Pallative Care π§ Flashcards
What is neuropathic pain?
Pain which arises following damage or disruption of the nervous system
It often responds poorly to standard analgesia.
List four examples of neuropathic pain.
- Diabetic neuropathy
- Post-herpetic neuralgia
- Trigeminal neuralgia
- Prolapsed intervertebral disc
What are the first-line treatments for neuropathic pain according to NICE?
- Amitriptyline
- Duloxetine
- Gabapentin
- Pregabalin
True or False: Drugs for neuropathic pain are typically used as combination therapy.
False
They are typically used as monotherapy.
What may be used as βrescue therapyβ for exacerbations of neuropathic pain?
Tramadol
What is the role of topical capsaicin in neuropathic pain management?
Used for localized neuropathic pain (e.g., post-herpetic neuralgia)
What are the key opioid receptors involved in pain transmission?
- Mu (Β΅) Receptors
- Kappa (ΞΊ) Receptors
- Delta (Ξ) Receptors
Where are mu (Β΅) receptors primarily located?
In the brain, brainstem, and spinal cord
What is the primary site of metabolism for opioids?
The liver
What is a key role of cytochrome P450 enzymes in opioid metabolism?
Modifying opioids to form more water-soluble metabolites
What is the significance of genetic polymorphisms in CYP450 enzymes?
They can significantly affect the metabolism of certain opioids, leading to variability in clinical response.
What should be prescribed for all patients initiating strong opioids?
Laxatives
What is the breakthrough dose of morphine for patients on opioids?
One-sixth the daily dose of morphine
Which opioid is preferred in palliative patients with mild-moderate renal impairment?
Oxycodone
What is the conversion factor from oral codeine to oral morphine?
Divide by 10
What is the recommended first-line treatment for intractable hiccups?
Chlorpromazine
What is the most common symptom of Superior Vena Cava (SVC) obstruction?
Dyspnoea
List three common malignancies associated with SVC obstruction.
- Small cell lung cancer
- Lymphoma
- Breast cancer
What is the first-line treatment for nausea and vomiting due to reduced gastric motility?
Pro-kinetic agents
What are two first-line medications recommended for chemically mediated nausea?
- Ondansetron
- Haloperidol
What is the role of cyclizine in palliative care?
Recommended as a first-line treatment for vestibular-related nausea
Fill in the blank: Guillain-Barre syndrome describes an immune-mediated demyelination of the _______.
Peripheral nervous system
What are two initial symptoms experienced by patients with Guillain-Barre syndrome?
- Back pain
- Leg pain
What is the characteristic feature of Guillain-Barre syndrome?
Progressive, symmetrical weakness of all the limbs
What type of investigation shows albuminocytologic dissociation in Guillain-Barre syndrome?
Lumbar puncture
What is autonomic involvement?
A condition where the autonomic nervous system is affected, potentially leading to symptoms like urinary retention and diarrhea.
What is urinary retention?
The inability to empty the bladder completely, which can lead to discomfort and other complications.
What is diarrhoea?
A condition characterized by frequent loose or watery bowel movements.
What is papilloedema?
Swelling of the optic disc due to increased intracranial pressure, thought to be secondary to reduced CSF resorption.
What is albuminocytologic dissociation?
A rise in protein with a normal white blood cell count, found in 66% of certain conditions.
What are some features of pulmonary oedema on a chest x-ray? (6)
- Interstitial oedema
- Batβs wing appearance
- Upper lobe diversion
- Kerley B lines
- Pleural effusion
- Cardiomegaly
What is the first-line investigation for all patients HF according to NICE guidelines issued in 2018?
An N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test.
What should be arranged if NT-proBNP levels are βhighβ?
Specialist assessment, including transthoracic echocardiography, within 2 weeks.
What is B-type natriuretic peptide (BNP)?
A hormone produced mainly by the left ventricular myocardium in response to strain.
What are the high levels of BNP and NT-proBNP?
- BNP: > 400 pg/ml (116 pmol/litre)
- NT-proBNP: > 2000 pg/ml (236 pmol/litre)
What factors can increase BNP levels? (11)
- Left ventricular hypertrophy
- Ischaemia
- Tachycardia
- Right ventricular overload
- Hypoxaemia
- GFR < 60 ml/min
- Sepsis
- COPD
- Diabetes
- Age > 70
- Liver cirrhosis
What is the first-line treatment for heart failure?
