Odds and Ends Flashcards
Diltiazem + opioid interaction via CYP
Ca-channel blockers increase serum fentanyl by inhibiting 3A4
“Only” drug approved for HIV cachexia
dronabinol
“Mild” thrush and can swallow
Nystatin over azoles (though less effective)
fleet enema precautions
renal failure, CHF, cirrhosis, elderly and frail: can deplete intravascular volume and cause hyperPHOS, hypoK and hypoCa
NK-1 (arprepitant) and steroids may be best for
delayed chemo n/v
antipsychotics in morphine toxicity
may worsen symptoms
Malignant cord compression first things
Steroids and surgery consult! Pick surgery consult before RT
Dementia: dependent in ADLs but not incontinent
FAST 6 even if nonverbal!
6 month mortality for dementia plus hip fracture
55%
Prevalence of major depression or anxiety at end of life (range)
10-40%
depression, insomnia, anorexia, nausea
mirtazipine
depression, anxiety, insomnia, neuropathy
nortriptyline
activating antidepressants
fluoxetine and bupropion
depression, anxiety, neuropathy, advanced age
duloxetine (don’t give elders TCAs on the boards)
riluzole
in ALS, prolongs median survival 2-3 months, but does not improve symptoms or QoL
Once admitted GIP, one goal must be
transition to a lower level of care. No time limit on GIP, but you don’t get to stay for “imminent dying”
Does Medicare require 24h home caregiver for hospice?
No
I say burnout, you say
mindfulness
defibrilator question
tape a magnet to him!
what to tell children
truthful disclosure to children of all ages
tx painful bleeding malodourous tongue lesion
hypofractionated RT
Even on hospice, nonwhite people
get less care, have less pain control, are less likely to receive emotional support
Cultures that prefer death at home
Samoan, Vietnamese, Asian Indian
Piperdine metabolism
3A4, EXCEPT remifentanil, which has an ester sidechain and is metabolized by erythrocytes
Alfentanil metabolism
3A5, polymorphic and highly variable
norfentanil
The inactive metabolite the fentanyl becomes after hepatic metabolism (3A4)
fentanyl’s elimination halflife
very dependent on total infusion time (even greater than morphine)
complicated grief, fMRI and psychology
Increased activation of the nucleus accumbens (reward center); the attachement model
worse prognosis in colon cancer (5)
signet, KRAS wildtype, NOT having microsattelite instability, high CEA pre-op, right-sided (proximal(
NSAIDs by half-life, shortest to longest
celecoxib (6-12h)
naproxen (14h)
meloxicam (15-20h)
nabumetone (20-24h)
oxeprozen (40-60h)
megestrol AE’s (3)
VENOUS thrombosis
Adrenal insufficiency
Androgen insufficiency (males)
“hard stool in the vault”
enema first
Common inhibitors of 3A4
will increase FENTANYL concentrations!
Valproate
Isoniazid
Disulfiram
Erythro, Clarithromycin (not Azithro)
Omeprazole
Cimetidine
Allopurinol
Sulfonamides
Ethanol (Acute)
pain assessment, patient with dementia
PAIDAD: breathing, facial expression, vocalizations, body language, consolability
lowest rate of hospice utilization
asian/pacific islander
bupe binding
high affinity, low activity (partial agonist); lipophilic,
25-50x more potent than morphine
constipation exam
digital rectal more valueable than abdominal exam or xray
metabolite unique to heroin
6-MAM
6-monoacetylmorphine
death notice in person
if the family is less than 1h away
patients with hallucinations and delirium while dying
often develop myoclonus and seizures
Antidepressants with tamoxifen
venlafaxine, desvanlafaxine
(NOT SSRIs or bupropion due to 2D6 inhibition)
phenelzine and other MAO cautions
need 5+ weeks between SSRI or serotonin syndrome develops; get hypertensive with wine or cheese
one year survival of Child-Pugh C
45%, better than MELD 35 (die within months)
pain scale for neonates, infants and kids under 7
CRIES for NEONATES
FLACC for children 2-7
6 Faces also works for kids over 3
pruritis of unknown cause tx
gabapentin or paroxetine
test before citalopram
EKG for QTc
communication dissatisfaction stats
white is most satisified, then black, then hispanic,
lung cancer causes after smoking
radon
certification must occur
within 2 calendar days of hospice admission
meperidine caution
normeperidine, toxic metabolite that causes seizures in renal impariment and elderly
