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Y4 > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

what is metoclopramide

A

an anti-emetic that mainly acts as a dopamine antagonist
often prescribed for nausea and vomiting related to reduced gastric motility

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2
Q

what is ondansetron

A

an anti-emetic that is a serotonin (5-HT3) antagonist
for chemotherapy-related nausea and vomiting

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3
Q

role of dexamethasone

A

steroid used to treat raised ICP
helps to alleviate headaches, nausea & vomiting, and neurological deficits

Once satisfactory improvements have been achieved, the dose should be weaned to the lowest effective dose

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4
Q

how long do fentanyl patches take to work

A

can take up to 72 hours to reach peak serum concentrations

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5
Q

why is oxycodone given in mild to moderate renal failure

A

It is metabolized in the liver to noroxycodone and oxymorphine and ten percent of unmetabolized oxycodone is renally excreted

even though noroxycodone and oxymorphone are renally excreted, their accumulation does not lead to any adverse side effects

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6
Q

role of opioids in palliative care

A

good control of pain & breathlessness

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7
Q

diamorphine vs morphine

A

Diamorphine is much more soluble than morphine and therefore easier to administer in higher doses.

It is also compatible with most other drugs which may need to be administered by a subcutaneous infusion. However, morphine is preferred in most cases as most people do not require doses large enough to cause solubility issues:

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8
Q

what anti-respiratory secretion medication is less likely to cause CNS side effects e.g. sedation

A

Hyoscine butylbromide and glycopyrronium bromide, do not cross the blood-brain barrier

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9
Q

breakthrough opioid drug doses

A

between 1/10 and 1/6

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10
Q

What is the approach for agitation and confusion in palliative care

A

Reversible or not

Reversible: think of PINCH ME
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment

*** hypercalcemia, urinary retention

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11
Q

Medical treatment for confusion and agitation

A

First line: haloperidol
Then chlorpromazine, levomepromazine (6.25-12.5 for anti-emetic and 25 for sedative properties)

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12
Q

What drug is used in terminal phase of illness for agitation or restlessness

A

Midazolam

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13
Q

Causes of hiccups in palliative care

A

Gastric stasis and distension
GORD
Metabolic disturbances e.g. hypercalcemia, uraemia
Infection
Irritation of diaphragm or phrenic nerve
Hepatic disease/hepatomegaly
Cerebral causes e.g tumour

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14
Q

Management of hiccups

A

Chlorpromazine
- haloperidol, gabapentin also used

Dexamethasone is also used, particularly if hepatic lesions

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15
Q

What are hiccups

A

Diaphragm contracting involuntarily, causing vocal cords to shut and an abrupt increase of air into the lungs

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16
Q

2 main forms of morphine

A

MR (modified release) and immediate release

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17
Q

How to start patients on opioids

A

If no comorbidities, use 20-30mg of MR a day with 5mg for breakthrough pain e.g. 15mg 2x a day

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18
Q

What should be started in conjunction with strong opioids

A

Laxatives

**nausea is often transient, if persists than anti-emetic

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19
Q

Side effects of opioids

A

Constipation
Nausea
Drowsiness, confusion
Hallucinations
Pruritis
Dry mouth
Respiratory depression

*** opioids slow everything down

20
Q

MOA of opioids

A

Act centrally in the PAG by enhancing descending inhibition

21
Q

Opioids and patients with kidney disease

A

Mild to moderate: oxycodone
Moderate to severe: fentanyl, alfentanyl, buprenorphine

22
Q

Treatment of metastatic bone pain

A

Strong opioids (lowest number needed to treat)
Bisphosphonates
Radiotherapy
Denosumab also

23
Q

How much to increase dose of opioids by

A

30-50%

Or increase the dose by the amount of PRNs in the previous 24 hours

24
Q

Transient and persistent opioid side effects

A

Transient = nausea, drowsiness (adjust dose accordingly for drowsiness)
Persistent = constipation

25
Q

Conversion of codeine to morphine

A

/ 10

26
Q

Differences between oxycodone and morphine

A

Oxycodone causes less sedation, vomiting, and priorities, but causes more constipation

