Bone Marrow Failure and Chemotherapy Flashcards
why is it important to identify dying patients?
advanced care planning, they want to know, plan finances, say goodbye, ensure loved ones are prepared
what can be used to try and identify dying patients?
GSF, RCP, SPICT
what factors is it important to consider when assessing dying patients?
Advanced, progressive, incurable condition
General frailty and coexisting conditions (expected to die in next year)
Existing condition where they are at risk of dying from sudden acute crisis
Life threatening acute condition caused by sudden catastorophic event (PE
what is advanced care planning?
A process of discussion between an individual and their care providers (may be family or friends)
Facititates and enables individuals to think about the care they would like to receive
what is the SPICT tool?
Guide to identify people at risk of death in next year
Looks at genera indicators for deteriorating health as well as indicators of specific diseases
what are the general indicators of poor health looked for using the SPICT tool?
- unplanned hospital admission
- performance status poor or deteriorating
- depends onothers for care
- significant weight loss
- persistent symptoms despite treatment
- patient or family asks for palliative care
what are the features of advanced care planning?
Step by step approach Process not a singe event Patient needs to be ready Comfortable, unhurried surroundings Appropriate documentation Information sharing with team and GP (DNACPR and preferred place of care
why is advanced care planning important
Most people (85%) don’t die suddenly-after chronic illness
50% are not in a position to make their own decisions when close to death
A doctor who is uncertain about what to do and who has to make a decision will often treat aggressively
Many kept alive under circumstances that they wouldn’t want
what are the aims of advanced care planning
aim to improve planning
Improved symptom control
Better end of life decision making (withholding treatment)
Decision to reduce active treatments and resuscitation even if deemed medically appropriate
Discussions around place of care/death
what are the important things to consider in a progressive illness in an acute setting for a dying patient?
Advanced care planning AMBER care bundle DNACPR Escalation ceilings PPC Pre-emptive prescribing Rapid discharge Home to die EoL care plan
what symptoms can be expected in a patient at end of life?
Pain. Respiratory tract secretions, restlessness and agitation, delirium, dyspnea, emesis
describe the prescription of drugs in end of life care?
Drugs prescribed preemptively in last weeks of life
Drugs – antimuscarininc, opioid, antipsychotic, benxodiazepine,
when are anticipatory drugs prescribed
When patient cant swallow
When near end of life
When patient might not be able to swallow soon
describe the role of anticipatory prescribing?
May be needed for symptom management Symptoms might not be present yet Might bot be able to swallow Needed at home, hospital or hospice Not definitive treatment just to aid comfort
how should anticipatory drugs be administered in cachexic patients?
not give IM injections-use subcutaneous route
as well as anticipatory prescribing, what other action should be taken?
Avoid unnecessary interventions such as observations, investigations, assess fluids when necessary, DNACPR
Discontinue unnecessary medication (steroids, antibiotics, hormones, antidepressants, diabetic drugs (not type 1), cardiovascular drugs/statins, vitamins/iron, prophylactic LMWH)
describe prescription of anticipatory medication in patients not currently taking any pain medication?
- diamorphine s/c injection 1.25mg-2.5mg (1-2 hourly)
- if 2-3PRN needed-syringe driver. diamorphine 5-10mg s/c over 24 hours
- reassess every 24 hours
describe prescription of anticipatory pain medication in patients already taking oral morphine?
- convert oral morphine to diamorphine s/c (24 hour dose of morphine divided by 3
- also prescribe prn diamorphine s/c for breakthrough pain (1/6 dose in driver)
- reassess every 24 hours
describe prescription of anticipatory pain medication in patients already on fentanyl?
- maintain fentanyl patch and prescribe diamorhpine s/c prn in anticipation of breakthrough pain. (calculate fentanyl patch by 5)
- if 2-3prn doses needed in 24h, commence diamorphine s/c via syringe driver over 24 hours
- reassess every 24 hours
what are the common indications for syringe driver?
Persistent nausea and vomiting
Severe dysphagia
describe the management of respiratory tract secretions
Assessment
Look for cause and reverse if possible
Non pharmacological managmenet Stop fluids
Explanation to family (most important)
Repositioning
Anti-muscarinic – review effects and side effects
suction
describe the anticipatory treatment given for respiratory tract secretions if symptoms are currently absent?
prescribe in anticipation to commence treatment at first sign
glycopyrronium 200micrograms s/c prn
describe the anticipatory treatment given for respiratory tract secretions if symptoms are present
- try turning the patient first and explain to family
- administer glycopyrronium 200micrograms s/c, commence syringe driver glycopyyronium 800micrograms over 24h
- continue to administer s/c prn dose as needed upto maximum 1200micrograms
describe anticipatory treatment for restlessness and agitation if symptoms are currently absent?
- midazolam s/c 2.5mg-5mg pm
- optimise non pharmacological measures
describe anticipatory treatment for restlessness and agitation if symptoms are present?