herb that causes serotonin syndrome
St John’s Wort (acts as an SSRI)
intercostal nerve blocks
enter below inferior rib border, hit at least 2 levels
wintergreen oil (bengay) cautions
no hot packs! no blood thinners
post-op ibuprofen and tylenol
reduce pain and better outcomes in children to give both
complicated grief prevalence spouse versus child
10-20% spouse, 60% child
specific phobia and agoraphobia in cancer patients
higher than general population
tx pneumothorax at home
heimlich valve
gender and depression in cancer patients
no difference
octreotide for diarrhea TYPES (3)
secretory not osmotic–HIV, chemo-induced and high stoma output
“itching all over” in patient on opioids without cancer
diphenhydramine for some reason
Childs-Pugh criteria
encephalopathy, ascites
albumin, bili, INR
first line for unspecificied nausea
metaclopramide, if not contraindicated
osteosarcoma to lungs only
best prognosis for metastatic osteosarcoma, 40% survival
religious beliefs are associated with
aggressive care at end of life
Contraindications for organ donations (7)
active extracranial cancer, severe untreated sepsis, active HBV, HCV, WNV, rabies, CJD
Most patients on hospice die
At home
Medicare recipients who receive hospice
51.6%
tx neuropathic stump pain
ultrasound guided radiofrequency ablation
STEMI 30d mortality
2.5-10%
EF with increased risk in sudden cardiac death
35%
duration for complicated grief
1 year
most common causes of death associated with bereavement
cancer and cardiac disease
lower side effect TCAs
Nortriptyline, desipramine (secondary amines)
centrally acting antitussives
opioids, gabapentin (less evidence for TCAs, benzos)
dextromethorphan cautions
serotonin syndrome
CA15-3
breast cancer, along with CA 27.29
CA19-9
pancreatic and GI cancers
CA 117
GI stroma tumors and seminoma
Wound care: powder and cream
powder first; no hot water
Stark Law
limitations on self-referrals and kickbacks
myocardial vs pericardial mets
melanoma to myocardium, lung cancer to pericardium (and lung cuases more effusions)
ramelteon caution
CYP450 interactions
don’t give benzos in
COPD
psych disorders caused or worsened by bereavement
depression, bipolar, PTSD, SUD, anxiety disorders
how TCAs cause sedation, weight gain, tachycardia, blurred vision and dry mouth
H1 histamine blockade
cancers associated most with recurrence anxiety
lung and melanoma
causes tachycardia, only used for rigors
meperidine (demerol)
high risk features of hormone resistant prostate cancer
anemia, poor functional status, cord compression
(anemia is worse prognosis than hypoalbumin in prostate ca)
elevated beta-2-microglobulin
poor prognosis in MM, CLL, some lymphomas
elevated AFP
poor prognosis in liver cancer and germ cell tumors
neuropathic pain and fistulas
radiation injury
NSAIDs in pregnacy
safest before 20 weeks
opioids in first trimester
increase risk of birth defects
acupuncture most validated for this pain syndrome
migraine
Strontium-89 and Sumarium-153
bone-seeking radionucleotides that provide 3-6 months of pain relief from bone mets
life expectancy in vascular dementia
3-5 years (compared to 7 for LBD, 9 for AD)
morphine half-life in neonates and infants
increased due to decreased total body clearance
early morning awakening and increased total sleep
more consistent with depression than grief
Potency compared to morphine: hydrocodone
3/4 as potent
Potency compared to morphine: hydromorphone
5-10x
Potency compared to morphine: fenantyl and sufentanyl
fent is 100x, sufentanyl is 500-1000x
Potency compared to morphine: oxymorphone
3x
secondary amine TCA, unlikely to be antichoinergic
desimipramine (desi doesn’t cause urnibary retention)
methadone metabolite
2-ethylidene-1,5-dimethyl-3,3 diphenylpyrrolidine (EDDP)
methadone false positives on a drug test
verapamil, quetiapine, diphenhydramine, doxylamine (unisom, an antihistamine sleep aid)
6-MAM
heroin urine metabolite, clears in 24h
hydrocodone is synthesized from
thebaine and codeine
oxycodone is synthesized from
thebaine
prevalence of elder abuse/neglect
10%
best predictor of mortality risk in NAFLD
degree of fibrosis
nausea, anorexia, dehydration and orthostasis
consider adrenal insufficiency
L tryptophan caution
