Early Tests and Prognostication Flashcards
COPD relief before opioids:
oxygen, fans, pulmonary rehabc
Hiccup-genic meds:
benzos, dex
Drug of choice for hiccups:
baclofen
treats peripheral hiccups
reglan
30% of TIPS patients develope
encephalopathy
block for pelvic pain
hypogastric plexus
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SSRIs and tamoxifen
Some (fluoxetine, paroxetine) inhibit cyto 2D6 and cannot be given with tamoxifen
Target of Aprepitant
Antiemetic, targets Neurokinin receptors in the the CRTZ
Treat cholestatic pruritis
cholestyramine, rifampin, naltrexone for opioid build up, methotrexate, sertraline, paroxetine, dronabinol
RLS at EOL
same as ever: pramipexole, ropinerole
drugs metabolized to morphine
codeine, heroin (codeine would be drug screen positive for codeine and morphine)
false positive for morphine
quinolones: ciprofloxacin, doxifloxacin, moxifloxacin
fentanyl class
phenylpiperdine (with pethidine, alfentanil, fentanyl, sufentanil and remifentanil) (synthetic)
methadone class
diphenylheptane derivatives (methadone, propoxyphene), (synthetic)
Natural opioids
Morphine, codeine, thebaine, papaverdine
semi-synthetic opioids
diamorphine (heroin), diahydromorphone, oxycodone, buprnorphine
synthetic opioids
fentanyl, methadone, tapentadol
MOP/mu agonism
How opioids provide analgesia
MOP/mu neuro pathway
indirectly INHIBITS periaqueductal grey (PAG) and nucleus reticularis paragigantocellularis (NRPG). INCREASES signal to the nucleus raphe magnus (NRM), increasing stimulation of 5-hydroxytryptamine and enkephalin-containing neurons which connect directly with the substantia gelatinosa of the dorsal horn.
4 A’s of pain treatment outcomes
analgesia, activities of daily living, adverse effects, aberrant behaviors
oxycodone or morphine–higher oral bioavailability?
oxycodone
Logistics of filling opioids q3m
2 post-dated prescriptions are allowed for scheduled II opioids. When this is done, prescribing clinicians should counsel patients to leave the post-dated prescriptions with their pharmacist for safe keeping
incidence of epidural mets is highest in these cancers, which frequently spread to the axial skeleton
breast, lung, prostate, myeloma, melanoma and hypernephroma
predicting mortality in dementia
7A qualifies for hospice, but dysphagia/feeding issues more strongly predicts death
when to increase basal morphine PCA
8 hours (accounts for 5 halflives)
time to peak effect of intranasal naloxone
20-30min, halflife is 2 hours. Always call 911 when giving naloxone
KPS
est 1949, 100-point scale for functional status in oncology settings. baseline activity levels, disease related disability, and dependence, 0 being dead, and 100 no functional limitation
KPS 40 or less predicts
median life expectancy of 3 months in cancer pt
ECOG
5-point global functional scale with 0 set as a normal and 4 being a moribund. Higher scores have been correlated with shorter survival. Not accurate in non-malignant illnesses.
Median survival 3 months (KPS, ECOG)
Karnofsky score <40 or ECOG > 3.
Prognosis for malignant hypercalcemia (except new dx breast)
8 weeks
Prognosis for malignant pericardial effusion
8 weeks
Prognosis for LMD
8-12 weeks
Prognosis for multiple brain mets
1-2 months without RT, 3-6 months with RT
Prognosis for malignant ascites, pleural effusion or bowel obstruction
<6 months
tx malignant hypercalcemia
treat cancer, bisphosphonates, hydration (and loop diuretics)
CPR survival
44% at 20 minutes; 17% leave the hospital. Arrhythmia 35%, asystole/PEA 10%
Worse prognosis CPR
Sepsis day prior, Cr > 1.5, metastatic cancer, dementia, dependent stats
Prognosis in compensated vs decompensated liver disease
12y vs 2y
prognosis for: metastatic solid cancer, acute leukemia or high-grade lymphoma, untreated (and 2 exceptions)
< 6 months, except breast or prostate with high KPS
In hospital mortality if feeding tube is placed:
15-25%; one year mortality is 60%
factors predicting high mortality from TF placement
advanced age, CNS pathology (stroke, dementia), cancer (except early stage head/neck cancer), disorientation, and low serum albumin.
Modified Glasgow Prognostic Score mGPS
high mGPS means high CRP and low albumin; reduced survival in all cancer types
PaP, palliative prognostic score
three risk groups of 30d survival: KPS, dyspnea, anorexia, white count and lymphs, clinical prediction of survival in weeks (D variant adds delirium)
PPS, Palliative Prognostic Scale:
parallel to KPS (0-100), ambulation, activity level, self-care, intake, level of consciousness, determines estimated mean survival
LMD by cancer type (solid)
common in breast cancer, small cell lung cancer, and melanoma while rare in gastrointestinal and gynecologic cancers.
LMD in heme onc
found in 40-50% of patients, mostly commonly the acute leukemias, high-grade lymphomas (such as large cell and Burkitt lymphomas), and lymphomas in which the primary cancer site is the breast, testes, or vitreoretinal space.
Best treatment response in LMD
hormone or HER2 receptor positive breast cancer, EGFR or ALK mutant lung cancers, BRAF or immunotherapy-responsive melanoma, some lymphomas, etc.
Prognosis for patients with LMD who are treated with comfort care
weeks to months
COPD prognosis factors:
age, degree of dyspnea, weight loss (BMI), functional status, and FEV1 are relevant prognostic factors for predicting 1-3 year survival.
