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Year 4 Cancer Care and Haem > Complication Management > Flashcards

Complication Management Flashcards

1
Q

Define Nausea

A

Unpleasant feeling of needing to vomit, accompanied by autonomic symptoms

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2
Q

Define Vomiting

A

Forceful expulsion of gastric contents through the mouth

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3
Q

What are the four inputs to the Vomiting Centre?

A

Vestibular Input
High Centres
CTZ
Vagal Afferents

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4
Q

Where in Vomiting Centre inputs are Dopamine Receptors located?

A

CTZ

Vagal Afferents

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5
Q

Name three Dopamine antagonists

A

Domperidone
Metacloperamide
Haloperidol

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6
Q

Where in Vomiting Centre inputs are 5HT3 Receptors located?

A

CTZ

Vagal Afferents

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7
Q

What would be the Antiemetic of choice in impaired gastric emptying?

A

Metacloperamide

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8
Q

What would be the Antiemetic of choice in impaired Post Op/Radiotherapy?

A

Ondansetron

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9
Q

What would be the Antiemetic of choice in Bowel Obstruction?

A

Cyclizine

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10
Q

What would be the Antiemetic of choice in Drug SE?

A

Haloperidol

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11
Q

What would be the Antiemetic of choice with a Metabolic cause?

A

Haloperidol

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12
Q

What would be the Antiemetic of choice in Chemotherapy?

A

Metacloperamide

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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

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14
Q

Describe two central and two peripheral side effects of Anticholinergics

A

Central: Agitation and Restlessness
Peripheral: Dry Mouth and Constipation

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15
Q

Who should not recieve Anticholinergics?

A

Known heart disease/Arrhythmias

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16
Q

Why should you not combine Anticholinergics and Domperidone/Metacloperamide?

A

Domperidone and Metacloperamide have some cholinergic action

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17
Q

What level of Levomepromazine becomes sedating?

A

Above 12.5mg

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18
Q

What is a common side effect of 5HT3 Antagonists?

A

Constipation

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19
Q

Name three non pharmacological interventions for Nausea and Vomiting

A

Small Meals
Ginger
Accupuncture/Accupressure

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20
Q

What would be the Antiemetic of choice in Intracranial aetiology?

A

Cyclizine +/- Dexamethasone

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21
Q

What would be the Antiemetic of choice in vestibular aetiology?

A

Cyclizine

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22
Q

What would be the Antiemetic of choice in unclear aetiology?

A

Cyclizine

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23
Q

How does Biochemical vomiting present?

A

Constant Nausea
Small frequent vomits
Doesn’t improve with being sick

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24
Q

How does Nausea due to Brain Metastases present?

A

Projectile vomiting
Confusion
Headache

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25
Q

How does Nausea due to Bowel Obstruction present?

A

Colicky Pain
Distension
Improvement with vomiting

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26
Q

State three types of Nausea and Vomiting related to Chemotherapy

A

Acute - Within 24h
Delayed - 1-5d post treatment
Anticipatory - brought on by taste/odor/memories

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27
Q

What is Breathlessness in Oncology?

A

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

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28
Q

Give four Oncological causes of Breathlessness

A

Tumour compression
Pleural/Pericardial Effusion/Ascites
Phrenic Nerve Palsy
SVCO

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29
Q

Give two treatment related causes of Breathlessness

A

Surgery (Lobectomy/Pneomonectomy)

Radio/Chemo (Fibrosis)

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30
Q

Give three ‘other’ causes of Breathlessness

A

PE
Pneumothorax
Pneumonia

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31
Q

Give four non pharmacological interventions for Breathlessness

A

A fan
Positioning (Tripod)
Breathing techniques
NIV

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32
Q

Each cause of Breathlessness would be treated specifically if there was an underlying cause. What four general agents can be used?

A

Opioids (improve breathlessness and sleep, 2.5mg every 4h)
Corticosteroids (reduces any oedema)
Benzodiazepines (Lorazepam 0.5mg sublingual)
Oxygen

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33
Q

How would you manage terminal breathlessness?