Both an ACE-inhibitor and a beta-blocker.
Which beta-blockers are licensed to treat heart failure in the UK?
- Bisoprolol
- Carvedilol
- Nebivolol
What is the standard second-line treatment for heart failure?
An aldosterone antagonist, also known as a mineralocorticoid receptor antagonist.
What are examples of aldosterone antagonists?
- Spironolactone
- Eplerenone
What role do SGLT-2 inhibitors have in heart failure management?
They reduce glucose reabsorption and increase urinary glucose excretion.
What are examples of SGLT-2 inhibitors?
- Canagliflozin
- Dapagliflozin
- Empagliflozin
What is the third-line treatment for heart failure?
Options include ivabradine, sacubitril-valsartan, hydralazine with nitrate, digoxin, and cardiac resynchronisation therapy.
What are the criteria for prescribing ivabradine?
Sinus rhythm > 75/min and a left ventricular fraction < 35%.
What are the indications for cardiac resynchronisation therapy?
Widened QRS complex on ECG, typically left bundle branch block.
What does the New York Heart Association (NYHA) Class I indicate?
No symptoms and no limitation in physical activity.
What does the New York Heart Association (NYHA) Class IV indicate?
Severe symptoms, unable to carry out any physical activity without discomfort.
What is acute heart failure (AHF)?
A life-threatening emergency characterized by sudden onset or worsening of heart failure symptoms.
What is de-novo AHF?
Acute heart failure occurring without a prior history of heart failure.
What are common precipitating causes of acute heart failure?
- Acute coronary syndrome
- Hypertensive crisis
- Acute arrhythmia
- Valvular disease
What are the typical symptoms of acute heart failure?
- Breathlessness
- Oedema
- Fatigue
- Chest signs
What is the recommended initial treatment for all patients with acute heart failure?
IV loop diuretics like furosemide or bumetanide.
What is the role of oxygen in treating acute heart failure?
To keep oxygen saturations at 94-98% as per guidelines.
What should be monitored in patients on both ACE inhibitors and aldosterone antagonists?
Potassium levels, due to the risk of hyperkalaemia.
What is high-output heart failure?
A condition where a normal heart cannot meet the bodyβs metabolic demands.
What are some causes of high-output heart failure? (6)
- Anaemia
- Arteriovenous malformation
- Pagetβs disease
- Pregnancy
- Thyrotoxicosis
- Thiamine deficiency
What is the most common site for bone metastases?
Spine.
What investigations does NICE recommend for all patients with suspected cancer? (9)
- FBC
- U&E
- LFT
- Calcium
- Urinalysis
- LDH
- Chest X-ray
- CT of chest, abdomen, pelvis
- AFP and hCG
What are βcannonball metastasesβ?
Multiple, round well-defined lung secondaries, often seen with renal cell cancer.
What investigations does NICE recommend for patients with suspected malignancies? (4)
- Urinalysis, LDH
- Chest X-ray
- CT of chest, abdomen and pelvis
- AFP and hCG
These investigations are tailored for specific patient presentations.
What is the purpose of a myeloma screen?
To investigate if there are lytic bone lesions present
This is part of the investigations recommended by NICE.
What is the role of endoscopy in cancer diagnosis?
Directed towards symptoms
Endoscopy can help visualize internal structures to identify malignancies.
What is the significance of PSA testing?
Used for prostate cancer screening in men
PSA stands for Prostate-Specific Antigen.
What does CA 125 indicate in women?
Potential peritoneal malignancy or ascites
CA 125 is a tumor marker often associated with ovarian cancer.
What imaging technique is recommended for men with germ cell tumors?
Testicular ultrasound
This imaging helps assess testicular masses.
What is mammography used for?
Screening for breast cancer in women with clinical or pathological features
Mammography is a specialized imaging technique for breast tissue.
How are metastatic bone tumors categorized?
Blastic, lytic, or mixed
This classification helps in understanding the nature of the lesions.
Which type of metastatic disease has the lowest risk of spontaneous fracture?
Osteoblastic metastatic disease
In contrast, osteolytic lesions carry a higher risk of fracture.
