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year 4-oncology block > 16 - Cancer Comorbidity Management > Flashcards

16 - Cancer Comorbidity Management Flashcards

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1
Q

How may patients with advanced cancer experience breathlessness and how can we recognise this?

A
  • 70-85%
  • Ask the patient, no way to measure it with NEWS score etc
  • Increases likelihood of in-hospital death
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2
Q

What are some reversible causes of breathlessness in EOLC AND how can they be reversed?

A
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3
Q

How can intractable breathlessness in palliative care be managed non-pharmacologically?

A
  • Position patient upright
  • Open window or fan on their face
  • Physiotherapy
  • CBT
  • Breathing control techniques
  • Pulmonary rehabilitation if well enough
  • Trial of oxygen if hypoxic
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4
Q

How can intractable breathlessness be managed pharmacologically in palliative care?

A
  • Very low dose opioids
  • Benzodiazepines if anxiety related
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5
Q

What is the pathophysiology of vomiting and what are the different receptors involved in each step?

A
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6
Q

What are some causes of N+V in cancer patients?

A

Reduced gastric motility

  • May be opioid related
  • Related to serotonin (5HT4) and dopamine (D2) receptors

Chemically mediated

  • Secondary to hypercalcaemia, opioids, or chemotherapy

Visceral/serosal

  • Due to constipation
  • Oral candidiasis

Raised ICP

  • Usually in context of cerebral metastases

Vestibular

  • Related to activation of acetylcholine and histamine (H1) receptors
  • Most frequently in palliative care is opioid related
  • Can be motion related, or due to base of skull tumours

Cortical

  • May be due to anxiety, pain, fear and/or anticipatory nausea
  • Related to GABA and histamine (H1) receptors in the cerebral cortex
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7
Q

Which receptors do each of the following anti-emetics work on?

A
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8
Q

Describe the nature of nausea and what antiemetic is best for chemically induced nausea?

A

Ondansetron, haloperidol and levomepromazine

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9
Q

Describe the nature of nausea and what antiemetic is best for gastric stasis induced nausea? e.g tumour or ascites obstructing gastric outflow

A

Do not use metoclopramide if bowel obstruction or after gastric surgery

  • Fullness/regurgitation of undigested food
  • Reduced appetite
  • Vomiting (often large volume) relieves nausea
  • Epigastric discomfort
  • Hiccups
  • Reflux
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10
Q

Describe the nature of nausea and what antiemetic is best for bowel obstruction induced nausea?

A

High: regurgitation, forceful vomiting of undigested food

Low: colicky pain, large faeculant vomits, visible peristalsis

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11
Q

Describe the nature of nausea and what antiemetic is best for raised ICP induced nausea?

A

Use cyclizine and dexamethasone together

Can also use radiotherapy

  • Nausea worse in the morning
  • Projectile vomiting
  • Worse on head movement
  • Headache
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12
Q

Describe the nature of nausea and what antiemetic is best for psychologically induced nausea?

A

Anxiety, fear, anticipation

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13
Q

Describe the nature of nausea and what antiemetic is best for post op/radiotherapy induced nausea?

A
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14
Q

Describe the nature of nausea and what antiemetic is best for constipation induced nausea?

A
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15
Q

What are some risk factors for vomiting with chemotherapy?

A

75% will experience it

  • Specific chemo agents
  • Anxiety
  • Female gender
  • Age <50 years
  • Past Hx of N&V (pregnancy, prior chemotherapy use, motion sickness)
  • Concurrent use of opioids
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16
Q

What are the phases of CINV and what antiemetics are used for CINV?

A

Anticipatory, Acute, Delayed

Low risk

  • Metoclopramide

High risk

  • 5HT3: Ondansetron. Used more for acute.
  • NK1: Aprepitant. Used more for delayed.
  • +/- Dexamethasone
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17
Q

What is Aprepitant and what are the side effects of this?

A
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18
Q

What antiemetics are used for EOLC?

A

LEVOMEPROMAZINE: very broad spectrum

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19
Q

What route should anti-emetics be given?

