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Palliative Care Flashcards

1
Q

What is an unlicensed medication?

A

one not approved for marketing in the UK for use in humans for any indication

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2
Q

what is an off-license use of medication?

A

a licensed medication used for an unlicensed indication - can be route or dose as well as indication

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3
Q

How long does pain have to be present for it to be defined as chronic?

A

3 months or more

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4
Q

what is pain?

A

An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage

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5
Q

what is allodynia?

A

when pain is experienced with sensory inputs that do not normally cause pain

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6
Q

what are the two types of primary afferent nociceptors (nerve fibres) that transmit pain?

A

C-fibres
A-Delta fibres

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7
Q

what kind of pain do C fibres transmit?

A

transmit signals slowly and produce dull, diffuse pain sensations

unmyelinated and small diameter neurons

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8
Q

what kind of pain do A-delta fibres transmit?

A

fast and sharp, localised pain sensation

myelinated larger neurones

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9
Q

what are 2 ways to measure pain?

A

Numerical rating scale
Visual analogue scale

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10
Q

what is step one on the pain ladder?

A

non-opioid simple pain killers - paracetamol, NSAIDs

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11
Q

what is step 2 on the pain ladder?

A

weak opioids - codeine, tramadol

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12
Q

what is step 3 on the pain ladder?

A

strong opioids - morphine, oxycodone, fentanyl, buprenorphine

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13
Q

what are 4 medications used to treat neuropathic pain?

A

Amitriptyline
gabapentin
pregabalin
duloxetine

Also capsaicin cream (from chillis) for localised areas

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14
Q

what questionnaire can be used to assess the likelihood of neuropathic pain?

A

DN4 questionnaire - score >4

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15
Q

what are 6 key side effects of NSAIDs?

A

Gastritis + dyspepsia
stomach ulcers
exacerbation of asthma
hypertension
renal impairement
coronary artery disease, HF, stroke

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16
Q

what are 6 key side effects of opioids?

A

constipation
pruitus
nausea and vomiting
altered mental state - sedation, confusion, cognitive impairement, hallucination
respiratory depression
urinary retention

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17
Q

what is the antidote to opioids?

A

naloxone

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18
Q

what specialist medication can be used to prevent opioid constipation while maintaining analgesia?

A

methylnaltrexone bromide SC injection dose dependant on body weight

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19
Q

what laxatives should be prescribed alongside opioids?

A

Stimulant - senna

15mg in the evening - not constipated

15mg BD - constipated

increase dose if ineffective to max of 30mg TDS

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20
Q

how long does modified release morphine last?

A

12 hours

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21
Q

what does should PRN rescue opioids be?

A

1/10th to 1/6th of the daily 24h dose

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22
Q

what is the equivalent 10mg PO morphine dose of codeine?

A

100mg PO codeine

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23
Q

what is the equivalent 10mg PO morphine dose of tramadol?

A

100mg PO Tramadol

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24
Q

what is the equivalent 10mg PO morphine dose of oxycodone?

