*** Needs pain management specialist or physician who is experienced

*** SUBCUTANEOUS INFUSION: • Change needle site weekly • use: Intractable pain, Nausea, Bowel obstruction, coma, debility, poor compliance *Rx: ** Fluids 500-1500 ml / 24hrs ** Morphine ** Antiemetics ** Haldol ** Reglan ** Dilaudid • contraindication: severe Thrombocytopenia

*** Eternal tube feeding: Patient, family & team preference, not helpful in last few days

*** TPN (Total parenteral nutrition): does not improve nutritional status, may be inappropriate in hospice

*** TRIGGER POINT: *Rx: ** Local injection of Bupivacaine & Methylprednisolone ** Ethyl chloride spray ** Lidoderm patches 12 hrs on 12 off
*** EPIDURAL OPIOID THERAPY: • Analgesia • less sedation • less side effects • Titratable

*** NERVE BLOCKS: Blocking the nerve • Marcaine + Depomedrol

*** SYMPATHETIC BLOCKS: •+ Local anesthetics + 50% alcohol or phenol 5-10% in water

*** CELIAC PLEXIS BLOCK: • Pancreatic ca • upper abdominal cancers

*** STELLATE GANGLION BLOCK: • For pain in the head, neck and arm, Complications: Pneumothorax, infection, Horner’s syndrome, laryngeal nerve, phrenic nerve & brachial plexis injury

*** NEUROABLATION: • Cordotomy, for severe pain below that level • Partial posterior rhizotomy

*** RADIATION: • Shortest treatment • Bone Pain • Spinal cord compression • Fungating ulcer Control of hemorrhage • Obstruction (SVC, airway, esophagus) • Brain metastases • Reduce tumor bulk • SE: Nausea and vomiting; • skin reactions: starts in 21 days; lasts 1 or 2 weeks after the last *Rx