27
Q

What chemical released is involved in itchiness

A

Histamine

28
Q

Conversion of oral morphine to sub cut morphine

A

/ 2

29
Q

Conversion of oral morphine to subcut diamorphine

A

/ 3

30
Q

Oral oxycodone to subcut diamorphine

A

/ 1.5

31
Q

What are the secretions in palliative care

A

Build up of mucus and saliva at the back of the throat and airways
Patient weaker and unable to clear it

32
Q

Management of secretions

A

Conservative: over fluid overload, stopping IV and subcut fluids
Educate family if distressed

Medical: hyoscine hydrobromide or hyoscine butylbromide (buscopan - may be less sedative)
Or glycopyrronium bromide

33
Q

What type of drug are the anti secretory medications

A

Anti-muscarinic

34
Q

What anti secretory medications might be less sedating

A

Hyoscine hydrobromide and glycopyrronium bromide
* don’t pass BBB

35
Q

Category causes of nausea and vomiting

A

Reduced gastric motility
- can be opioid related
- related to serotonin and dopamine (D2) receptors

Chemical
- chemotherapy, opioids, hypercalcemia

Visceral/serosal
- constipation
- oral candidiasis

Raised ICP
- cerebral mets

Vestibular
- activation of acetylcholine & histamine receptors
- opioid related, motion related, base of skull tumours

Cortical
- pain, anxiety, fear, and/or anticipatory nausea
- Related to GABA and histamine (H1 receptors)

36
Q

Drugs for nausea and vomiting

A

Reduced gastric mobility:
Metoclopramide (can cross BBB) and domperidone (pro-kinetic agents)
** metoclopramide normalises stomach mobility and acts directly on brain to reduce sensation of nausea
** not used in complete bowel obstruction, GI perforation or after gastric surgery

Chemical: correct disturbance
Or ondansetron, haloperidol, levomepromazine

Visceral/serosal: cyclizine, levomepromazine

Raised ICP
Dex
Cyclizine for nausea and vomiting (histamine receptor in cortex triggered by ICP)

Vestibular: cyclizine

Cortical: if anticipatory nausea, lorazepam or short acting BZD then cyclizine

37
Q

Pathophysiology of vomiting

A

Vomiting centre in medulla

Close to vomiting centre in medulla is the chemoreceptor trigger zone. (CTZ) Have multiple receptors 5HT and D2
When these receptors are stimulated, stimulates muscarinic receptors of vomiting centre causing the reflex

1) CTZ located outside of BBB even though it is still part of the medulla , more permeable to circulating agents e.g. chemotherapy

2) When vestibular nuclei stimulated in motion sickness via vestibulocochlear nerve, H1 (histamine) and muscarinic receptors stimulated and pass signals to CTZ and then vomiting centre

3) Higher brain centres send signals to vomiting centre if emotional, pain, repulsive smell/sight - stimulate through muscarinic receptors

4) enterochromaffin cells in the gut release serotonin in response to cytotoxic agents, innervates vagus nerve to vomiting centre

These all cause relaxation of LOS, and causes diaphragm and stomach to contract
Increase salivation and tachycardia
Epiglottis closes

38
Q

Route of anti-emetics

A

Oral is preferred

If vomiting, malabsorption, or severe gastric stasis, then parenteral can be used

39
Q

When is a syringe driver used

A

In palliative care setting when patient unable to take oral medication due to nausea and vomiting, dysphagia, intestinal obstruction, weakness or coma

40
Q

What is a syringe driver

A

Provides continuous medication over an hour or 24 hour period

Blue: delivery rate mm per hour
Green: mm per 24 hours

41
Q

What is used for reducing discomfort of painful mouth

A

Benzydamine hydrochloride

42
Q

What is common following radiotherapy to head and neck

A

Mucositis
Inflammation of oral mucosa, white lesions with central ulceration

43
Q

When are transdermal patches recommended

A

Stable levels of pain who will not require regular titration of pain relief
Not always the case in palliative patients

44
Q

Symptoms of raised ICP

A

Headaches, worse in mornings and better when standing
Nausea and vomiting
Blown pupils
Papilloedema
Neurological deficits
Occasional vision changes

45
Q

Symptoms of opioid toxicity

A

Decreased consciousness
Pin prick pupils
Myoclonic jerks

Y4 (16 decks)

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