A
  • PO preferable
  • If the patient is vomiting, has issues with malabsorption, or there is severe gastric stasis can use SC or IV access
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20
Q

What antiemetic is best for vestibular causes of nausea?

A

Cyclizine

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21
Q

What are some non-pharmacological management options for nausea?

A
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22
Q

What are some causes of constipation in cancer patients?

(important)

A
  • Exercise
  • Increase fluids
  • Increase fibre in diet
  • Laxido
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23
Q

Give some examples of the following classes of laxatives and their MOA?

A
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24
Q

How can we manage constipation in cancer patients?

A
  • Exercise
  • Increase fluids
  • Increase fibre in diet
  • Laxido
25
Q

What is the pathophysiology of malignant bowel obstruction?

A

Usually ovarian and colon cancers and has a gradual onset

  1. Mechanical: tumour within gut lumen or outside bowel wall

2. Functional: infiltration of myenteric plexus +/or gut musculature

3. Combination of mechanical + functional

26
Q

How may a malignant bowel obstruction present?

A
  • Abdominal pain with distension (Initially colicky then continuous)
  • Bloating and vomiting (often bilious)
  • Failure to pass flatus or stool
  • History of abdominal/gynaecological surgery or hernia
  • Tympanic, high-pitched bowel sounds on examination
  • Empty rectum on examination in complete bowel obstruction

Can lead to ischaemia bowel and perforation if left untreated

27
Q

What investigations should you do for a malignant bowel obstruction?

A
  • FBC
  • U+Es
  • Lactate: see if bowel ischaemia or necrosis
  • Amylase: always important in all cases of acute abdomen
  • Coagulation and G+S
  • Abdominal and Upright CXR
  • CT abdomen and pelvis: best diagnostic test
28
Q

How may a malignant bowel obstruction be managed?

(image is important)

A

Tend to avoid surgery and invasive procedures e.g NG if poor prognosis

Surgical

  • High post op morbidity, mortality and re-obstruction rate so tend to avoid
  • Endoscopic stenting or venting gastrostomy

Inoperable

  • Rest bowel initially to see if will resolve
  • Limit oral fluids to sips and give IVI
  • NG tube for large volume vomiting
  • Correct electrolyte imbalance (low K, low Mg)
  • Analgesics (opioids and antispasmodics), antiemetics and antisecretory drugs
  • Trial of dexamethasone
29
Q

What effect can having cancer have on mental health?

A

High rate of depression (20%) and anxiety (10%)

Linked to poorer prognosis with cancer

30
Q

What are some causes of depression in cancer patients?

A
  • Chemotherapy
  • Steroids
  • Major life change
  • Pain
  • Pancreatic and lung cancers can release chemicals thought to cause depression
31
Q

How is depression in cancer patients managed?

A
  • Early recognition
  • Support e.g Macmillan Nurse
  • Psychological input e.g CBT
  • Medical e.g Citalopram and Sertraline
32
Q

How may bowel colic and excessive respiratory secretions in palliative cancer patients be managed?

A
  • Hyoscine hydrobromide
  • Hyoscine butylbromide
  • Glycopyronium bromide

Give these antimuscarincs every 4 hours SC. Be careful of dry mouth

33
Q

Some patients are susceptible to convulsions with cerebral tumours/mets or raised ICP. How is this managed?

A
  • Prophylactic: Phenytoin or Carbamazepine. If PO not option give Diazepam rectally or Phenobarbital injection
34
Q

How is dry mouth in cancer patients managed?

A
  • Chew sugar free gum
  • Suck ice or pineapple chunks
  • Artificial saliva
  • Nystatin if any thrush
  • Alter any antiemetics or antimuscarinics causing dry mouth
35
Q

If there is dysphagia due to an obstructing tumour, what medication can you give to resolve this?

A

Dexamethasone

36
Q

How can insomnia in cancer patients be treated?

A

Insomnia due to discomfort, cramps, night sweats, fear

Temazepam if above cannot be resolved

37
Q

How can cough be managed in palliative care?