- midazolam 2.5-5mg s/c
- if still symptoms - give 5-10mg s/c over 24h via syringe driver
- max dose 30mg/24 hours
- 2nd line - levomepromazine 6.25mg s/c PRN (15.5-25mg s/c over 24 hours)
what is delirium?
acute confused state characterized by cognitive impairment and mental clouding, fluctuant. May include hallucinations, aggression, plucking and increased or decreased psychomotor activity. Assessment. Look for underlying cause and reverse if appropriate. Optimise non pharmacological measures. Antipsychotics
what is first line treatment for delirium in anticipatory care
haloperidol 0.5mg-1.5mg s/c PRN (increase to 1.5-3mg s/c over 24 hours by syringe driver / administer midazolam 2.5-5mg s/c)
describe anticipatory treatment for dyspnoea in patient not requiring strong opioids for analgesia or breathlessness?
diamorphine 1.25-2.5mg s/c prn
describe anticipatory treatment for dyspnoea in patient requiring strong opioids for analgesia or breathlessness?
prescribe 1/20th of 24hour analgesic dose as prn dose
titrate upto full analgesic breakthrough dose
diamorphine
what anticipatory medication can be given for nausea and vomiting?
depends on aetiology
ondansetron, haloperidol, cyclizine, metoclopramide
describe the anticipatory medication given for nausea and vomiting in patients with
- absent symtoms
- symptoms under control
- symptoms present
- haloperidol .5-1.5mg s/c prn/4 hourly
- convert current dose to s/c via syringe driver
- appropriate anti-emetic. s/c prn dose
what medication is given for nausea/vomiting likely due to chemical causes (hypercalcaemia or opiate induced)
haloperidol
- 5-1.5mg prn
- 5-3mg syringe driver
what medication is given for nausea/vomiting likely due to gastric stasis, peristaltic failure, partial bowel obstruction w/o colic?
metoclopramide
10mg s/c prn
30-60mg syringe driver
what medication is given for nausea/vomiting likely due to bowel obstruction with colic?
hyoscine butlbromide 20mg s/cor 60-120mg syringe driver
glycopyrronium 200micrograms prn or 800micrograms syringe driver 24h
what medication is given for nausea/vomiting likely due to raised intracranial pressure, complete bowel obstruction with coli?
cyclizine
upto 50mg TDS
150mg 24h syringe driver
what medication is given for nausea/vomiting with unknown cause or after other drugs ineffective?
levomepromazine 6.25mg s/c or 6.25-12.5mg 24h syringe driver
what are the classification of chemotherapy?
Cytotoxic – largely work by damaging DNA and inducing programmed cell death (apoptosis)
Hormone eg tamoxifen
Immunotherapy – eg herceptin
Miscellaneous eg bisphosphonates
describe the clinical uses of adjuvant chemotherapy?
treatment used to mop up micrometastatic disease post surgery in order to prolong surgery eg breast, lung, colorectal cancers. Produces small but significant improvements in survival
describe the clinical uses of neoadjuvant chemotherapy?
used to downstage tumours prior to surgery eg oesophageal and rectal cancers
describe the clinical uses of curative chemotherapy?
chemotherapy used as sole or main modality to cure malignancy eg testicular cancers, lymphomas, leukaemias and many paediatric malignancies
describe the clinical uses of palliative chemotherapy?
chemotherapy is used to relieve symptoms, improve quality of life and prolong life but is not curative. Eg for small cell lung cancer. Improves symptoms such as dyspnea, improves wuality of life and modest improvement in survival
describe the potential toxicities of cytotoxic chemotherapy?
mucositis nausea/vomiting diarrhoea cystitis sterility myalgia neuropathy
give examples of cytotoxic chemotherapy agents?
antimetabolites (methotrexate) alkylating agents (cyclophosphamide) spindle poisons (taxanes intercalating agents (doxorubicin)
what are the acute (reversible) side effects of chemotherapy?
Myelosuppression Nausea and vomiting Darrhoea Alopecia Skin and nail changes Local reactions
what are the late (irreversible) side effects of chemotherapy?
Neuropathies Sterility Cardiovascular Pulmonary fibrosis Renal insufficiency
what are the potential infective complications of chemotherapy?
Localised infections – bacterial, viral (herpes zoster), fungal
Systemic infections – febrile neutropenia, septic shock
Management of neutropaenic sepsis – IV fluids, broad spectrum antibiotics
describe chemotherapy induced nausea and vomiting?
Acute-first 24 hours
Delayed-24 hours plus
Anticipatory – pavlovian response induces emesis before chemotherapy is given, triggered by sites or smells associated with chemotherapy administration (rare due to better antiemetics)
describe the management of chemotherapy induced emesis by risk classification?
High – cisplatin, dacarbazine, doxorubicin/epirubicin, ifosafamide, streptozocin
Moderate – cyclophosphamide, carboplatin, irinotecan, oxaliplatin
Low – methotrexate, 5-FU, taxanes, topotecan
Minimal – vincristine, bleomycin
describe alopecia as a side effect of chemotherapy?
Not universal (drugs such as anthracycline and taxanes invariably cause alopecia but 5FU and vincristine virtually never cause it)
Always reversible
Can be ameliorated by scalp colling during period of chemotherapy administration
describe chemotherapy induced peripheral neuropathies?
Drugs- cicsplatin, oxaliplatin, vinca alkaloids, taxanes
Sites affected – hands and feet, autonomic system
Time course – tends to be cumulative ie worse with increasing cumulative dose, tends to be irreversible
describe chemotherapy induced sterility?
Tends to occur when alkylating agents are used
Spontaenous recovery can occur especially in younger patients
For male sperms storage should be offered
Females ovarian tissue storage or oocyte storage is experimental
describe the effect of chemotherapy on the heart?
Anthracyclines are cytotoxic drugs most commonly cause cardiac problems which are usually manifested by congestive heart failure but this is rare if cumulative dose is kept below a certain cumulative dose level.
Many drugs eg taxanes and anthracyclines can cause arrythmias