CHF hospice criteria
a) symptoms of recurrent HF at rest (NYHA class IV) and b) optimal treatment // EF < 20% is helpful but not required.
CHF 1y mortality by class
- Class II (mild symptoms): 5-10%.
- Class III (moderate symptoms): 10-15%.
- Class IV (severe symptoms): 30-40%.
Negative prognostic indicators in CHF
hospitalization, treatment intolerance, hypotension, tachycardia, renal disease, low LVEF, arrhythmia, anemia, hyponatremia, cachexia, orthopnea, co-morbid diseases
FAST stage 7A (impaired ADLs, incontinence, and can only speak 6 words) is appropriate for hospice enrollment if
also has aspiration, upper urinary tract infection, sepsis, multiple stage 3-4 ulcers, persistent fever, or weight loss >10% within six months
MRI scale for dementia
morality risk index, uses variables and comorbidities, greater value at 6 months but only validated in new nursing home admits
Dex dosing for bone pain:
2 to 8 mg of oral dexamethasone either given once in the AM or divided over BID dosing
Maslach Burnout Inventory: three domains
a) Emotional Exhaustion: being emotionally overextended and exhausted by one’s work. B) Depersonalization C) Personal accomplishment: feeling competent and successful
Survival from a traumatic adult brain injury, with an initial Glasgow Coma Score of 3-5 can be expected in:
15-20%
neurologic damage related to a fracture is a relative contraindication for
vertebroplasty.
antispasmodics in mechanical back pain
not effective beyond 2 weeks
most sedating muscle relaxant
Tizanidine, avoid in elderly
least sedating muscle relaxant
metaxolone
atropine and scopalomine structure
tertiary amines, cross the BBB
glycopyrolate structure
quaternary amine, does not cross BBB
testosterone recovery after opioid cessation
days!
known to cause skin irritation in SQ infusion
methadone
Peak effect of IV tylenol
10 minutes (vs 1 hour for PO, likely due to increased CNS concentration)
lido patch facts (4)
best for neuropathic pain, can be cut, contraindicated in liver disease, absorbed less than 5% so does not cause topical numbness
an example of a small intestine secretogogue
liactolide
an example of a selective chloride channel-2 activator
lubiprostone
Answering “Yes” to the surprise question
93% while the positive predictive value of “no” answers may only be 37%. More accurate for cancer patients, has been studied and validated in almost every setting
Tx acute urinary retention
alpha antagonists like doxazosin
Only strong negative predictor of poor CPR outcome
myoclonic status epilepticus within 1 day of CPR or rewarming
diffuse muscle loss associated with an increase in fat mass and abdominal circumference.
Sarcopenia
how opioids cause myoclonus
3-glucuronide opioid metabolites
opioid induced nausea
is not an allergic reaction, but rather a side effect to which tolerance develops within 3-7 days in most patients.
increased risk of hospitalization from hypoglycemia
tramadol
opioid metabolites are secrete by
kidneys
proportion of active drug that enters systemic circulation
bioavailability
legal standard of informed consent
varies by state
does botox treat dry mouth
no, it treats hypersalivation (and depression!)
skin wound that commonly occurs over the sacrum during dying process; usually irregularly shaped, pear-shaped, or butterfly-shaped; > 2 inches in diameter; and may include red, yellow, black, and/or purple discoloration.
Kennedy terminal ulcer
Prognosis in HRS
6 months or less
Liver disease, MELD score factors
serum creatinine, total bilirubin, and INR.
One year mortality from onset of hepatic encephalopathy in end stage liver disease
60%
Anuric renal failure, prognosis off HD
5-12 days
Accuracy of prognosis in hospice discharges
20% of predictions were accurate, doctors overestimated by a factor of 5.3!
ESRD on HD, 1 and 5 year mortality
25%, 60%
ESRD on HD, KPS < 70
RR of dying within 3y is 1.44
ESRD on HD, strong predictor of death
Albumin < 3.5
Charleston Co-Morbidity Index
correlates to prognosis in ESRD
Prognosis of HIV
same as general population, except for Black people, OIs, poor functional status, low CD4 count, hhigh viral load, active substance use
Parkinsons complications, within 5 years of diagnosis
dyskinesias, psychosis, dystonia (treatment related)
Parkinsons complications, within 12 years of diagnosis
falls, gait disturbance, balance issues
Parkinsons complications, within 15-20 years of diagnosis
issues with dementia/hallucinations
Poor prognosis in stroke (at 3 months)
NIHSS > 16, age > 75, women, embolic, hemorrhagic conversion, low income, poor social support, treatment after >2 hours, ED stay > 8h; not getting tPA, not being at a stroke center
technical definition of cachexia
> 5% weight loss over 6 months in absence of starvation or BMI <20 and weight loss >2%; or appendicular skeletal muscle index consistent with sarcopenia and weight loss >2%
refractory cachexia prognosis
<3 months
ECOG 1
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (light housework/office work). (KPS 80-90)
ECOG 2
Ambulatory and capable of self-care but unable to carry out work activities. Up and about more than 50% of waking hours. (KPS 60-70)
ECOG 3
Capable of limited selfcare, confined to bed/chair more than 50% of waking hours. (KPS 40-50)
ECOG 4
Disabled, unable to perform any self-care, and totally confined to bed or chair. (KPS 10-30)
ECOG 5
Dead (KPS 0)
ECOG limitations
meant to capture functional impairments from cancer or cancer treatments. It is difficult to interpret for functional limitations from unrelated processes (e.g., a preexisting spinal cord injury) and it is not validated in children nor for prognostication in people without cancer.
ALS hospice criteria (3)
Impaired breathing, VC <30%; significant functional decline; life-threatening complications (sacral wound, sepsis, aspiration)
