1: Symptom Control Flashcards
1
Q
What is anticipatory prescribing
A
Prescribing based on symptoms you would expect individual to experience in last 12-months of life
2
Q
What is given for pain in palliative care
A
Opioids
3
Q
What opioids are given if someone has impaired renal function
A
Fentanyl
Alfentanyl
4
Q
If someone is palliative what do NICE recommended is offered in terms of opioids
A
- Modified release opioids
- Immediate release opioids (IR) with breakthrough
5
Q
What is preferred method of giving opioids
A
Oral
6
Q
What should be given with opioids in all patients
A
Laxatives. May need anti-emetics if nauseous
7
Q
If needing to increase dose of opioids, what should it be increased by
A
30-50%
8
Q
What do SIGN recommend is given for pain due to metastses
A
Bisphosphonates
Radiotherapy
Opioids
9
Q
If someone has colicky abdominal pain, what is given
A
Hyoscine butylbromide
10
Q
What is hyoscine butyl bromide also known as
A
Buscopan
11
Q
How are hiccups in palliative care managed
A
Chlorpromazine
12
Q
What is an alternative to chlorpromazine for hiccups
A
Haloperidol
Gabapentin
13
Q
If someone has hepatic lesions and hiccups what is used as an alternative
A
Dexamethasone
14
Q
If someone is agitated what is first-line
A
Find cause of agitation
15
Q
What can be given if someone is agitated acutely
A
Haloperidol
16
Q
In terminal phases, what is given for agitation
A
Midazolam
17
Q
What are conservative methods to stop fluid overload
A
Stop IV Fluids and SC injection
18
Q
What medications are indicated for fluid-overload in palliation
A
Hyoscience butyl bromide
Glycopyrronium bromide
19
Q
What often happens in last few days of life
A
Individuals may experience a death rattle. More troubling for patients, opposed to relatives
20
Q
What is first-line for nausea and vomiting in palliative care
A
- Haloperidol
- Cyclizine
- Metclopramide
21
Q
If nausea and vomiting is due to bowel obstruction in palliative care, what is first-line
A
Metclopramide
22
Q
If metabolic cause of N+V, what is first-line
A
Haloperidol
23
Q
If raised ICP, what is given to stop N+V
A
Cyclizine
24
Q
When should cyclizine not be given
A
Glaucoma
25
What is indicated for breathlessness in palliative care
Midazolam
Opioids
Fan therapy
26
What is a conservative measure to improve breathlessness in palliative care
Fan therapy
27
What is fan therapy
If individuals are struggling with sensation of breathlessness, holding a hand-held fan can help
28
What is first-line for constipation
Sodium docasate and Senna
29
What is the role of sodium docasate
Faecal sofnter
30
What is the role of senna
Stimulant
31
What is an alternative to sodium docasate and Senna
Laxido (Lactulose)
32
If patients are constipated and vomiting what is indicated
Phosphate enema
33
Define nociceptive pain
Pain due to actual or perceived tissue damage
34
What are two types of nociceptive pain
Somatic
| Visceral
35
What is somatic pain
Continuous ache
Worse on movement
Easily localised
36
What is visceral pain
Deep cramping pain
| Poorly localised
37
What is neuropathic pain
Pain caused by damage to somatosensory system
38
What is used to assess neuropathic pain
Lanns assessment tool
39
What score on Lanns assessment tool indicates neuropathic pain
>12
40
What % of cancer pain is neuropathic
20
41
What. % cancer pain is mixed
40
42
What is total pain
Individuals end perception of pain depends on physical, psychological, social and spiritual factors
43
What is breakthrough pain
Transient exacerbation of pain, when general pain is stable
44
When may breakthrough pain occur
Can occur spontaneously or in response to a particular trigger
45
Explain clinical presentation of breakthrough pain
Sudden-onset
Severe intensity
Usually lasts 30-minutes
46
What is incident pain
Breakthrough pain in response to a particular trigger (eg. physiotherapy)
47
How is incident pain managed
Give opioids 1h before
48
What should be considered before prescribing for pain
Cause of increase pain
49
What system governs pain prescribing in palliative care
WHO analgesia ladder
50
What is step-1 on WHO analgesia ladder
Non-opioid: Paracetamol or Aspirin
| And adjuvant
51
What is step-2 on WHO analgesia ladder
Weak opioid: Tramadol, Codeine
| And adjuvant
52
What are two weak opioids
Tramadol
| Codeine
53
What is step-3 on WHO analgesia ladder
Strong opioids - Morphine
54
What is a strong-opioid
Morphine
55
What are pharmacological adjuvants listed in WHO analgesia ladder
```
Gabapentin
Pregabalin
Amitriptyline
Bisphosphonates
Steroids
```
56
What are non-pharmacological adjuvants listed in WHO analgesia ladder
TENS
Massage
Counselling
Relaxation techniques
57
