13- Symptom management (Other symptoms) Flashcards
which symptoms except pain may be need to be managed
- Nausea and vomiting
- Intractable breathlessness
- Constipation
- Psychological distress, depression and anxiety
- Confusion and delirium
causes of nausea and vomiting
pathophysiology of N and V
drugs used to reduce stimulation of the chemoreceptor trigger zone (CTZ)
- Most are antagonists
summary of antiemetic action
features of N+V caused by chemotherapy
persistent, often severe nausea, unrelieved by vomiting, aggratated by sight/smell of food
management of N+V caused by chemotherapy/ biochemical burden of cancer
Haloperidol
(metoclopramide)
features of N+V caused by gastric stasis (35-44%)
fullness/regurg, reduced appetite, vomiting relieves nausea, epigastric discomfort, hiccups
management of N+V caused by gastric stasis
Metoclopramide
features of N+V caused by bowel obstruction
High: regurg, forceful vomiting of undigested food
Low: colicky pain, large faecalant vomits, visible peristalsis
management of N+V caused by bowel obstruction
cyclizine
dexamethasone
features of N+V caused by raised ICP
nausea worse in the morning in the morning, projectile vomiting, worse on head movement, headache
management of N+V caused by raised ICP
cyclizine
dexamethasone
management of N+V caused by constipation
laxatives
chemo induced nausea and vomiting risk factors
- Increased risk associated with specific chemo agents, female gender, age <50 years, past Hx of N&V (pregnancy, prior chemotherapy use, motion sickness)
Management after sickness inducing chemotherapy
- Metoclopramide
- Dexamethasone
- Ondansetron
Non-pharmacological management
* Advice and realistic aims
* Smell
* Taste - small appropriate meals
* Hypnosis?
* Acupuncture?
management of route and regime in a patient with nausea and vomtiing
Route and regime
* Oral absorption likely to be poor
* Consider SC route for at least 24 hours
* Regularanti-emetic
* Consider alternative if not improving
* Control of symptoms using one antiemetic is possible in ~60% of patients
* 1/3 require concurrent use of a second antiemetic
* Combine anti-emetics with different mechanisms of action
* Consider switch to oral if improving
* Cause resolves…?stop
Constipation
Background
- Hard faeces, which are uncomfortable or difficult to pass; reduced frequency compared with normal pattern
- Sense of incomplete evacuation after defecation; leakage of faecal fluid, faecal incontinence
- Colicky abdominal pain, abdominal distension, flatulence
- Nausea, vomiting, anorexia, malaise, headache and halitosis
- Constipation may lead to urinary frequency and retention
causes of constipation
- Disease related: immobility, reduced food intake/low residue diet, intra abdominal and pelvic disease.
- Fluid depletion: poor fluid intake, increased fluid loss e.g. vomiting, sweating, fistulae, excessively, exudating wounds.
- Weakness: inability to raise intra-abdominal pressure e.g. paraplegia, general debility, cardiac failure.
- Intestinal obstruction: disease presentation or recurrence, adhesions, recent surgery.
- Medication: opioids, diuretics, phenothiazines, anti-cholinergic drugs, 5HT antagonists,
- Biochemical: hypercalcaemia, hypokalaemia.
- Other: pain on defecation, lack of privacy, diverticulitis
management of constipation
- Laxido and Movicol popular in oncology
Rarely use lactulose because poorly tolerated due to sweetness, except encephalopathy
Breathlessness
Background
- 70% advanced cancer
- 90% lung cancer
- 95% COPD
- 88% heart disease
- 85% MND
- Prevalence and severity tend to increase as death nears
- Increases likelihood for in-hospital death
presentation of breathlessness
Presentation
- Patient-centred symptom
- Cannot be inferred from physical examination or investigation- must ask about it
causes of breathlessness
Management of intractable breathlessness
- Aim to reduce the perception
- Patients can quickly detect lack of HCP confidence- calm, positive, logical approach needed
- Position patient using gravity and not hinder weak diaphragm/ chest wall muscles
- Air flow across face: fan or open a window
- Trial of oxygen (if hypoxic)
- Non-drug approaches if feasible
cyclizine vs metoclopramide
metoclopramide -> prokinetic
- good for nausea and vomiting caused by chemo/ cancer
Cyclizine -> antikinetic (opposite affect to meto)
- good for bowel obstruction
