N/V/C Malignant BO

Question 1

In the terminal phase, is a dry mouth indicative of the need for parenteral fluid?

Answer 1

No - relationship between not clear (b/w dehydration and thirst). Sensation of thirst related to sensation dryness of the mouth.

Question 2

Mx dry mouth in palliative stages?

Answer 2

• Ask pt if dry mouth

- inspect oral cavity for inflammation, debris and infection

Question 3

What are the cause of xerostomia?

Answer 3

• Damage to salivary glands (RT, surgery, infection)
• Medications (TCAs, antihistamines, anti cholinergics)
• Mouth breathing

Question 4

How is xerostomia managed?

Answer 4

Meticulous mouth care

Question 5

What is involved in mouth care?

Answer 5

• Frequent (2h) mouth washes with water
• Bioetene products (mouthwash, toothpaste)
• Moisten oral cavity with sips of fluid / plain water sprays
• Gentle teeth brushing
• Lanolin based balm to lips

Question 6

What are biotene products?

Answer 6

Formulations of enzymes found normally in human saliva

Question 7

What is stomatitis?

Answer 7

Inflammation of mouth or lips

Question 8

Causes of stomatitis?

Answer 8

• Xerostomia
• RT
• Chemotherapy
• Infections (fungal, bacterial, viral)

Question 9

Mx stomatitis?

Answer 9

Symptomatic and Rx cause
-General mouth care
-systemic or topical oral antifungals
>nystatin 100000U/mL 1mL
>fluconazole 50-100mg PO OD x3/7

Question 10

When is metoclopramide contraindicated?

Answer 10

Suspected bowel obstruction

Question 11

Rx N/V secondary to poor gastric emptying?

Answer 11

-Metoclopramide 10mg PO QID
OR
-domperidone 10mg PO QID

Question 12

Mx hyperacidity (i.e reflux) causing N/V?

Answer 12

• Simple antacids if occasional

- PPI e.g. omeprazole 20mg PO daily

Question 13

Rx N/V due to CTZ causes?

Answer 13

• Haloperidol 0.5-2.5mg PO or SC BD; max 7.5
• Metoclopramide 10-20mg PO QID
• Prochlorperazine 5-10 PO TDS

Question 14

How do drugs used to Mx CTZ N/V act? Uses?

Answer 14

i.e. Halo, Metoclopramide and prochlorperazine.
-inhibit dopamine in CNS
SEs:
-drowsiness
-postural hTN
-akathisia
-extrapyramidal Sx (e.g. acute dystonia)

Question 15

Rx vestibular cause N/V?

Answer 15

Prochlorperazine 5-10mg orally TDS-QID
OR
Haloperidol 0.5-2.5mg orally BD
Poor response, ADD
-Promethazine
-Cyclizine

Question 16

Rx N/V a/w anxiety?

Answer 16

• Alprazolam .125-5 6h

- Lorazepam 0.5-1 6h

Question 17

Mx N/V secondary to raised ICP?

Answer 17

Dexamethasone 8-16mg PO
PLUE
-haloperidol 0.5-2.5 BD

Question 18

Mx chemotherapy/RT associated N/V?

Answer 18

5-HT3 antagonist e.g. ondansetron 4mg PO BD

Question 19

Constipation prophylaxis?

Answer 19

• Encourage regular toileting
• Ensure adequate hydration and fibre
• Encourage general activity through control of other symptoms
• Treat any cause (i.e. lack of privacy, pain, poor mobility)

Question 20

In which patients do bulk forming agents have no role?

Answer 20

• Patients taking opioids

- Nonambulant patients

Question 21

What must be prescribed with opioids?

Answer 21

The hand that writes the opioid order must also write the aperient order.

Question 22

Constipation prophylaxis in PC patients?

Answer 22

Prophylactic lax best = faecal softening agent and bowel stimulant
docusate + sennoside B 100+ 16 mg (= 2 tablets) orally, once or twice daily.

Question 23

Mx difficulty expelling soft stool?

Answer 23

Propulsive stimulant agent

Bisacodyl 10 mg (=2 tablets) orally, at night, increasing to a maximum of 10 mg twice daily

Question 24

What are the causes of bowel obstruction in palliative cancer patients?

Answer 24

• Instrinsic (e.g. CRC 1”)
• Extrinsic compression (e.g. pancreatic Ca)
• Peristaltic dysfunction (e.g. ovarian Ca)

Question 25

medical Mx of bowel obstruction (after exclusion of surgically reversible cause)?

Answer 25

• Reduce parenteral fluids
• Withdraw stimulant laxatives (senna and bisacodyl)
• avoid pro kinetic anti emetics (metoclopramide, domperidone)
• control sx of pain, N/V: analgesics, anti-spasmodics, anti-emetics
• reduce volume of gastric secretions with ranitidine
• gastric decompression (NGT, gastrostomy)

Question 26

Mx colic malignant BO?

Answer 26

hyoscine butylbromide (Buscopan) 60 to 80 mg/24 hours (initially) by continuous SC infusion, and titrate to effect (to a maximum of 120 mg/24 hours).

Question 27

What are the mechanisms of opioid induced nausea and vomiting?

Answer 27

1. Contipation
2. Gastroparesis
3. CTZ stimulation
4. Labyrinth sensitisation

Question 28

when is methylnaltrexone indicated?

Answer 28

mx severe constipation used if rectal preparations are ineffective or hazardous (e.g. neutropenic from chemotherapy)