A

Difficult to control

Syring driver morphine/midazolam/levomepromazine

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34
Q

Define Constipation

A

Hard faeces which are uncomfortable or difficult to pass/reduction in frequency compared to normal pattern
Sense of incomplete evacuation
Faecal incontinence

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35
Q

Give three disease related causes of Constipation

A 
Immobility
Decreased food intake
General weakness (paraplegia etc)
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36
Q

Give four other general causes of Constipation

A

Opioids
5HT3 Antagonists
Hypercalcaemia
Hypokalaemia

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37
Q

Name a stimulant laxative

A

Senna

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38
Q

Name a stool softener

A

Docusate Sodium

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39
Q

Name a Stimulant/Softener

A

Sodium Picosulfate

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40
Q

Name an Osmotic Laxative

A

Movicol

41
Q

State the four diagnostic criteria for Malignant Bowel Obstruction

A

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
Q

What two cancers commonly cause Malignant Bowel Obstruction

A

25% Bowel Cancer

40% Ovarian Cancer

43
Q

What are the four aims of management in Malignant Bowel Obstruction?

A

Minimise bowel wall oedema
Control Nausea and Vomiting/Gut Motility
Control Pain
Reduce volume of intestinal secretions

44
Q

What are the pharmacological options for Malignant BO

A

Centrally acting anti-emetics

Antisecretory (Hyoscine)

45
Q

What are the three broad causes of Depression and Anxiety in Oncology patients?

A

Physical concerns
Social concerns
Existential concerns

46
Q

What two scales can be used to diagnose Depression/Anxiety in Oncological patients?

A

HAD scale

BEDS (Brief Edinburgh Depression Scale)

47
Q

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

A

SSRI - monitor if coprescribing tramadol
TCAs - increased cardiotoxicity
Venlafaxine - avoided if recent MI

48
Q

Define Delirium

A

Global cerebral dysfunction characterised by disordered awareness, attention and cognition

49
Q

Define Terminal Restlessness

A

Occurring in the last few days of life

50
Q

Give three oncology specific causes of Delirium

A

Brain Metastases
Paraneoplastic Syndrome
High Dose IV Methotrexate/Vincristine etc

51
Q

Name two paraneoplastic syndromes associated with Delirium

A 
SIADH
Limbic Encephalitis (associated with SCC)
52
Q

Other than a variety of bloods, name two other investigations that could be done for Acute Delirium?

A

CT/MRI

LP

53
Q

Name three impacts of Delirium

A

High level of distress for patients/family/HCW

Increased risk of incontinence and falls

Psychomotor agitation might be percieved as increased pain

54
Q

Give four non pharmacological managements of Delirium

A

Well lit room with familiar objects
Visible clock/calendar
Reduced noise stimulation
Presence of family

55
Q

What is the first line Pharmacological management for Delirium?

A

Haloperidol

56
Q

If the Delirium was refractory, what medication could you consider?

A

Midazolam

57
Q

What pharmacological option could you consider to treat hypoactive delirium?

A

Psychostimulants such as Methylphenidate

58
Q

Causes of Oncological Seizures can be split into Toxic/Metabolic and Structural causes. State three Toxic/Metabolic causes

A

Hypercalcaemia
Hypomagnesaemia (Chemo or Excess Vomit)
Hepatic/Renal Failure

59
Q

Causes of Oncological Seizures can be split into Toxic/Metabolic and Structural causes. State three Structural causes

A

Brain Metastases
Dural Metastases
Meningeal Carcinoma

60
Q

What investigation on top of the standards for Delirium would you consider for Oncological Seizures?

A

EEG

61
Q

How would you manage Oncological Seizures?

A

Lorazepam Acutely

May require prophylaxis with Benzodiazepines

62
Q

What can cause Aseptic Meningitis in Oncological patients?

A

Intrathecal Chemotherapy

63
Q

What is the most common cause of raised ICP in Oncology patients?

A

SOL or Obstructive Hydrocephalus

64
Q

How does raised ICP present?

A

Headache, Vomiting, Hypertension, Bradycardia

Severe - reduced consciousness and papilloedema

65
Q

What is the emergency management of Raised ICP?

A

IV Dexamethasone and Omeprazole

66
Q

In raised ICP an urgent CT should be done. If the cause was a tumour, how should the patient be managed?

