Complication Management Flashcards
1
Q
Define Nausea
A
Unpleasant feeling of needing to vomit, accompanied by autonomic symptoms
2
Q
Define Vomiting
A
Forceful expulsion of gastric contents through the mouth
3
Q
What are the four inputs to the Vomiting Centre?
A
Vestibular Input
High Centres
CTZ
Vagal Afferents
4
Q
Where in Vomiting Centre inputs are Dopamine Receptors located?
A
CTZ
Vagal Afferents
5
Q
Name three Dopamine antagonists
A
Domperidone
Metacloperamide
Haloperidol
6
Q
Where in Vomiting Centre inputs are 5HT3 Receptors located?
A
CTZ
Vagal Afferents
7
Q
What would be the Antiemetic of choice in impaired gastric emptying?
A
Metacloperamide
8
Q
What would be the Antiemetic of choice in impaired Post Op/Radiotherapy?
A
Ondansetron
9
Q
What would be the Antiemetic of choice in Bowel Obstruction?
A
Cyclizine
10
Q
What would be the Antiemetic of choice in Drug SE?
A
Haloperidol
11
Q
What would be the Antiemetic of choice with a Metabolic cause?
A
Haloperidol
12
Q
What would be the Antiemetic of choice in Chemotherapy?
A
Metacloperamide
13
Q
What are the side effects of D2 Antagonists?
A
Extrapyramidal (eg involuntary movements and Akathisia)
Should not combine D2 receptors
May enhance EP side effects of SSRIs and TCAs
Do not use in PArkinsons
14
Q
Describe two central and two peripheral side effects of Anticholinergics
A
Central: Agitation and Restlessness
Peripheral: Dry Mouth and Constipation
15
Q
Who should not recieve Anticholinergics?
A
Known heart disease/Arrhythmias
16
Q
Why should you not combine Anticholinergics and Domperidone/Metacloperamide?
A
Domperidone and Metacloperamide have some cholinergic action
17
Q
What level of Levomepromazine becomes sedating?
A
Above 12.5mg
18
Q
What is a common side effect of 5HT3 Antagonists?
A
Constipation
19
Q
Name three non pharmacological interventions for Nausea and Vomiting
A
Small Meals
Ginger
Accupuncture/Accupressure
20
Q
What would be the Antiemetic of choice in Intracranial aetiology?
A
Cyclizine +/- Dexamethasone
21
Q
What would be the Antiemetic of choice in vestibular aetiology?
A
Cyclizine
22
Q
What would be the Antiemetic of choice in unclear aetiology?
A
Cyclizine
23
Q
How does Biochemical vomiting present?
A
Constant Nausea
Small frequent vomits
Doesn’t improve with being sick
24
Q
How does Nausea due to Brain Metastases present?
A
Projectile vomiting
Confusion
Headache
25
How does Nausea due to Bowel Obstruction present?
Colicky Pain
Distension
Improvement with vomiting
26
State three types of Nausea and Vomiting related to Chemotherapy
Acute - Within 24h
Delayed - 1-5d post treatment
Anticipatory - brought on by taste/odor/memories
27
What is Breathlessness in Oncology?
Subjective experience of breathing discomfort that varies in intensity, should not be mistaken for tachypnoea necessarily
Normally due to distortion and stimulation of mechanical receptors
28
Give four Oncological causes of Breathlessness
Tumour compression
Pleural/Pericardial Effusion/Ascites
Phrenic Nerve Palsy
SVCO
29
Give two treatment related causes of Breathlessness
Surgery (Lobectomy/Pneomonectomy)
| Radio/Chemo (Fibrosis)
30
Give three 'other' causes of Breathlessness
PE
Pneumothorax
Pneumonia
31
Give four non pharmacological interventions for Breathlessness
A fan
Positioning (Tripod)
Breathing techniques
NIV
32
Each cause of Breathlessness would be treated specifically if there was an underlying cause. What four general agents can be used?
Opioids (improve breathlessness and sleep, 2.5mg every 4h)
Corticosteroids (reduces any oedema)
Benzodiazepines (Lorazepam 0.5mg sublingual)
Oxygen
33
How would you manage terminal breathlessness?
