Management of CA SE and Pain Flashcards
Anti-neoplastic Agents
- aka
- cause of SE?
aka: chemo
Cause: these agents are unable to discriminate between neoplastic and normal cells.
Alopecia:
-tx
Anorexia
-tx
Alopecia: wigs, will grow back once finished with chemo.
Anorexia: antiemetics, megesterol* (Megace), dronabinol* (Marinol)
- = appetite stimulants
Cardiotoxicity
- acute or chronic?
- main drug causing this
- tx
usually chronic from cumulative dosing of cardiotoxic drugs, irreversible
Doxorubicin
Tx:
- MUGA scan*, exercise and diet modification, dose reduction, EKG
- Dexrazoxone (Zinecard) = cardioprotective, prevents free radicals
Constipation:
- pathophys
- cause
- tx
Pathphys: neurotoxic effects resulting in decreased peristalsis
Cause: vinca alkaloid, hypercalcemia, opiod pain management, dehydration
Management: bowel program, exercise and diet modifications, laxative and stool softener, increase fluids.
Skin or cutaneous responses:
- MC manifestations
- tx
- example; what is this? MC associated with which drug? prevention?
MC reactions include rash, photosensitivity, hypersensitivity
Tx: skin care
Example: acral erythema (aka hand-foot syndrome)
- MC associated with 5FU, capecitabine, doxirubicin
- prevention: holding ice packs during infusion and/or taking pyridoxine.
Diarrhea:
-tx
Fatigue:
- pathophys
- tx
Tx: hydration
- IV fluids
- loperamide/diphenoxylate
Fatigue:
-pathophys: anemia, changes in sleep patterns, pain, psychosocial factors
Tx: energy management, referral ?
Hemorrhagic cystitis:
- pathophys
- cause
- sx
- tx
Pathophys: bladder mucosal irritation from metabolic by-product of drugs
Cause: cyclophosphamide**, high dose methotrexate
Sx: dysuria, urinary frequency, burning, hematuria, previous hx of pelvic radiation
Tx:
PO/IV hydration with diuretics (to keep the bladder flushed)
Hepatotoxicity
- pathophysiology
- cause
- signs and sx
- tx
pathophys: direct toxic effect to liver when drugs are being metabolized
cause: ETOH use, liver dz, medication use,
signs and sx: jaundice, ascites, hepatomegaly, pain
Tx:
- limit acetaminophen to less than 4g/day
- avoid alcohol
- *if they get this you must stop the medication.
Hypersensitivity Rxn
- pathophys
- tx
pathophys: antigen/aby rxn
Tx: premedication prior to chemo, steroids, H1 and H2 blockers, epi
treated just like any other allergic rxn
Mucositis/Stomatitis/Esophagitis
- pathophys
- cause
- sx
- tx
Pathophys: direct effect of drug or radiation on oral mucosa
Cause: leukemia, lymphoma, just about all head and neck CA patients
Sx:
-xerostomia: dysphagia, plaque formation, pale dry oral mucosa (non-painful)
- mucositis: erythemia, desquamation, ulceration (painful)
- yeast infections: thrush, oral or esophageal candidiasis
Tx:
- dental referral
- magic mouthwash (viscous lidocaine, benadryl, nystatin susp.)
- chlorhexidine(Peridex) rinse
- cryotherapy (suck on ice)
- frequent oral hygiene, baking soda rinse QID.
Nausea and vomiting:
- pathophys
- associated with which drug class most commonly?
- tx
Pathophys:
- stimulation of the vagus nerve be the release of serotonin
- stimulation of the chemoreceptor trigger zone in the medulla
- stimulation of the true vomiting center
MC associated with alkylating agents.
Tx:
- MOST effective therapy is 5-HT3 agent PLUS dexamethasone.
- -Palonestron (aloxi) is now the preferred agent though it used to be zofran.
Other agents:
- lorazepam
- prochlorperazine (phenothiazine, compro)
Nephrotoxicity
- MC caused by which 2 drugs?
- tx
MC caused by cisplatin and high dose methotrexate
Tx:
-adequate IV hydration & fluid intake.
Neurotoxicity
- pathophysiology
- sx
- tx
pathophys: metabolic encephalopathy, intracranial hemorrhage d/t coagulopathy or myelosuppression
Sx:
-tinnitus, peripheral neuropathies, fine motor loss, numbness, tingling, gait disturbance, changes in mentation, urinary retention, constipation
Tx:
-avoid extremes in temperature
Pulmonary Toxicity:
- pathophys
- caused by which drug most commonly?
- tx
Pathophys: toxic damage to alveoli resulting in pneumonitis and pulmonary fibrosis
MC caused by bleomycin*
Tx: PFT prior to therapy & corticosteroids
-d/c chemo*
Sexual and reproductive dysfunction:
- signs
- tx
signs:
- early menopause, sterility
Tx: sperm banking, counseling
Myelosuppression:
- pathophys
- cause
pathophys: anemia, neutropenia, thrombocytopenia, pancytopenia
cause;
- leukemia
- taxanes
- alkylating agents
- antimetabolites
- etoposide
- nitrosureas
Anemia:
- sx
- tx
sx: dyspnea, fatigue, poor nutritional status
tx; RBC transfusions prn, iron supplememnts, O2, EPO only if absolutely necessary as increased risk of death associated with CA pts*
Neutropenia:
- pathophys
- sx
- tx
pathophys: absolute neutrophil count equal to or less than 1500. (Normal range is 1500-8000)
sx:
- signs of infection, malnutrition, prior chemotherapy or radiation
tx:
- filgrastim or pegfilgrastim (bone marrow stimulant)
* any fever gets admitted to the hospital*
How do you calculate the absolute neutrophil count?
