16 - Cancer Comorbidity Management Flashcards
How may patients with advanced cancer experience breathlessness and how can we recognise this?
- 70-85%
- Ask the patient, no way to measure it with NEWS score etc
- Increases likelihood of in-hospital death
What are some reversible causes of breathlessness in EOLC AND how can they be reversed?
How can intractable breathlessness in palliative care be managed non-pharmacologically?
- 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
How can intractable breathlessness be managed pharmacologically in palliative care?
- Very low dose opioids
- Benzodiazepines if anxiety related
What is the pathophysiology of vomiting and what are the different receptors involved in each step?
What are some causes of N+V in cancer patients?
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
Which receptors do each of the following anti-emetics work on?
Describe the nature of nausea and what antiemetic is best for chemically induced nausea?
Ondansetron, haloperidol and levomepromazine
Describe the nature of nausea and what antiemetic is best for gastric stasis induced nausea? e.g tumour or ascites obstructing gastric outflow
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
Describe the nature of nausea and what antiemetic is best for bowel obstruction induced nausea?
High: regurgitation, forceful vomiting of undigested food
Low: colicky pain, large faeculant vomits, visible peristalsis
Describe the nature of nausea and what antiemetic is best for raised ICP induced nausea?
Use cyclizine and dexamethasone together
Can also use radiotherapy
- Nausea worse in the morning
- Projectile vomiting
- Worse on head movement
- Headache
Describe the nature of nausea and what antiemetic is best for psychologically induced nausea?
Anxiety, fear, anticipation
Describe the nature of nausea and what antiemetic is best for post op/radiotherapy induced nausea?
Describe the nature of nausea and what antiemetic is best for constipation induced nausea?
What are some risk factors for vomiting with chemotherapy?
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
What are the phases of CINV and what antiemetics are used for CINV?
Anticipatory, Acute, Delayed
Low risk
- Metoclopramide
High risk
- 5HT3: Ondansetron. Used more for acute.
- NK1: Aprepitant. Used more for delayed.
- +/- Dexamethasone
What is Aprepitant and what are the side effects of this?
What antiemetics are used for EOLC?
LEVOMEPROMAZINE: very broad spectrum
What route should anti-emetics be given?
- PO preferable
- If the patient is vomiting, has issues with malabsorption, or there is severe gastric stasis can use SC or IV access
What antiemetic is best for vestibular causes of nausea?
Cyclizine
What are some non-pharmacological management options for nausea?
What are some causes of constipation in cancer patients?
(important)
- Exercise
- Increase fluids
- Increase fibre in diet
- Laxido
Give some examples of the following classes of laxatives and their MOA?
How can we manage constipation in cancer patients?
- Exercise
- Increase fluids
- Increase fibre in diet
- Laxido
What is the pathophysiology of malignant bowel obstruction?
Usually ovarian and colon cancers and has a gradual onset
- Mechanical: tumour within gut lumen or outside bowel wall
2. Functional: infiltration of myenteric plexus +/or gut musculature
3. Combination of mechanical + functional
How may a malignant bowel obstruction present?
- 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
What investigations should you do for a malignant bowel obstruction?
- 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
How may a malignant bowel obstruction be managed?
(image is important)
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
What effect can having cancer have on mental health?
High rate of depression (20%) and anxiety (10%)
Linked to poorer prognosis with cancer
What are some causes of depression in cancer patients?
- Chemotherapy
- Steroids
- Major life change
- Pain
- Pancreatic and lung cancers can release chemicals thought to cause depression
How is depression in cancer patients managed?
- Early recognition
- Support e.g Macmillan Nurse
- Psychological input e.g CBT
- Medical e.g Citalopram and Sertraline
How may bowel colic and excessive respiratory secretions in palliative cancer patients be managed?
- Hyoscine hydrobromide
- Hyoscine butylbromide
- Glycopyronium bromide
Give these antimuscarincs every 4 hours SC. Be careful of dry mouth
Some patients are susceptible to convulsions with cerebral tumours/mets or raised ICP. How is this managed?
- Prophylactic: Phenytoin or Carbamazepine. If PO not option give Diazepam rectally or Phenobarbital injection
How is dry mouth in cancer patients managed?
- Chew sugar free gum
- Suck ice or pineapple chunks
- Artificial saliva
- Nystatin if any thrush
- Alter any antiemetics or antimuscarinics causing dry mouth
If there is dysphagia due to an obstructing tumour, what medication can you give to resolve this?
Dexamethasone
How can insomnia in cancer patients be treated?
Insomnia due to discomfort, cramps, night sweats, fear
Temazepam if above cannot be resolved
How can cough be managed in palliative care?
Opioid (oral morphine)
How often should we review antiemetics in cancer patients?
Every 24 hours
How can we manage pruritus in cancer patients?
- Emollients
- Cholestyramine if due to obstructive jaundice
How can a headache due to a raised ICP in cancer be managed?
High dose Dexamethasone given before 6pm to avoid insomnia
How can restlessness and confusion be managed in cancer patients undergoing palliative care?
Antipsychotic: e.g Haloperidol or Levomepromazine by PO or SC every 2 hours
When may a syringe driver be used to deliver medication?
- 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
What medications can be used in the syringe driver for the following:
- Bowel colic and excess respiratory secretions
- Confusion
- Convulsions
- N+V
- Pain
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
How are lots of medications given when a patient is on a syringe driver?
Can be mixed if compatible
What medications can cause local skin irritation so need to use with caution in a syringe driver?
- Cyclizine
- Levomepromazine
- CI are chlorpromazine, prochlorperazine and diazepam
How do you convert oral morphine to parenteral diamorphine?
⅓rd of oral morphine
If was parental morphine would be ½ of oral morphine
When a new patient with leukaemia presents what do you need to be thinking about management wise?
- Access
- Chemo?
- Renal failure from high WCC
- Any transfusion needed
- Antiviral/Antifungal prophylaxis
- Fertility preservation
If a patient with cancer becomes unwell with suspected neutropenic sepsis, what do you need to do on examination?
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
Where is the source of infection in the majority of cancer patients with neutropenic sepsis?
Translocation of gut bacteria (gram -ve)
Due to mucositis breaking the lining of the GI tract
What is the risk of transfusing red cells to someone with leukaemia who has a high WCC?
VTE risk, blood is already hyper viscous due to leucostasis
What medication is used for SEVERE TLS?
Rasburicase as can convert existing uric acid to Allantoin. Very expensive
It is urate oxidase
What do we give to women undergoing treatment for leukaemia?
Norethisterone to stop menstruation to prevent further anaemia and pregnancy
Do not do if high VTE risk
Males should also avoid getting anyone pregnant
What are the side effects of G-CSF?
- Allergic reaction
- Bone pain
- Headache
What are all leukaemia patients given prophylactically during chemo?
- Aciclovir
- Co-trimoxazole (PCP prophylaxis)
- Fluconazole/Isavuconazole/Posaconazole
When do we consider that a haematology patient with neutropenic sepsis has a fungal source of infection and how do we treat this?
What is the best imaging modality for diagnosing brain metastases?
MRI head
What antiemetics should you not give to Parkinson’s patients?
- Metoclopramide
- Haloperidol
How long do syringe drivers take for effective pain relief?
4 Hours
Should only put regular meds in syringe driver. If using regular PRNs e.g regular midazolam add it to syringe driver
What antiemetic should you use for:
- Gastric stasis
- Raised ICP
- Chemical
- Bowel obstruction
- Post Op
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