Difficult to control
| Syring driver morphine/midazolam/levomepromazine
34
Define Constipation
Hard faeces which are uncomfortable or difficult to pass/reduction in frequency compared to normal pattern
Sense of incomplete evacuation
Faecal incontinence
35
Give three disease related causes of Constipation
```
Immobility
Decreased food intake
General weakness (paraplegia etc)
```
36
Give four other general causes of Constipation
Opioids
5HT3 Antagonists
Hypercalcaemia
Hypokalaemia
37
Name a stimulant laxative
Senna
38
Name a stool softener
Docusate Sodium
39
Name a Stimulant/Softener
Sodium Picosulfate
40
Name an Osmotic Laxative
Movicol
41
State the four diagnostic criteria for Malignant Bowel Obstruction
A - Clinical evidence of Bowel Obstruction
B - Obstruction distal to Treitz ligament
C - Presence of primary intra-abdo, or peritoneal mets
D - Absence of reasonable possibilities for cure
42
What two cancers commonly cause Malignant Bowel Obstruction
25% Bowel Cancer
| 40% Ovarian Cancer
43
What are the four aims of management in Malignant Bowel Obstruction?
Minimise bowel wall oedema
Control Nausea and Vomiting/Gut Motility
Control Pain
Reduce volume of intestinal secretions
44
What are the pharmacological options for Malignant BO
Centrally acting anti-emetics
| Antisecretory (Hyoscine)
45
What are the three broad causes of Depression and Anxiety in Oncology patients?
Physical concerns
Social concerns
Existential concerns
46
What two scales can be used to diagnose Depression/Anxiety in Oncological patients?
HAD scale
| BEDS (Brief Edinburgh Depression Scale)
47
Patients should be advised that Anti-Depressants will not work immediately and need to be titrated up more carefully. Give three options and a contraindication for each
SSRI - monitor if coprescribing tramadol
TCAs - increased cardiotoxicity
Venlafaxine - avoided if recent MI
48
Define Delirium
Global cerebral dysfunction characterised by disordered awareness, attention and cognition
49
Define Terminal Restlessness
Occurring in the last few days of life
50
Give three oncology specific causes of Delirium
Brain Metastases
Paraneoplastic Syndrome
High Dose IV Methotrexate/Vincristine etc
51
Name two paraneoplastic syndromes associated with Delirium
```
SIADH
Limbic Encephalitis (associated with SCC)
```
52
Other than a variety of bloods, name two other investigations that could be done for Acute Delirium?
CT/MRI
| LP
53
Name three impacts of Delirium
High level of distress for patients/family/HCW
Increased risk of incontinence and falls
Psychomotor agitation might be percieved as increased pain
54
Give four non pharmacological managements of Delirium
Well lit room with familiar objects
Visible clock/calendar
Reduced noise stimulation
Presence of family
55
What is the first line Pharmacological management for Delirium?
Haloperidol
56
If the Delirium was refractory, what medication could you consider?
Midazolam
57
What pharmacological option could you consider to treat hypoactive delirium?
Psychostimulants such as Methylphenidate
58
Causes of Oncological Seizures can be split into Toxic/Metabolic and Structural causes. State three Toxic/Metabolic causes
Hypercalcaemia
Hypomagnesaemia (Chemo or Excess Vomit)
Hepatic/Renal Failure
59
Causes of Oncological Seizures can be split into Toxic/Metabolic and Structural causes. State three Structural causes
Brain Metastases
Dural Metastases
Meningeal Carcinoma
60
What investigation on top of the standards for Delirium would you consider for Oncological Seizures?
EEG
61
How would you manage Oncological Seizures?
Lorazepam Acutely
May require prophylaxis with Benzodiazepines
62
What can cause Aseptic Meningitis in Oncological patients?
Intrathecal Chemotherapy
63
What is the most common cause of raised ICP in Oncology patients?
SOL or Obstructive Hydrocephalus
64
How does raised ICP present?
Headache, Vomiting, Hypertension, Bradycardia
Severe - reduced consciousness and papilloedema
65
What is the emergency management of Raised ICP?