Where are lesions most prone to spontaneous fracture?
Peritrochanteric region
This is due to loading forces at that site.
What is the purpose of the Mirel Scoring system?
To stratify the risk of spontaneous fracture for bone metastasis
It helps guide treatment decisions based on fracture risk.
What score indicates an impending fracture according to the Mirel Scoring system?
9 or greater
This score suggests a 33% risk of fracture.
What treatment is recommended for a Mirel score of 8?
Consider fixation
This score is considered borderline for fracture risk.
What is the recommended management for a Mirel score of 7 or less?
Non-operative management
This indicates a low risk of fracture (4%).
What symptoms may indicate spinal metastases?
- Unrelenting lumbar back pain
- Thoracic or cervical back pain
- Worse with sneezing, coughing or straining
- Nocturnal pain
- Associated tenderness
These symptoms can be indicative of underlying malignancy.
What should be suspected if neurological features are present with back pain?
Spinal cord compression
Prompt action is necessary to address potential neurological compromise.
What imaging should be performed if no neurological features are present?
Whole spine MRI within one week
This is crucial as patients often present with multi-level disease.
What are the usually transient side effects of opioids?
Nausea, Drowsiness
These side effects typically resolve over time.
What are the usually persistent side effects of opioids?
Constipation
This side effect often continues as long as opioid treatment is maintained.
What is the conversion factor from oral codeine to oral morphine?
Divide by 10
This means that for every 10 mg of codeine, one should use 1 mg of morphine.
What is the conversion factor from oral tramadol to oral morphine?
Divide by 10
This indicates that 10 mg of tramadol is equivalent to 1 mg of morphine.
How does oxycodone compare to morphine in terms of sedation, vomiting, pruritis, and constipation?
Less sedation, vomiting, and pruritis; more constipation
Oxycodone is preferred for its reduced sedative effects.
What is the conversion factor from oral morphine to oral oxycodone?
Divide by 1.5-2
This range indicates that for every 1.5 to 2 mg of morphine, one should use 1 mg of oxycodone.
What does a transdermal fentanyl 12 microgram patch equate to in oral morphine daily?
Approximately 30 mg oral morphine daily
This conversion helps in managing pain through alternative delivery methods.
What does a transdermal buprenorphine 10 microgram patch equate to in oral morphine daily?
Approximately 24 mg oral morphine daily
Understanding this conversion assists in opioid rotation and dosing.
What is the conversion factor from oral morphine to subcutaneous morphine?
Divide by 2
This indicates that to convert from oral to subcutaneous, you halve the oral dose.
What is the conversion factor from oral morphine to subcutaneous diamorphine?
Divide by 3
This means that the subcutaneous dose is one-third of the oral morphine dose.
What is the conversion factor from oral oxycodone to subcutaneous diamorphine?
Divide by 1.5
This indicates that for every 1.5 mg of oxycodone, one should use 1 mg of diamorphine.
What is the first-line treatment for acute constipation not associated with opioid use?
Bulk-forming laxatives such as ispaghula husk
Ispaghula husk is recommended alongside dietary changes, hydration, and physical activity.
What type of laxative is docusate?
A stool softener and a mild stimulant laxative
Docusate can be used for opioid-induced constipation or as an enema in faecal impaction.
What is lactulose classified as?
An osmotic laxative
Lactulose is used in the treatment of acute constipation if bulk-forming laxatives and macrogol are ineffective.
What is macrogol 3350 used for in acute constipation?
It is added second-line if treatment with a bulk-forming laxative is not successful
Macrogol is classified as an osmotic laxative.
What type of laxative is senna?
A stimulant laxative
Senna is the first-line treatment for opioid-induced constipation, used with an osmotic laxative.
True or False: Ispaghula husk should be used for acute constipation associated with opioid use.
False
Ispaghula husk is not recommended for constipation related to opioid use.
Fill in the blank: Docusate can be given for _______ constipation.
opioid-induced
Docusate is also used as an enema for faecal impaction.
Fill in the blank: Lactulose is added in treatment if bulk-forming laxatives and _______ have not been successful.
macrogol
Lactulose is an osmotic laxative.
Fill in the blank: Senna is not commonly used first-line in acute constipation that is not associated with _______.
opioid use
Senna is primarily for opioid-induced constipation.