Add neutrophils and bands and then convert to a %. multiply the total WBC by the total neutrophil percentage.
Ex. WBC = 1600, neutrophils = 48, bands =5
48+5 = 53 53/100 = 0.53 1600x0.53= 848 ANC = 848.
Thrombocytopenia
- what is this?
- signs and sx
- tx
what: decreased platelet production
* platelets less than 50,000 risk of bleeding, less than 20,000 high risk for bleeding, less than 10,000 critical risk
Normal: 150x10^9- 440x10^9)
signs and sx:
-petechiae, bruising, hemorrhage
Tx:
- platelet transfusion
- thrombocytopenic precautions: electric raxor, no suppositories, no dental flossing, no injections)
Radiation SE
Long term:
-nausea, vomiting, trouble swallowing, fatigue**, decreased platelets and lymphocytes
- skin: erythema, hair loss at site
- mucous membranes: fibrin plaquing, urinary bladder changes
- reproductive organs: sterility
bone: suppress osteoblast activity, decreased osteocytes
Signs and sx of pain
Pain measurement tools
hypertension, tachycardia, diaphoresis
agitation or confusion
apathy, inactivity, or irritability
refusal to eat
guarding
Tools:
- pain scale
- McGill pain questionnaire
- Memorial Pain assessment card
Somatic pain
- what is this?
- everyday example
- MC cause of somatic pain in CA pts
what: potential or real injury to tissues and is typical pain that is tender and localised to the site of injury. Constant and sometimes throbbing or aching.
ex. pain associated with cutaneous burn or an arthritic joint
MC cause is bone mets in CA pts.
Visceral Pain
- what is this?
- MOA
- common causes in CA pts?
what: poorly localized and often referred to a distant site which may be tender. it may be less constant than somatic pain, occurring in dull, colicky waves. often associated with nausea and diaphoresis
MOA: activation of pain receptors resulting from infiltration, compression, extension, or stretching of the thoracic abdominal or pelvic viscera.
MC causes include pancreatic CA and mets in the abd.
Neuropathic pain
- what is this?
- sx
- resistant to what type of drugs?
- cause
what: prolonged, severe, burning or stabbing pain, constant but may be interrupted by paroxysms of dramatically increased pain
sx: autonomic instability (tachycardia and diaphoresis)
Resistant to opiods, making it the most challenging types of pain to treat
Caused by injury to the nervous system, tumor compressing nerves or spinal cord. Cancer infiltrating the nerves or spinal cord.
Pain management
radiation, chemo, and palliative surgery should be applied to debulk or shrink the tumor
pharmacological agents including both non-opioid and opioid agents, as well as analgesic adjuvants
neurosurgical and anesthetic interventional procedures which physically or pharmacologically abrogate the nerve conduction pathways for pain.
Step one of three pain management
Step 2 & 3
Non-steroidals (NSAIDS) and acetaminophen
Step 2:
-opiods (tramadol); short half life, PRN
Step 3:
-opiods (morphine, fentanyl, oxycodone); sustained-release preparation.
*Have baseline long acting aceteminophen around the clock, soemtimes yo give them morphine for quick relief
Most pts end up on long acting opiod with short acting formulation for rescue. Once they start using more rescue you go up on the dose of long acting opiod.
Which two drugs do you not use in CA pts?
Remember don’t use codiene or meperidine in CA!!You don’t use meperidine/demerol b/c it has unique metabolism and metabolites that are toxic and if you keep redosing it the toxic effects build up.
Tramodol
-MOA
MOA: inhibits neuronal reuptake of serotonin and NE, like TCA.
Why might we use antidepressants, anticonvulsants, and local anesthetics when treating CA pain?
use to provide opioid sparing effect therby lessening opioid SE and possibly slowing the development of opioid tolerance.
*treating neuropathic pain which is often difficult to treat with opioids alone.
What is the MD Anderson protocol of pain?
- mild to moderate pain
- moderate to severe pain
- tingling and burning pain
- pain caused by swelling
mild-mod: Non-opioids such as acetaminophen and NSAIDS such as aspirin and ibuprofen
Mod-severe: opioids such as morphine, hydromorphone (dilaudid), oxycodone, hydrocodone, codeine, fentanyl, and methadone
Tingle/burn: antidepressants such as amitriptyline, imipramine, doxepin
antiepileptics such as gabapentin (neurontin)
Swelling: steroids such as prednisone, and dexamethasone
Rating scale of pain:
- mild
- moderate
- severe
mild: 1-3
mod: 4-6
severe: 7-10
What are some anesthesic interventional approaches to the management of CA pain?
nerve blocks
- celiac plexus block
- superior hypogastric plexus block
- myofascial injection
- neuroma injections
- spinal cord stimulation
- intrathecal and epidural injections
Alternative pain management
-biofeedback: gaining conscious voluntary control and can influence their level of pain
Breathing and relaxation exercises
distraction
heat or cold
hypnosis
imagery
massage, pressure, and vibration
TENS: transcutaneous electrical nerve stimulation
