Palliative Flashcards
Types of pain
Nociceptive
- normal nervous system identifiable lesion causing tissue damage
- somatic - originates from skin/muscles/bone
- visceral - viscus or solid organ
Neuropathic
- malfunctioning nervous system
- nerve structure damaged
Description of types of pain
Nociceptive
- somatic - sharp, throbbing, well localised
- visceral - diffuse ache, difficult to localise
Neuropathic
- stabbing, shooting, burning, stinging, numbness
Who analgesic ladder
1
- non-opioid +/- adjuvant
2
- opioid for mild to moderate pain +/- non-opioid and adjuvant
3
- opioid for moderate to severe pain +/- non-opioid and adjuvant
Analgesics on WHO ladder
Step 1 - paracetamol - aspirin - NSAIDs Step 2 - co-codamol - codeine phosphate - tramadol - dihydrocodeine Step 3 - fentanyl - diamorphine - buprenorphine - oxycodiene - methadone
NSAIDs and COX2 inhibitors
No CV or GI risk - ibuprofen - diclofenac - naproxen GI risk but CV risk - COX2 - celecoxib CV risk but less GI risk - naproxen - ibuprofen Prescribe PPI for all HF exacerbated by all NSAIDS
Adjuvants for pain relief
Antidepressants - amitriptyline - duloxetine Anti-convulsant - gabapentin - pregabalin Benzodiazepines - diazepam - clonazepam Steroids - dexamthasone Bisphosphates and radiotherapy for bony pain
Side effects of amitriptyline
Confusion
Hypotension
Side effects of gabapentin
Sedation
Tremor
Confusion
Dizziness
WHO principles of pain relief
By the mouth By the clock By the ladder Individual dose titration Use of adjuvants at any step
Common side effects of opioids
Constipation
Dry mouth
N+V
Drowsiness/sedation
Dos for opioid prescription
Write up laxative and anti-emetic
- laxido and metoclopramide
Features of opioid toxicity
Pinpoint pupils, hallucinations, vomiting, confusion, myoclonic jerks and resp depression
Uncommon when following prescribing guidance
Can occur if dose escalated too quickly or AKI/renal impairment
Stepping up from maximum dose codeine
Codeine : morphine is 10:1
240mg codeine equates to 24mg of morphine
Total daily dose morphine = 24mg
Generally prescribe
- morphine SR 15mg BD plus morphine IR 5 mg PRN
How to calculate further titration of opioid dose
Add up 24 hours worth of morphine = total daily dose (TDD)
TDD/2 = new morphine SR dose
TDD/6 = new morphine IR PRN dose
When to titrate up opioid dose
Consistently needing PRN doses over at least 3/7
SC vs oral morphine
10mg SC morphine = 20mg oral morphine
How to write controlled drug prescription
Name and ID of patient
Write prescription as normal
Write supply and give pharmacist exact instructions
- drug name and formulation
- total number of tables or amount of drugs in words and figures
Morphine SR (Zomorph) capsules 10mg - supply 56 (fifty six) 10mg tablets
Oramorph oral liquid 10mg/5ml - supply 1 (one) 300ml bottle
Features of fentanyl patches
25 micrograms/hour - apply every 3 days
Approx 90mg morphine per 24 hours
Causes of N+V
Infection Metabolic - renal impairment - hepatic impairment - low Na - high Ca - tumour toxins Drug related - opioid - diuretics Gastric stasis - pyloric stenosis - acites - hepatomegaly - opioids GI disturbance - constipation - gastritis - ulceration Organ damage - distension - obstruction - RT Neurological - raised ICP - motion sickness - meningeal disease Psychological - anxiety/fear
Features of chemical nausea
Persistent severe nausea Unrelieved by vomiting Aggravated by sight/smell of food Drowsiness and confusion Tx = HALOPERIDOL
Features of gastric stasis nausea
Fullness/regurgitation Reduced appetite Vomiting - often large volume and relieve nausea Epigastric discomfort Hiccups Tx = METOCLOPRAMIDE or DOMPERIDONE
Features of bowel obstruction nausea
High - regurgitation - forceful vomiting of undigested food Low - colicky pain - large faeculent vomits - visible peristalsis Tx = CYCLIZINE or DEXAMETHASONE
Features of raised ICP nausea
Nausea worse in morning Projectile vomiting Worse on head movement Headache Tx = CYCLIZINE or DEXAMTHASONE
Features of psychological nausea
Anxiety
Fear
Anticipation
Tx = NON-DRUG or BENZODIAZEPINES
Features of post op/RT nausea