A

6.6mg PO oxycodone

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25
what is the equivalent 10mg PO morphine dose of IV/SC/IM morphine?
5mg IV/SC/IM morphine
26
what is the equivalent 10mg PO morphine dose of IV/IM/SC diamorphine?
3mg IV/IM/SC diamorphine
27
what dose of morphine over 24 hours is equivalent to a 5mcg/h patch of buprenorphine?
12mg/24 hours of oral morphine
28
what dose of morphine over 24 house is equivalent to 12mcg/h patch of fentayl?
30mg/24 hours of oral morphine
29
what are 5 alternative ways to deal with chronic pain?
supervised group exercise acceptance and commitment therapy (ACT) CBT Acupuncture Antidepressants
30
what 3 electrolyte imbalances can cause nausea?
Hyponatraemia Hypocalcaemia Hypercalcaemia
31
what are the 5 areas that can trigger the vomiting centre of the medulla?
GI Tract - gastric stasis, intestinal obstruction, gastric irritation Chemoreceptors - biochemical upset, drugs, electrolyte imbalance Vestibular input - motion sickness, morning sickness Higher centres - from cortex - anxiety, smells/sights Increased intracranial pressure
32
what are 4 non-pharmacological ways to manage nausea?
control odours minimise sight/smell of food small snacks not large meals acupressure wrist bands
33
what is the nausea and vomiting like in gastric stasis?
large volumes infrequent vomiting relives symptoms oesophageal reflux epigastric fullness early satiation
34
what is the nausea and vomiting like in gastric outflow obstruction?
Similar to gastric stasis more forceful and rapid dehydration
35
what is the nausea and vomiting like in oesophageal blockage?
brings just swallowed food back up soon after eating and drinking sensation of food sticking
36
what is the nausea and vomiting like in raised ICP?
effortless vomiting often in morning associated with headache, papilloedema nausea - may be diurnal
37
what is the nausea and vomiting like in chemically induced nausea?
constant nausea variable vomiting
38
What drug class is haloperidol?
Butyrophenone antipsychotics - used as antiemetic
39
what condition is a contraindication to the use of haloperidol?
parkinsons
40
what types of nausea is haloperidol good for?
chemical causes - opioids, chemotherapy
41
what are 4 side effects of haloperidol?
extrapyramidal side effects sedation QT prolongation Depression
42
what is the dosing of haloperidol for nausea in palliative care?
0.5mg - 1.5mg OD or every 2 hours as required Max dose 10mg/24h
43
what are 2 prokinetic antiemetics?
Metoclopramide - for things attached to the mesentery Domperidone
44
what receptors do prokinetic antiemetics act on?
D2 receptors metoclopramide also acts on 5-HT3/4 receptors
45
When should pro-kinetic antiemetics be used?
gastric stasis ileus delayed chemo induced n+v
46
what are the 1st line antiemetics for gastric stasis?
Metoclopramide Domperidone
47
what are 5 side effects of metoclopramide?
extrapyramidal effects drowsiness diarrhoea gynaecomastia hyperprolactinaemia
48
what are 5 side effects of domperidone?
QT prolongation drowsiness dry mouth diarrhoea malaise
49
in what condition should metoclopramide not be used in?
parkinsons
50
what dose is given of domperidone for nausea and vomiting?
10mg up to TDS (for max one week) - take before meals up to 80mg/24h in palliative care (off licence)
51
what other condition can metoclopramide be used to treat in palliative care?
hiccups - 10mg every 6-8h
52
what dose is given of metoclopramide for nausea and vomiting?
10mg PO TDS for 5 days <60kg => 500mcg/kg/day CSCI 30-80mg/24h - specialist only
53
what are 2 examples of phenothazine antipsychotics used as antiemetics?
levomepromazine prochlorperazine
54
what are 5 side effects with phenothiazine antipsychotics (used as antiemetics)?
extra-pyramidal symptoms drowsiness anti-muscarinic effects postural hypotension long QT
55
in what condition should phenothiazine antipsychotics (prochlorperazine) be avoided (used as antiemetics)?
parkinsons
56
what are 3 examples of antihistamines that can be used for nausea?
cyclizine cinnarizine promethazine
57
how do antihistamines work as antiemetics?
act on H1 receptors centrally and peripherally to suppress nausea
58
what antiemetic are used for vertigo/dizziness?
Cyclizine Prochlorperazine - for when you're feeling peculiar
59
what are 2 examples of 5-HT3 antagonists?
granisetron ondansetron
60
what is the MOA of ondansetron and granisetron?
act on 5HT3 receptors
61
what type of nausea are 5HT3 receptors useful for?
chemotherapy and radiotherapy induced nausea and vomiting and postoperative
62
what are 5 side effects of 5-HT3 antagonists (ondasetron)?
constipation headache flushing involuntary movements QT prolongation
63
what is the dose of ondansetron?
4-8mg BD/TDS PO/IV/SC 16-24mg/24h CSCI
64
what are 3 antimuscarinics that are used as antiemetics?
hyoscine butylbromide Hyoscine hydrobromide Glycopryrronium bromide
65
what is the MOA of antimuscarinics in nausea and vomiting?
