Module 4.4 (Palliative Care) Flashcards

Question

General principles of management of nausea and vomiting?

Answer 1

Assess likely cause • Treat any reversible causes • Use non-pharmacological measures such as: * avoidance of foods with strong tastes and smells * small and frequent meals – distraction techniques Prescribe an anti-emetic depending on the aetiology Review if necessary and make adjustments such as: * Up titration of dose – * Changing the route of administration – * Adding a second anti-emetic

Answer 2

Gastric stasis Medications Intestinal obstruction Raised intraocular pressure Biochemical Other

Answer 3

**Chemoreceptor trigger zone** * NT: dopamine, serotonin * Medications: metoclopramide, haloperidol, prochlorperazine **Cortical** * NT: GABA and serotonin * Medications: dexamethasone and BZDs **Vestibular** * NT: histamine1, acetylcholine muscarinic * Medications: promethazine, prochlorperazine and cyclizine **Gastrointestinal** * NT: dopamine, serotonin, acetylcholine muscarinic * Medications: metoclopramide, hyoscine, ondansetron **Vomiting centre** * NT: acetylcholine muscarinic, histamine, serotonin * Medications: promethazine, cyclizine, hyoscine

Answer 4

**Prokinetic (gastric stasis)** * ****metoclopramide 10mg tds **Chemoreceptor trigger zone (drugs, biochemical)** * haloperidol 0.5-2.5mg bd **Vomiting centre** * raised intracranial pressure, motion sickness * promethazine 10-25mg bd * cyclizine 25-50mg tds

Answer 5

* distressing for patient and family * 70% cancer patients in last 6 weeks * cardiac disease, lung disease, renal disease * prevalence and severity increases closer to death * subjective and does not correlate to objective measures dyspnoea: difficult or laboured breathing

Answer 6

Treat any reversible casues **Non-pharmacological mangement** * reassurance * positioning * calm environment --\> help with anxiety * windows open or fans blowing in face

Answer 7

Morphine is drug of choice for dyspnoea * oral or subcutaneous (not nebulised) * relieves sensation of dyspnoea * no detrimental effect on respiratory function * small doses usually effective \>1-2mg prn orally of morphine * dyspnoea is more severe in patients with unrelieved pain

Answer 8

Dyspnoea associated with anxiety Adding BZD to morphine beneficial effect \>lorazepam 0.5-1mg sublingual bd prn \> midazolam 5-10mg/day via subcut infusion

Answer 9

Very common symptom \>multiple reasons for constipation * decreased diet, fluids * disease state * medications **general good bowel hygiene** * if possible fluids, exercise, dietary fibre **avoid osmotic or fibre products** * if only eating and drinking minimum amounts

Answer 10

Stimulants with a softener * Coloxyl and Senna® 2 nocte – 3 bd * Coloxyl® 120mg 1-2 bd PLUS Bisalax® 10-20mg nocte OR Senokot® 4-6 nocte Macrogol * e.g. Movicol® * isosmotic 1-6 sachets per day Methylnaltrexone * peripheral opioid receptor antagonist * Indicated for opioid induced constipation

Answer 11

Delirium particular to the last days of life * Confusion, agitation, hallucinations Incidence nearly 90% Often multifactorial in palliative care patients * **Main cause is often primary irreversible disease (s)** * Other causes: \> decreasing renal and hepatic function, medications, hypoxia, dehydration, hypoglycaemia, infection or drug withdrawal

Answer 12

Less able to reverse causes Aim to reduce harm to patient or family **Simple non-pharmacological management** * Regular reorientation and reassurance * Familiar surrounds and carers, reduce distressing stimulation * Pain assessment and management * Correct dehydration, constipation and urinary retention * Oxygenation may be appropriate if hypoxia * Avoid physical restrain

Answer 13

Management: • * haloperidol 0.5–1 mg subcut prn • * haloperidol 2.5-5 mg/day subcut infusion If sedation required ADD: * clonazepam 0.2 mg subling prn – * clonazepam 0.5-1 mg/day subcut infusion – * midazolam 1 mg subcut prn – * midazolam 5-10mg /day subcut infusion

Answer 14

generally taking many medications number of medications increases as health deteoriates * more for symptom management * secondary prevention medications continued * increased number high risk medications * anticholinergic load increased

Answer 15

* Beers * Medication Appropriateness Index * Drug Burden Index * Anticholinergic Risk Scale * STOPP

Answer 16

Life epectancy Goals of care Time until benefit Effects of continuing therapy --\> risk-benefit ratio Short term benefit **(****anything not going to work in weeks/months = uselss)** \>survival \>quality of life \>symptom management

Answer 17

* Cease smoking * Decrease weight * Increase exercise * Control BP * Treat dyslipidaemia * Antiplatelet * Blood glucose control Aim to decrease complications \>macrovascular (CVD, stroke) \>microvascular (neuropathy, nephropathy, retinopathy)

Answer 18

* portable * less infection risk than IV * reliable absorption * filled on daily bassis * increased patient comfort * can be used easily at home

Answer 19

Unable to take oral medicatiosn because: * nausea and vomiting * dysphagia * severe weakness or unconscious * poor oral absorption due to dsease process

Answer 20

Scapular region Anterior chest wall Anterior aspect of thighs Anterior aspect of upper arms Anterior abdominal wall

Answer 21

**Common medications** * Analgesics \> morphine, hydromorphone * Antiemetics \> metoclopramide, haloperidol, promethazine * Sedatives \> clonazepam, midazolam * Others \> hyoscine butylbromide, glycopyrronium (glycopyrrolate)