Palliative care Flashcards
Neuropathic pain management
1st line: amitriptyline, duloxetine, gabapentin or pregabalin
(if one doesn’t work try another)
Tramadol: rescue therapy for exacerbations of pain
Topical capsaicin: localised neuropathic pain (e.g. post-herpetic neuralgia)
Pain management clinics
Palliative care pain prescribing
NICE Guidelines:
- start by offering regular oral modified release (MR) or oral immediate release morphine
- no comorbidities: 20-30mg of MR a day with 5mg morphine for breakthrough pain
- oral modified-release morphine should be used in preference to transdermal patches
- laxatives should be prescribed for all patients initiating strong opioids
- patients should be advised that nausea & drowsiness is transient
SIGN guidelines:
- breakthrough dose of morphine is 1/6 daily morphone dose
- CKD: oxycodone preferred to morphine in mild-mod renal impairment
- if severe renal impairment: use alfentanil, buprenorphine and fentanyl
- metastatic bone pain: may respond to strong opioids, bisphosphonates or radiotherapy
When increasing the dose of opioids the next dose should be increased by 30-50%.
Opioid side effects
Transient - nausea, drowsiness
Persistent - constipation
Converting between opioids
- Oral codeine to oral morphine: divide by 10
- Oral tramadol to oral morphone: divide by 10
- Oral morphine to oral oxycodone: divide by 1.5-2
- a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
- a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily
- oral morphine to SC morphine: divide by 2
- oral morphine to SC diamorphine: divide by 3
- oral oxycodone to SC diamorphine: divide by 1.5
Pallaitive care: agigtation and confusion
First choice: haloperidol
Other options: chlorpromazine, levomepromazine
In the terminal phase of the illness then agitation or restlessness is best treated with midazolam
Palliative care: secretions
Conservative:
- avoid fluid overload
- educate family
Medical:
- hyoscine hydrobromide or hyoscine butylbromide
- glycopyrronium bromide may also be used
Palliative care: hiccups
1st: chlorpromazine
haloperidol, gabapentin also use
dexamethasone if hepatic lesions
Palliative care: haematuria
Large bleed: admission
Non-threatening bleeds:
- encourage fluids
- exclude UTI
- etamsylate 500mg qds may decrease bleeding
- consider referral for palliative radiotherapy
SVC obstruction
Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC. It is most commonly associated with lung cancer.
Features: dysponea, swelling, headache, visual disturbance, pulseless jugular venous distention
Causes:
- malignancies: SCLC, lymphoma
- aortic aneurysm
- mediastinal fibrosis
- goitre
- SVC thrombosis
Mx:
- endovascular stenting
- chemo/radiotherapy
Palliative care: nausea & vomiting
- Reduced gastric motility: metoclopramide, domperidone
- Chemically mediated: ondansetron, haloperidol and levomepromazine
- Visceral/serosal causes: cyclizine, levomepromazine
- Raised ICP: cyclizine, dex
- Vestibular: cyclizine
- Cortical: lorazepam
1st line: oral route
2nd line: parenteral route
3rd: IV if IV access established
Chronic HF: drug management
FIRST LINE:
- ACEi and B-blocker (bisprolol)
- No effect on mortality in HF with preserved EF
SECOND LINE:
- aldosterone antagonist e.g. spirinolactone
- SGLT-2 inhibitors
THIRD LINE:
- ivabradine: sinus rhythm > 75/min and a left ventricular fraction < 35%
- sacubitril-valsartan: left ventricular fraction < 35%
- digoxin: if coexisting AF
- hydralazine + nitrate
- cardiac resynch
Annual influenza
One-off pneumococcal
Bone metastases
Most common tumour causing bone metastases (in descending order)
- prostate
- breast
- lung
Most common site (in descending order):
* spine
* pelvis
* ribs
* skull
* long bones