A

Opioid (oral morphine)

38
Q

How often should we review antiemetics in cancer patients?

A

Every 24 hours

39
Q

How can we manage pruritus in cancer patients?

A
  • Emollients
  • Cholestyramine if due to obstructive jaundice
40
Q

How can a headache due to a raised ICP in cancer be managed?

A

High dose Dexamethasone given before 6pm to avoid insomnia

41
Q

How can restlessness and confusion be managed in cancer patients undergoing palliative care?

A

Antipsychotic: e.g Haloperidol or Levomepromazine by PO or SC every 2 hours

42
Q

When may a syringe driver be used to deliver medication?

A
  • Patient unable to take medication by mouth: N+V, dysphagia, severe weakness, coma
  • Malignant Bowel Obstruction for whom surgery is not appropriate
  • If patient does not wish to take medication orally
43
Q

What medications can be used in the syringe driver for the following:

  • Bowel colic and excess respiratory secretions
  • Confusion
  • Convulsions
  • N+V
  • Pain
A

Bowel colic and excess respiratory secretions

Hyoscine hydrobromide/butylbromide or Glycopyronium bromide

Confusion

Haloperidol or Midazolam

Convulsions

Midazolam

N+V

Haloperidol and Levomepromazine (sedating), Octreotide

Pain

Diamorphine

44
Q

How are lots of medications given when a patient is on a syringe driver?

A

Can be mixed if compatible

45
Q

What medications can cause local skin irritation so need to use with caution in a syringe driver?

A
  • Cyclizine
  • Levomepromazine
  • CI are chlorpromazine, prochlorperazine and diazepam
46
Q

How do you convert oral morphine to parenteral diamorphine?

A

⅓rd of oral morphine

If was parental morphine would be ½ of oral morphine

47
Q

When a new patient with leukaemia presents what do you need to be thinking about management wise?

A
  • Access
  • Chemo?
  • Renal failure from high WCC
  • Any transfusion needed
  • Antiviral/Antifungal prophylaxis
  • Fertility preservation
48
Q

If a patient with cancer becomes unwell with suspected neutropenic sepsis, what do you need to do on examination?

A

INSPECT ALL LINES AND REMOVE IF ANY ERYTHEMA

Also need to do central and peripheral blood cultures to see if infection just in the line

49
Q

Where is the source of infection in the majority of cancer patients with neutropenic sepsis?

A

Translocation of gut bacteria (gram -ve)

Due to mucositis breaking the lining of the GI tract

50
Q

What is the risk of transfusing red cells to someone with leukaemia who has a high WCC?

A

VTE risk, blood is already hyper viscous due to leucostasis

51
Q

What medication is used for SEVERE TLS?

A

Rasburicase as can convert existing uric acid to Allantoin. Very expensive

It is urate oxidase

52
Q

What do we give to women undergoing treatment for leukaemia?

A

Norethisterone to stop menstruation to prevent further anaemia and pregnancy

Do not do if high VTE risk

Males should also avoid getting anyone pregnant

53
Q

What are the side effects of G-CSF?

A
  • Allergic reaction
  • Bone pain
  • Headache
54
Q

What are all leukaemia patients given prophylactically during chemo?

A
  • Aciclovir
  • Co-trimoxazole (PCP prophylaxis)
  • Fluconazole/Isavuconazole/Posaconazole
55
Q

When do we consider that a haematology patient with neutropenic sepsis has a fungal source of infection and how do we treat this?

A
56
Q

What is the best imaging modality for diagnosing brain metastases?

A

MRI head

57
Q

What antiemetics should you not give to Parkinson’s patients?

A
  • Metoclopramide
  • Haloperidol
58
Q

How long do syringe drivers take for effective pain relief?

A

4 Hours

Should only put regular meds in syringe driver. If using regular PRNs e.g regular midazolam add it to syringe driver

59
Q

What antiemetic should you use for:

  • Gastric stasis
  • Raised ICP
  • Chemical
  • Bowel obstruction
    • Post Op

IMPORTANT

A

year 4-oncology block (19 decks)

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