What does ESMO (oncology) state about analgesia
Analgesia for pain should be prescribed around the clock. Oral medications are always preferred except where it is not possible (eg. N+V, dysphagia)
58
How should pain medication be prescribed
Regular prescription section opposed to PRN
59
Why should pain medication not be prescribed PRN
As individual will only take it when they have pain and therefore will not improve
60
How often should oromorph be prescribed
4-6 hourly
61
What times is oromorph usually given
2pm, 6pm and 10pm
62
What is first-line for individuals with severe pain
Morphine Sulphate
63
What are the two types of morphine sulphate
1. Immediate-release
| 2. Modified-release
64
What is the duration of action of immediate release morphine sulphate
4-hours
65
What is the liquid form of immediate-release morphine sulphate
Oromorph
66
What is the tablet form of immediate-release morphine sulphate
Sevredol
67
Why may sevredol be preferred
Improve taste compared to oromorph
68
What is the lowest dose of IR morphine sulphate that can be prescribed
2.5mg
69
Explain prescribing IR morphine sulphate
Prescribe at lowest possible dose (2.5mg) and increase
70
What is the duration of action of modified-release morphine sulphate
12hrly
71
What are the MR-morphine sulphate capsules called
Zomorph (capsules)
72
What are MR-morphine sulphate tablets called
MST (morphine slow-release tablets)
73
Name another strong opioid
Oxycodone
74
How can oxycodone be given
IR, MR, Injectable
75
When is oxycodone preferable to morphine
GFR <30
76
When should oxycodone not be given and why
Liver Impairment
| As oxycodone depends on liver for oxidation
77
If patients have GFR <30 and liver impairment, what is given as an alternative to oxycodone
Alfentanil
78
How is alfentanil given
Injectable
79
What are indications for alfentanil
GFR <15
80
Name another strong opioid
Diamorphine
81
When should opioid patches NOT be given
If someones pain is unstable
82
When are opioid patches beneficial
Unable to take opioids orally
83
What two opioids can be given in patches
Buprenorphine
| Fentanyl
84
What are the two buprenorphine patches
- Butrans
| - Transtec
85
How often should butrans be changed
7-days
86
How often should transtec be changed
96-hours
87
How often should fentanyl be changed
72-hours
88
When doing opioid calculations what opioid should you always covert back to
Convert back to morphine
89
What is the 'relative potency' of morphine
1
90
What is the 'relative potency of oxycodone'
Oxycodone is twice as strong as morphine. Therefore relative potency compared to morphine is 2
91
If wanting to convert oxycodone to morphine what should you do and why.
Multiply by 2.
As oxycodone is twice are strong as morphine. Twice-dose of morphine would be required to equal the same dose of oxycodone.
92
Explain potency of tramadol and codeine
Tramadol and codeine are 1/10 as potent as morphine.
93
If wanting to covert tramadol and codeine to morphine what do you do and why
Divide by 10.
If had 10mg Tramadol/Codiene, it would only contain 1mg of moprhine.
94
How do you convert oral morphine to SC morphine
Divide by 2
95
How do you convert oral oxycodone to SC oxycodone
Divide by 2
96
What should be prescribed in addition to regular opioids
PRN for breakthrough pain
97
How is breakthrough pain calculated
1/6 24h opioid dose
98
What is the maximum allowed dose for PRN prescriptions
3 PRN in 4h
99
If more than 3 breakthrough doses of opioids what should be done
Review cause for increased pain
100
What doses does morphine come in
2.5mg, 5mg, 7mg
101
What are syringe drivers
Continuous SC dose of opioid
102
When are syringe drivers indicated
- N+V
- Poor oral absorption
- Dysphagia
103
What is the initial side effect of syringe drivers
N+V
104
How do you calculate dose for syringe drivers
Divide by 2
105
What are 4 common initial side-effects of opioids
1. Drowsiness
2. Unsteadiness
3. N+V
4. Delirium
106
What are 3 common ongoing side effects
1. N+V
2. Dry mouth
3. Constipation
107
What are 5 occasional side-effects of opioids
1. Hallucinations
2. Myoclonus
3. Urinary retention
4. Pruritus
5. Sweating
108
What are 2 rare side effects of opioids
Psychological depression
| Respiratory depression
109
What should opioids be prescribed with
Laxative and anti-emetic
110
What is often used as laxative with opioids
Senna (stimulant) and sodium docusate (stool softner)
111
What is used to determine if someone is constipated
Rome IV criteria
112
What usually precipitates opioid toxicity
Sepsis or AKI
113
What are features of opioid toxicity
- Drowsy
- Confused
- Myoclonic jerkes
- Hallucinations
- Resp depression
