13- Symptom management (Other symptoms)

Question 1

which symptoms except pain may be need to be managed

Answer 1

• Nausea and vomiting
• Intractable breathlessness
• Constipation
• Psychological distress, depression and anxiety
• Confusion and delirium

Question 2

causes of nausea and vomiting

Answer 2

Question 3

pathophysiology of N and V

Answer 3

Question 4

drugs used to reduce stimulation of the chemoreceptor trigger zone (CTZ)

Answer 4

• Most are antagonists

Question 5

summary of antiemetic action

Answer 5

Question 6

features of N+V caused by chemotherapy

Answer 6

persistent, often severe nausea, unrelieved by vomiting, aggratated by sight/smell of food

Question 7

management of N+V caused by chemotherapy/ biochemical burden of cancer

Answer 7

Haloperidol

(metoclopramide)

Question 8

features of N+V caused by gastric stasis (35-44%)

Answer 8

fullness/regurg, reduced appetite, vomiting relieves nausea, epigastric discomfort, hiccups

Question 9

management of N+V caused by gastric stasis

Answer 9

Metoclopramide

Question 10

features of N+V caused by bowel obstruction

Answer 10

High: regurg, forceful vomiting of undigested food
Low: colicky pain, large faecalant vomits, visible peristalsis

Question 11

management of N+V caused by bowel obstruction

Answer 11

cyclizine
dexamethasone

Question 12

features of N+V caused by raised ICP

Answer 12

nausea worse in the morning in the morning, projectile vomiting, worse on head movement, headache

Question 13

management of N+V caused by raised ICP

Answer 13

cyclizine
dexamethasone

Question 14

management of N+V caused by constipation

Answer 14

laxatives

Question 15

chemo induced nausea and vomiting risk factors

Answer 15

• Increased risk associated with specific chemo agents, female gender, age <50 years, past Hx of N&V (pregnancy, prior chemotherapy use, motion sickness)

Question 16

Management after sickness inducing chemotherapy

Answer 16

• Metoclopramide
• Dexamethasone
• Ondansetron

Non-pharmacological management
* Advice and realistic aims
* Smell
* Taste - small appropriate meals
* Hypnosis?
* Acupuncture?

Question 17

management of route and regime in a patient with nausea and vomtiing

Answer 17

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

Question 18

Constipation
Background

Answer 18

• 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

Question 19

causes of constipation

Answer 19

• 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

Question 20

management of constipation

Answer 20

• Laxido and Movicol popular in oncology

Rarely use lactulose because poorly tolerated due to sweetness, except encephalopathy

Question 21

Breathlessness
Background

Answer 21

• 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

Question 22

presentation of breathlessness

Answer 22

Presentation
- Patient-centred symptom
- Cannot be inferred from physical examination or investigation- must ask about it

Question 23

causes of breathlessness

Answer 23

Question 24

Management of intractable breathlessness

Answer 24

• 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

Question 25

cyclizine vs metoclopramide

Answer 25

metoclopramide -> prokinetic
- good for nausea and vomiting caused by chemo/ cancer

Cyclizine -> antikinetic (opposite affect to meto)
- good for bowel obstruction