IV Dexamethasone and Omeprazole
66
In raised ICP an urgent CT should be done. If the cause was a tumour, how should the patient be managed?
Head elevation
Dexamethasone and Omeprazole
If no change then IV Mannitol
67
In raised ICP an urgent CT should be done. If the cause was NOT a tumour, how should the patient be managed?
Dexamethasone
| do not escalate to Mannitol
68
In raised ICP an urgent CT should be done. If the cause was obstructive hydrocephalus, how should the patient be managed?
Dexamethasone and Shunt insertion
69
Define Pain
Unpleasant sensory and emotional experience associated with actual or potential tissue damage
70
Name two things that exacerbate and reduce pain respectively
Anger, Anxiety
Acceptance, Relaxation
71
What is Nociceptive Pain?
Nervous system is normal but there is an identifiable lesion causing tissue damage
Somatic - Skin/Muscle/Bone
Visceral - Hollow viscus or solid organ
72
What is Neuropathic Pain?
Malfunctioning Nervous System where nerve structure is damaged
Stabbing/Shooting/Burning pain
73
What does a Pain Assessment involve?
Impact of pain on all areas of life
Their understanding of pain
Any concerns about treatment
74
Describe the WHO Analgesic Ladder
1 - Non Opioid +/- Adjuvant
2 - Opioid for Mild to Mod pain (+ or - non opioid/adjuvant)
3 - Opioid for Mod to Sev pain (+ or - non opioid/adjuvant)
75
What NSAID would you prescribe for pain if the patient had no GI or CVS risk?
Naproxen (+PPI)
76
What NSAID would you prescribe for pain if the patient had GI but no CVS risk?
Celecoxib (+PPI)
77
What NSAID would you prescribe for pain if the patient had CVS but no GI risk?
Naproxen/Ibuprofen (+PPI)
78
Adjuvant treatments are agents whose primary action is not pain relief, but can be used alongside other medications. Give four examples
Antidepressants (Amitriptyline)
Anticonvulsants (Gabapentin)
Benzodiazepines (Diazepam)
Bisphosphonates
79
What pain locations have a good opioid response?
Soft tissue
| Visceral
80
What pain locations have a moderate opioid response?
Bone
| Incidental Pain
81
What pain location has a poor opioid response?
Neuropathic
82
Name four common side effects of opioids
Constipation
Dry mouth
Nausea and Vomiting
Drowsiness
83
What are the three main worries patients have associated with opioid use?
Addiction
Tolerance
'End of the Road'
84
What two medications should always be co-prescribed with opioids
Antiemetic (Metacloperamide)
| Laxative (Laxido)
85
Describe PRN use of opioids
Minimum one hourly
| If three doses in two hours - review
86
What can cause Opioid toxicity in the hospital setting?
Escalating dose too quickly
| AKI/Renal Impairment
87
How does Opioid toxicity present?
Drowsy
Hallucinations
Respiratory Depression
Pinpoint pupils
88
What is the conversion of Codeine to Morphine?
10:1
89
Give an example of a Slow Release and Immediate Release Morphine
SR - Zomorph
| IR - Oromorph
90
How do you titrate morphine to get new SR and PRN dose?
Add up total 24h Morphine = TDD
TDD/2 is new SR dose BD
TDD/6 is new PRN dose
Same principle for Syringe Driver except not BD - given over 24h
91
Name three features of successful pain control
Regular AND PRN doses prescribed
Dose prevents return of pain before next dose
Appropriate Timing
92
Name three features of Controlled Drug Prescribing
Name, ID, Drug Name, Formulation and Strength
Total amount in words and figures
Always prescribed in mg (not ml)
93
How strong is a Fentanyl patch and how frequently is it changed?
25mcg/h
Every 3 days
94
What (non patch) opioid should be given in mild to moderate renal impairment?
Oxycodone
95
What is the ratio of oral to SC morphine?
2:1
96
What opioids could be given in moderate to severe renal impairment?
Alfentanil
Fentanyl
Buprenorphine
97
What is the standard starting opioid regime for opioid naive patients?
15mg BD SR
5mg PRN IR
98
How do you convert morphine to oxycodone?
Divide by 1.5-2
