Pain management in a patient with renal and hepatic dysfunction

The assessment and management of pain in cirrhosis

Purpose of review

The treatment of pain in patients with cirrhosis is complicated by unpredictable hepatic drug metabolism and a higher risk of adverse drug reactions. We aimed to conduct a scoping review regarding pain management in cirrhosis.

Recent findings

Despite the high prevalence of pain in patients with cirrhosis, there is little literature to guide the management of pain in this population. Complex pain syndromes and disease-specific pain etiologies exist are common in patients with cirrhosis. There are numerous contraindications and limitations when considering pharmacotherapy for analgesia in cirrhosis, specifically with non-steroidal anti-inflammatory drugs (NSAIDS) and opioid medications. Non-pharmacologic therapies for pain have not been specifically assessed in this population.

Summary

As with other populations, a multi-dimensional treatment approach to pain with a focus on physical, behavioral, procedural and pharmacologic treatment is recommended when caring for patients with cirrhosis and pain. However, more research is needed to evaluate opioid-sparing and non-pharmacologic analgesia in this population.

Clinical Excellence in Palliative Care: Examples From the Published Literature

Background:

With the expansion of palliative care, the concept of clinical excellence is worthy of study and has not been described well in the literature.

Objective:

To apply the domains of clinical excellence, as proposed and published by the Miller Coulson Academy of Clinical Excellence, to the field of palliative care.

Design:

Review of the literature to identify episodes of superb palliative care delivered by individuals and teams.

Measurement and Main Results:

In reviewing 821 publications, we found multiple palliative care case reports to serve as exemplars for each of the distinct domains of clinical excellence.

Conclusions:

The domains of excellence are relevant and applicable to the field of palliative care. This article aims to inspire clinicians—and advance the field—by promoting thoughtful reflection on what clinical excellence in palliative care entails.