Palliative care Flashcards
Pre-emptive prescribing - 5 core symptoms to prescribe for
Pain - Morphine Breathlessness - morphine PRN Agitation - Midazolam Secretions - hyoscine butybromide Nausea - Haloperidol
Syringe driver ratio
injectable is 2x strength of oral opioids so give half
Opioid SE
nausea, constipation, drowsiness, dry mouth
Adjuvant analgesics
For neuropathic pain – amitriptyline, pregabalin, gabapentin
Muscle spasms – baclofen, clonazepam, diazepam
Compression symptoms – dexamethasone
Bone pain – zolendronic acid
Oncology emergency - spinal compression mx
Neurosurgery - MRI whole spine
IV Dex and VTE prophylaxis
Neutropenic sepsis ivx
FBC, LFT, U+E, CRP, clotting, lactate, glucose
Blood cultures, venous blood gas
Urine culture
Swab/culture central line
Neutropenic sepsis mx
Sepsis 6
Tazocin 4.5g IV TDS
Can give granulocyte colony stimulating factor - Filgrastim
Neutropenic sepsis mx viral/fungal
Aciclovir, Fluconazole
Hypercalcaemia of malignancy
parathyroid hormone related peptide secretion by tumour
Osteoblast suppression, osteoclast activation
Calcitriol production in lymphoma
Ectopic hyperparathyroidism in SCLC
Symptoms of hypercalcaemia
Dehydration and - Bones, Stone, groans, thrones and psychic moans
Hypercalcaemia management
Hydration
Malignancy therapy
U+E monitoring
If severe - IV Bis/denosumab
Furosemide
Hypercalcaemia ivx
Total calcium elevated, corrected calcium >2.6
Urgent if over 3
Check ECG (may have short QT)
PTH elevated if ectopic, serum PTHrP elevated if humoral, calcitriol high in lymphoma
Skeletal XRs if not known metastases
CXR – lung Ca, sarcoidosis
Superior vena cava obstruction mechanisms
intraluminal obstruction or extrinsic compression, or a thrombus
Superior vena cava obstruction symptoms
Oedema of face and upper limbs, dyspnoea, venous engorgement (facial plethora, neck and chest), cough, hoarse voice
Venous engorgement worse leaning forward
Fixed non pulsatile raised JVP
Superior vena cava obstruction ix
Do CXR for lung mass, CT thorax with contrast for collateral vessels and location, and USS upper extremities (for dilation SVC, thrombi)
Superior vena cava obstruction mx
Dex
Radiotherapy
Malignancy treatment
Tumour lysis syndrome cause
Metabolic and electrolyte abnormalities and renal impairment
Usually hours/days into chemotherapy
Usually chemosensitive lymphoma/leukaemia
Tumour lysis syndrome electrolytes
Hyperuricaemia – can cause uric acid nephropathy and AKI
Hyperphosphataemia – can cause calcium phosphate deposition and obstruction
Secondary hypocalcaemia (from high phosphate)
Hyperkalaemia (from cell degradation)
Tumour lysis syndrome presentation
Syncope/chest pain/dyspnoea
Seizures
Nausea, D+V
Muscle weakness and cramps
25% INCREASE in uric acid, phosphate, potassium
25% DECREASE in calcium
High creatinine and LDH
Tumour lysis syndrome mx
Prevention is key
Prechemotherapy IV fluids, avoid nephrotoxic meds, use allopurinol (blocks conversion to uric acid)
Treating – hydrate, correct high potassium, give rasburicase (oxidises uric acid), give aluminium hydroxide (phosphate binder)
Cheyne-Stokes breathing
rapid breaths followed by apnoea
Anti-emetics
Bowels
Domperidone – D2 antagonist
Hyoscine butylbromide - antimuscarinic
Brain and bowels
Ondansetron – 5HT3 antagonist
Metoclopramide – D2 antagonist
Brain
Cyclizine – H2 antagonist
Prochlorperazine
Biochemistry and brain
Haloperidol – D2 antagonist
Levopromazine – D2, H2, 5HT3 antagonist
NSCLC paraneoplastic syndromes
Hypercalcaemia, and occasionally Cushing’s syndrome
Carcinoid syndrome
mainly gastric carcinoma, also bronchial or pancreatic
Flushing, wheeze, abdo pain
treat with resection, octreotide (somatostatin analogue)
Aggressive sarcomas
angiosarcoma (long term bruising at breast) and Ewing’s sarcoma (bone sarcoma young males)
Lymphoedema
Lymphatic stasis and loss of thoracic duct return
thickened skin, honeycombing of fluid and fibrous tissue
Blood smear may show parasite filariasis
filiariasis tx
diethylcarbamazine
Pancreatic cancer blood test monitoring
CA 19-9
Ovarian cancer tumour marker
CA 125
Breast cancer tumour marker
CA 15-3
Colorectal cancer marker
Carcinoembryonic antigen (CEA)
Hepatocellular carcinoma, teratoma marker
Alpha-feto protein (AFP)
Melanoma, schwannomas marker
S-100
Small cell lung carcinoma, gastric cancer, neuroblastoma marker
Bombesin
Reducing mouth pain
Benzydamine hydrochloride mouthwash
Bowel colic relief
hyoscine hydrobromide,
Confusion management in palliative prescribing
first choice: haloperidol
other options: chlorpromazine, levomepromazine
HPVs associated with cervical cancer
16,18,33
Cancer drug with peripheral neuropathy
Vincristine
Cancer drug with cardiac hypertrophy
Doxorubicin
Lung fibrosis cytotoxic
Bleomycin
Calcitonin marker of?
Medullary thyroid cancer
Hiccup management
chlorpromazine or haloperidol