A

Head elevation
Dexamethasone and Omeprazole

If no change then IV Mannitol

67
Q

In raised ICP an urgent CT should be done. If the cause was NOT a tumour, how should the patient be managed?

A

Dexamethasone

do not escalate to Mannitol

68
Q

In raised ICP an urgent CT should be done. If the cause was obstructive hydrocephalus, how should the patient be managed?

A

Dexamethasone and Shunt insertion

69
Q

Define Pain

A

Unpleasant sensory and emotional experience associated with actual or potential tissue damage

70
Q

Name two things that exacerbate and reduce pain respectively

A

Anger, Anxiety

Acceptance, Relaxation

71
Q

What is Nociceptive Pain?

A

Nervous system is normal but there is an identifiable lesion causing tissue damage

Somatic - Skin/Muscle/Bone
Visceral - Hollow viscus or solid organ

72
Q

What is Neuropathic Pain?

A

Malfunctioning Nervous System where nerve structure is damaged

Stabbing/Shooting/Burning pain

73
Q

What does a Pain Assessment involve?

A

Impact of pain on all areas of life
Their understanding of pain
Any concerns about treatment

74
Q

Describe the WHO Analgesic Ladder

A

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
Q

What NSAID would you prescribe for pain if the patient had no GI or CVS risk?

A

Naproxen (+PPI)

76
Q

What NSAID would you prescribe for pain if the patient had GI but no CVS risk?

A

Celecoxib (+PPI)

77
Q

What NSAID would you prescribe for pain if the patient had CVS but no GI risk?

A

Naproxen/Ibuprofen (+PPI)

78
Q

Adjuvant treatments are agents whose primary action is not pain relief, but can be used alongside other medications. Give four examples

A

Antidepressants (Amitriptyline)
Anticonvulsants (Gabapentin)
Benzodiazepines (Diazepam)
Bisphosphonates

79
Q

What pain locations have a good opioid response?

A

Soft tissue

Visceral

80
Q

What pain locations have a moderate opioid response?

A

Bone

Incidental Pain

81
Q

What pain location has a poor opioid response?

A

Neuropathic

82
Q

Name four common side effects of opioids

A

Constipation
Dry mouth
Nausea and Vomiting
Drowsiness

83
Q

What are the three main worries patients have associated with opioid use?

A

Addiction
Tolerance
‘End of the Road’

84
Q

What two medications should always be co-prescribed with opioids

A

Antiemetic (Metacloperamide)

Laxative (Laxido)

85
Q

Describe PRN use of opioids

A

Minimum one hourly

If three doses in two hours - review

86
Q

What can cause Opioid toxicity in the hospital setting?

A

Escalating dose too quickly

AKI/Renal Impairment

87
Q

How does Opioid toxicity present?

A

Drowsy
Hallucinations
Respiratory Depression
Pinpoint pupils

88
Q

What is the conversion of Codeine to Morphine?

A

10:1

89
Q

Give an example of a Slow Release and Immediate Release Morphine

A

SR - Zomorph

IR - Oromorph

90
Q

How do you titrate morphine to get new SR and PRN dose?

A

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
Q

Name three features of successful pain control

A

Regular AND PRN doses prescribed
Dose prevents return of pain before next dose
Appropriate Timing

92
Q

Name three features of Controlled Drug Prescribing

A

Name, ID, Drug Name, Formulation and Strength

Total amount in words and figures

Always prescribed in mg (not ml)

93
Q

How strong is a Fentanyl patch and how frequently is it changed?

A

25mcg/h

Every 3 days

94
Q

What (non patch) opioid should be given in mild to moderate renal impairment?

A

Oxycodone

95
Q

What is the ratio of oral to SC morphine?

A

2:1

96
Q

What opioids could be given in moderate to severe renal impairment?

A

Alfentanil
Fentanyl
Buprenorphine

97
Q

What is the standard starting opioid regime for opioid naive patients?

A

15mg BD SR

5mg PRN IR

98
Q

How do you convert morphine to oxycodone?

A

Divide by 1.5-2

Year 4 Cancer Care and Haem (16 decks)

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