serotonin syndrome, don’t give with fluoxetine
complicated grief
doesn’t exist. Prolonged grief disorder (since 2022) 6-12 months after loss
Hgb < 3 prognosis
4-5 days
Most fatal blood transfusion risk
TRALI
Predict mortality in CKD/ESRD
degree of GFR reduction and proteinuria
continous care definition
8 hours of hospice care per day, >50% done by a nurse
AD prevalence over age 85
30-50%
Sepsis + AKI mortality
up to 35%
most common delirium subtype
mixed
morphine, hydromorphone and oxymorphone do not
have phase one metabolism, are not metabolized by CYP system
central alpha-2 adrenergic agonist, increases presynaptic inhibition of motor neurons
tizidanidine
Gaba agonist, works in the spinal cord, reduces substance P
baclofen
hospice at SNF is called
“routine home care”
celiac nerve fibers are
antero-crural, going from pancreas to large intestine (up to transverse)
cancer patients who meet criteria for psychiatric disorder
50%
worse prognosis at stage 4
small cell lung cancer
5HT antagonist with halflife of 40 hours
Palonosetron (note: zofran’s halflife is about 5 hours)
loss of motor, pain, light touch and temperature after celiac plexus block
anterior cord syndrome
NSAID with highest cardiac risk
diclofenac
first line for cancer cachexia
olanzapine, then dex
EKG before TCA at what age
40+
highly emetogenic chemos (3)
cisplatin, cyclophosphomide, dacarbazine
ramelteon or trazadone
trazodone, since ramelteon has not been studied in a palliative setting for insomnia
IV NSAIDs (4)
meloxicam, ketorolac, ibuprofen and diclofenac
best assessment of curative resection in colon cancer
histology
Calculates risk of death from alcoholic hepatitis
Maddrey discrimination function (Lille determines response to treatment)
best SC opioid
fentanyl
days to repeat skin site for butrans
21
preferred benzo for panic disorder
alprazolam
common medications causing esophagitis
doxycycline, bisphosphonates, iron, potassium, NSAIDs
3 day rule
Medicare will cover SNF if you have a necessary 3 day hospitalization (hospice would be revoked)`
first line for nausea from bowel obstruction
haloperidol (by the way is less sedating than thorazine)
Behavioral pain scale (BPS) is used for
adults on ventilators
FLACC score
Pain scale for nonverbal children: Face, leg movements, activity, crying, consolability
biological / elimination halflife
same thing: time it takes a drig to lose 50% of its activity
context-sensitve half life
decreasing drug concentrations after infusion at steady state
most common incontinence
urge
increased depression risk after surviving cancer
smoking, poor body impage (women only)
ALS, place feeding tube before
VC drops below 50%
bupropion is safe with what other antidepressant
SSRIs
chronic cough most common in
head and neck cancer
SSRI least likely to cause withdrawal
fluoxetine, long half life
most families agree to this when asked
autopsy (not required at any percent threshold by JCHO)
Latino disease where your soul gets scared out of your body
susto
most common side effect of modafinil
headache! can also agitate and disturb sleep but headache is most common
respiratory alkolosis and opioids
increased nonionized forms and increases CNS penetrance
phenytoin and opioids
inducer, increases metabolism and decreased effect
best steroid for energy in cancer
dex
does megace increase energy
yes
screener for complicated grrief
inventory of complicated grief (25 is suggestive, 30 is very suggestive)
does hospice cover PT/OT
yes
NMS rather than serotonin syndrome
faster onset, clonus
metabolized to meprobamate
carisoprodol (soma)
epidural morphine
bimodal, can caused delayed OD, not safe for outpatient
ABCD for cultural needs
attitudes, beliefs, context, decision-making style
morphine decreases minute ventilation by
decreasing RR, not tidal volume
on opioids, the carbon dioxide curve
has decreased slope and RIGHTward shift (central response to CO2 is decreased)
HER2 positive
unfavorable, as are circulating cancer cells, age <35 at dx
naproxen and ibuprofen class
propionic acide derivative NSAID (indomethacin is indole derivative and ketorolac is mixed)
REAL duration of prolonged grief disorder
6 months for children/adolescents
1 year for adults
of yearning OR preoccupation