act on Ach receptors and cause smooth muscle relaxation and drying up of secretions
66
when are antimuscarinics used in nausea and vomiting? (3)
in smooth muscle spasm - bladder/gi tract excessive secretions and death rattle inoperable bowel obstruction
67
what is the dosing for hyoscine butylbromide for bowel symptoms?
10-20mg 4 hourly PO 20mg up to hourly PRN SC 60-300mg/24hCSCI
68
what are 6 side effects of hyoscine butylbromide and hyoscine hydrobromide?
constipation urinary retention tachycardia hypotension blurred vision drowsiness/confusion
69
what is the dose for hyoscine hydrobromide for nausea and vomiting?
400 micrograms PRN SC 4 hourly 1.2-2mg/24 hour CSCI
70
what is the dose of glycopyronium bromide for bowel colic and resp secretions?
200 micrograms every 4 hours PRN 0.6-1.2 mg/24 hours CSCI
71
what are a type of antiemetics that are licenced for prevention of chemo related n+v?
Neurokinin- receptor antagonists
72
what are 2 examples of Neurokinin- receptor antagonists used as antiemetics?
aprepitant - oral fosaprepitant - IV
73
what is usually the 1st line antiemetic for chemo nausea?
Ondansetron from your oncologist
74
what antiemetics are used for neuro causes of nausea?
Haloperidol for you head Cyclizine Dexamethasone
75
what are 6 signs of dying?
Sleeping more/Less conscious Weaker and less able to move around Breathing changes - shallower or less regular Upper airway secretions Loss of appetite Withdrawal or restlessness
76
what always needs to be prescribed with a syringe driver?
water for injection or Sodium chloride 0.9%
77
what should always be prescribed with opioids?
laxatives - senna (simulant laxitive) first and then osmotic (lactulose, macrogol)
78
what are 3 medications that can be helpful for hiccups?
prokinetics - metoclopramide antiflatulents - peppermint oil PPIs
79
what medication can be given in palliative care for breathlessness?
morphine benzodiazapines for anxiety related
80
what medication can be used for bowel colic in palliative care?
hyoscine butylbromide
81
what are 5 reasons cancer can cause constipation directly?
Bowel obstruction Compression of infiltration of spinal cord, cauda equina or pelvic plexus Hypercalcaemia Painful defecation Autonomic neuropathy - small cell carcinoma and carcinoid tumours
82
what is the 1st line pharmological management of palliative constipation?
Stimulant laxative - sena
83
what is 2nd line management of constipation in palliative care?
ADD osmotic laxative - lactulose or macrogol OR Surface wetting laxative - docusate (if ado colic is a problem)
84
what is the 3rd line management of constipation in palliative care?
Soft stool - bisacodyl OR sodium citrate suppository Hard - glycerol suppository VERY hard - arachis oil enema over night
85
what are 2 laxatives types that should be avoided in palliative care?
Bulk forming Phosphate enemas - can cause electrolyte disturbance
86
who should not get rectal constipation interventions?
people on chemo who may be neutropenic people with thrombocytopenia rectal or anal disease
87
what medication can be used for agitation in palliative care?
haloperidol
88
what antidepressant is good for patients with nausea, insomnia or reduced appetite?
mirtazapine
89
what is the first line medication for seizure in palliative care?
levetiracetam
90
what antiepileptic is generally used in CSCIs due to compatibility?
midazolam
91
what are 2 medications that can be used for respiratory secretions in palliative care?
hyoscine butylbromide glycopyrronium bromide
92
what are 2 medications that can be given in pruritus?
levomenthol cream antihistamines
93
what 4 medications are commonly in a syringe driver and what doses?
Morphine 10mg/ml - 2.5-5mg if opioid naive otherwise use conversion Haloperidol 5mg/1ml => 2.5-5mg Midazolam 10mg/2ml => 10-30mg Hyoscine butylbromide 20mg/1ml => 60-120mg
94
what is multiple organ dysfunction syndrome?
a hypometabolic, immunodepressed state with clinical and biochemical evidence of the failure of 2 or more organ systems
95
what are 6 common causes of multiple organ dysfunction syndrome?
sepsis traumatic injury - burns, blood loss pancreatitis MI Liver failure toxic injury/poisoning
96
what medications can be used to suppress cough?
Opioids soothing agents - syrups
97
what are 3 antiemetics that are good for chemically induced nausea?
Haloperidol Metoclopramide Levomepromazine
98
what 2 antiemetics are good for nausea due to raised ICP?
Cyclizine - if just intracranial disease Dexamethasone - if raised
99
what antiemetic is used 1st line for vestibular disease and motion sickness?
cyclizine
100
what are 4 antiemetics which are good for vestibular disease?
Hyoscine hydrobromide Cinnarizine levomepromazine prochlorperazine
101
what is one medication that can be used to reduce mouth discomfort at the end of life (mucositis)?
benzydamine hydrochloride

Phase 4 (22 decks)

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