Serotonin release
Tx = ONDANSETRON
Features of constipation nausea
Nausea
Faeculent vomiting
Abdominal distension
Tx = PROKINETIC or LAXATIVES
Risk factors for chemotherapy induced nausea and vomiting (CINV)
Specific chemo agents
Female
Age < 50
Past Hx of N+V
Features of Aprepitant
Prevent CINV
NK1 antagonist - acts centrally
Augments 5HT3 and dexamethasone
SE = constipation and headache
Causes of consipation
Disease related - immobility - reduced food-intake/low residue diet - intra-abdominal and pelvic disease Fluid depletion - poor fluid intake - increased fluid loss - vomiting, sweating, fistulae, exudating wounds Weakness - inability to raise intra-abdominal pressure Intestinal obstruction Medication - opioids - diuretics - phenothiazines - anti-cholinergic drugs - recent surgery Biochemical - hypercalcaemia - hypokalaemia
Laxative in oncology
Stimulant - senna, bisacodyl - reduce bowel transit time Softener - docusate - increase water penetration of stool Stimulant - sodium picosulfate Osmotic - lactulose, movicol, laxido - can cause flatulence and bloating - need to drink reasonable volume of water Suppositories - glycerin - softner - bisacodyl - stimulant
Clinical features of bowel obstruction
Colicky pain Vomiting Nausea Abdominal distention Anorexia Bowel sounds increased Overflow diarrhoea Constipation Continuous pain Dry mouth
Mx of bowel obstruction
Chemo Stent Surgery Gastrostomy NG drainage
Causes of breathlessness
Anaemia - transfusion
PE - LMWH
CCF - diuretics, ACEi
COPD - bronchodilators
Respiratory tract infection - abx
Pleural effusion - aspiration, pleurodesis
Pericardial effusion - paracentesis, corticosteroids
SVCO - stent, RV, steroids
Anxiety - CBT, relaxation, benzodiazepines, SSRIs
Neurophysiology of breathlessness
Mismatch between patient’s perceived need to breath (respiratory drive) and ability to do so (physiological capacity)
Mx of breathlessness
Aim to reduce perception Calm, logical approach Position patient upright Air flow across face Trial of O2 if hypoxic Non-drug approaches if feasible Treat underlying cause Morphine
Symptoms and signs of dying
Functional and physical ability
- fatigue, increasing weakness, worsening mobility, inability to lift head off pillow
Psychosocial and spiritual symptoms
- concern for those left behind, fear of unknown, nearing death awareness, increased spiritual focus
Reduced food and fluid intake
Loss of ability to swallow
Bowels and bladder
- incontinence, oliguria to anuria urinary retention
CVS changes
- tachycardia, hypertension, cyanosis, mottling of skin, peripheral oedema
Increasing physical symptoms
- pain, N+V, resp symptoms, restlessness
Resp
- SOB, shallow and laboured breathing, apnea
Decreasing level of consciousness
Anticpatory prescribing
Morphine 2.5-5mg sc PRN
Midazolam - dyspnoa, agitation
Glycopryrronium - secretions
Levomepromazine - nausea
Side effects of opioid analgesia
Constipation - increase fibre and fluid - increase mobility if possible - faecal softeners (docusate sodium) with stimulants (senna) N+V - dopamine antagonist (domperidone, metoclopramide) Drowsiness and sedation Addiction unlikely if used correctly
Define consitpation
Hard faeces which are uncomfortable to pass
- reduced frequency
Colicky abdo pain, distention and N+V
Causes of constipation
Disease related – immobility, decreased food intake, intra-abdominal disease
· Fluid depletion – decreased intake, sweating, vomiting
· Weakness
· Intestinal obstruction
· Medication – opioids, diuretics, anti-cholinergics, 5-HT antagonists
· Biochemical – hypercalcaemia, hypokalaemia
· Psychological – pain of defaecation, lack of privacy
Complications of constipation
Overflow diarrhoea
Acute urinary retention
Haemorrhoids
Mx of constipation
High fibre high fluid diet
Increase mobility
Stimulants - sodium picosulfate, co-danthramer, senna
Faecal softeners - docusate sodium, glycerol
Osmotic - lactulose
Features of an amber care bundle
In cases where we are unsure if patients are going to recover
- encourages continued care in aim of recovery while also planning for end of life
