

Everyone recognizes the common opioid side effects: constipation, nausea, pruritis, and urinary retention. Less well appreciated are the neuroexcitatory effects, commonly seen among patients on chronic opioids. Among these, myoclonus is typically the herald symptom. Myoclonus may occur in patients on chronic therapy with most opioids including morphine, hydromorphone, fentanyl, meperidine, and sufentanil. Higher doses more frequently result in myoclonus, but the dose relationship is variable. Myoclonus can occur with all routes of administration.

Myoclonus, the uncontrollable twitching and jerking of muscles or muscle groups, usually occurs in the extremities, starting with only an occasional random jerking movement; a patient's spouse may be the first to recognize this symptom. With continued administration, the jerking may increase in frequency; at the extreme, there is constant jerking of random muscle groups in all extremities. As myoclonus worsens, patients may develop other neuroexcitatory signs: hyperalgesia (increased sensitivity to noxious stimuli), delirium with hallucinations, and eventually, grand mal seizures. Well meaning clinicians may misinterpret the hyperalgesia as increasing pain, leading to a vicious cycle of increasing dose, increasing hyperalgesia, increasing dose, worsening delirium, and finally seizures. After identifying a patient with possible opioid toxicity, the clinician should complete the following assessment.

if they're drug-induced tremors, then it's up to the doc to determine which meds are causing it, and whether it necessitates a decrease or dc'ing.

if they're essential tremors, we have luck with propranolol, valium or antiseizure meds.

leslie

I actually have not seen this patient but I totally forgot about myoclonus tremors. Thanks for the reminder. I told the other nurse to call the MD. Thanks for both replies. Much appreciated.

I actually have not seen this patient but I totally forgot about myoclonus tremors. Thanks for the reminder. I told the other nurse to call the MD. Thanks for both replies. Much appreciated.

i'm very familiar w/the twitching, jerking that can accompany neurotoxicity w/opioids, but i still shudder when it is suggested.

often, pts have this reaction, but it is transient and resolves on its own.

so what i'm suggesting, is often it is not true toxicity but an adverse reaction that can abate on its own.

only if someone is getting high dosages, is when you could truly suspect toxic effects.

and more often than not, that is just not the case.

moreover, once the narcs are decreased/dc'd, pts seldom get the proper doses of the subsequent opioid, and are undermedicated.

unless the pt is truly in danger of seizing, i would be careful in dx'ing any twitching as neurotoxicity.

it's more important to weigh the benefit vs the burden.

leslie

i'm very familiar w/the twitching, jerking that can accompany neurotoxicity w/opioids, but i still shudder when it is suggested.

often, pts have this reaction, but it is transient and resolves on its own.

so what i'm suggesting, is often it is not true toxicity but an adverse reaction that can abate on its own.

only if someone is getting high dosages, is when you could truly suspect toxic effects.

and more often than not, that is just not the case.

moreover, once the narcs are decreased/dc'd, pts seldom get the proper doses of the subsequent opioid, and are undermedicated.

unless the pt is truly in danger of seizing, i would be careful in dx'ing any twitching as neurotoxicity.

it's more important to weigh the benefit vs the burden.

leslie

I understand your hesitation Leslie, but I have also seen (and participated in!) the opposite -- well meaning, but not understanding folks seeing every twitch as pain, giving more and more prn opioids and making the situation worse. Maybe it's a matter of setting, but when it has finally be recognized and med switched, the patient was so much more comfortable.

What we don't know is what other things are going on -- do we have brain mets and could it be some kinds of seizures? I don't think neurotoxicity should be the first thought, but I think it needs to be thought about, and especialy when someone is in a LTC setting, people are not likley to think of it at all.

we've had pts from ltc settings, and if anything, my experience has been that morphine is severely underutilized.

it has frustrated me to note the prevalence of ignorance and/or fear out there.

now, being inpatient hospice, we have had folks on megadoses of opioids and have indeed seen the neurotoxic effects.

just haven't seen it from any other settings.

now, we do see myoclonus r/t other etiologies, but not from opioids.

interesting we have such different experiences.:)

leslie

I spoke with the nurse for that patient but apparently the severe spasms/tremors are an expected part of the disease process ( doctors best guess ). I wish I could say the name of the disease but since this patient is unique it might be a HIPPA thing. ( i.e. this patient is only one with this in U.S. ) Doctor increased the Fentanyl to 75mcg and ordered scheduled Ativan 1 mg every 6 hours. Already had an order for ativan prn 1-2mg every 6 hours?

Doctor increased the Fentanyl to 75mcg and ordered scheduled Ativan 1 mg every 6 hours. Already had an order for ativan prn 1-2mg every 6 hours?

you're not understanding the lower, scheduled dose of ativan?

i'm sure he's thinking that 1mg q6h atc is better than the potential of 1-2mg q6h.

always start on lower side and titrate up.

leslie

you're not understanding the lower, scheduled dose of ativan?

i'm sure he's thinking that 1mg q6h atc is better than the potential of 1-2mg q6h.

always start on lower side and titrate up.

leslie

He did not d/c the order for the prn dosage. I know he added the scheduled to keep a steadier level in the pts system. I know keeping a prn dose available as well for increases in agitation/spasms. :wink2: I am questioning why he kept the prn dosage at 1-2 mg prn q6hrs. I know the max daily dose and would bear that in mind when giving prns but this patient is in a LTC facility and the day shift nurse is well ( can't think of anything nice to say ).Sorry for the vent there. Which I know is their license not mine, but then there is the patient and even though this patient is not mine I still feel for him/her. I've been collaborating on this one with another nurse so much I am going to go visit with the other nurse one of these days.

I am questioning why he kept the prn dosage at 1-2 mg prn q6hrs. I know the max daily dose and would bear that in mind when giving prns but this patient is in a LTC facility and the day shift nurse is well ( can't think of anything nice to say ).QUOTE]

sorry meli, not understanding what you're saying about the charge nurse.

and while the max amt of ativan would be 12mg/day, it is 'ok' to administer if pt needs it and is presenting alert enough...

you know, not obtunded or stuporous.

i guess i'm not understanding your exact concerns?

leslie

I know the day shift nurse from another facility. She is no longer at the other facility because of multiple med errors. I'm just concerned for the patient.

I know this is going to be a really dumb, but I thought the maximum dosage was 10mg a day. Now I looked in my pharmacology and got 10 mg as max daily dose and then googled and found 8mg on one site and 6mg to 10 mg depending on usage on another site. But I agree with what you wrote about assessing first before administering. The patient in question is comatose though. I believe the tremors/spasms are part of the neuro effects of the disease process. This patient has also been getting ativan for a awhile so may have developed a tolerance. Blood pressures when mentioned at IDT mtgs are low 70's -80's over 40's -50's. I believe weight was in the 90's. I'm still a newbie so I would definately value any wisdom shared.