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Phase 4 > Palliative Care > Flashcards

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
Q

what is the equivalent 10mg PO morphine dose of IV/SC/IM morphine?

A

5mg IV/SC/IM morphine

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26
Q

what is the equivalent 10mg PO morphine dose of IV/IM/SC diamorphine?

A

3mg IV/IM/SC diamorphine

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27
Q

what dose of morphine over 24 hours is equivalent to a 5mcg/h patch of buprenorphine?

A

12mg/24 hours of oral morphine

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28
Q

what dose of morphine over 24 house is equivalent to 12mcg/h patch of fentayl?

A

30mg/24 hours of oral morphine

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29
Q

what are 5 alternative ways to deal with chronic pain?

A

supervised group exercise
acceptance and commitment therapy (ACT)
CBT
Acupuncture
Antidepressants

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30
Q

what 3 electrolyte imbalances can cause nausea?

A

Hyponatraemia
Hypocalcaemia
Hypercalcaemia

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31
Q

what are the 5 areas that can trigger the vomiting centre of the medulla?

A

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

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32
Q

what are 4 non-pharmacological ways to manage nausea?

A

control odours
minimise sight/smell of food
small snacks not large meals
acupressure wrist bands

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33
Q

what is the nausea and vomiting like in gastric stasis?

A

large volumes
infrequent
vomiting relives symptoms

oesophageal reflux
epigastric fullness
early satiation

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34
Q

what is the nausea and vomiting like in gastric outflow obstruction?

A

Similar to gastric stasis

more forceful and rapid dehydration

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35
Q

what is the nausea and vomiting like in oesophageal blockage?

A

brings just swallowed food back up
soon after eating and drinking
sensation of food sticking

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36
Q

what is the nausea and vomiting like in raised ICP?

A

effortless vomiting often in morning

associated with headache, papilloedema

nausea - may be diurnal

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37
Q

what is the nausea and vomiting like in chemically induced nausea?

A

constant nausea
variable vomiting

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38
Q

What drug class is haloperidol?

A

Butyrophenone antipsychotics - used as antiemetic

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39
Q

what condition is a contraindication to the use of haloperidol?

A

parkinsons

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40
Q

what types of nausea is haloperidol good for?

A

chemical causes - opioids, chemotherapy

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41
Q

what are 4 side effects of haloperidol?

A

extrapyramidal side effects
sedation
QT prolongation
Depression

42
Q

what is the dosing of haloperidol for nausea in palliative care?

A

0.5mg - 1.5mg OD or every 2 hours as required

Max dose 10mg/24h

43
Q

what are 2 prokinetic antiemetics?

A

Metoclopramide - for things attached to the mesentery
Domperidone

44
Q

what receptors do prokinetic antiemetics act on?

A

D2 receptors
metoclopramide also acts on 5-HT3/4 receptors

45
Q

When should pro-kinetic antiemetics be used?

A

gastric stasis
ileus
delayed chemo induced n+v

46
Q

what are the 1st line antiemetics for gastric stasis?

A

Metoclopramide
Domperidone

47
Q

what are 5 side effects of metoclopramide?

A

extrapyramidal effects
drowsiness
diarrhoea
gynaecomastia
hyperprolactinaemia

48
Q

what are 5 side effects of domperidone?

A

QT prolongation
drowsiness
dry mouth
diarrhoea
malaise

49
Q

in what condition should metoclopramide not be used in?

A

parkinsons

50
Q

what dose is given of domperidone for nausea and vomiting?

A

10mg up to TDS (for max one week) - take before meals

up to 80mg/24h in palliative care (off licence)

51
Q

what other condition can metoclopramide be used to treat in palliative care?

A

hiccups - 10mg every 6-8h

52
Q

what dose is given of metoclopramide for nausea and vomiting?

A

10mg PO TDS for 5 days
<60kg => 500mcg/kg/day

CSCI 30-80mg/24h - specialist only

53
Q

what are 2 examples of phenothazine antipsychotics used as antiemetics?

A

levomepromazine
prochlorperazine

54
Q

what are 5 side effects with phenothiazine antipsychotics (used as antiemetics)?

A

extra-pyramidal symptoms
drowsiness
anti-muscarinic effects
postural hypotension
long QT

55
Q

in what condition should phenothiazine antipsychotics (prochlorperazine) be avoided (used as antiemetics)?

A

parkinsons

56
Q

what are 3 examples of antihistamines that can be used for nausea?

A

cyclizine
cinnarizine
promethazine

57
Q

how do antihistamines work as antiemetics?

A

act on H1 receptors centrally and peripherally to suppress nausea

58
Q

what antiemetic are used for vertigo/dizziness?

A

Cyclizine
Prochlorperazine - for when you’re feeling peculiar

59
Q

what are 2 examples of 5-HT3 antagonists?

A

granisetron
ondansetron

60
Q

what is the MOA of ondansetron and granisetron?

A

act on 5HT3 receptors

61
Q

what type of nausea are 5HT3 receptors useful for?

A

chemotherapy and radiotherapy induced nausea and vomiting and postoperative

62
Q

what are 5 side effects of 5-HT3 antagonists (ondasetron)?

A

constipation
headache
flushing
involuntary movements
QT prolongation

63
Q

what is the dose of ondansetron?

A

4-8mg BD/TDS PO/IV/SC

16-24mg/24h CSCI

64
Q

what are 3 antimuscarinics that are used as antiemetics?

A

hyoscine butylbromide
Hyoscine hydrobromide
Glycopryrronium bromide

65
Q

what is the MOA of antimuscarinics in nausea and vomiting?

A

act on Ach receptors and cause smooth muscle relaxation and drying up of secretions

66
Q

when are antimuscarinics used in nausea and vomiting? (3)

A

in smooth muscle spasm - bladder/gi tract
excessive secretions and death rattle
inoperable bowel obstruction

67
Q

what is the dosing for hyoscine butylbromide for bowel symptoms?

A

10-20mg 4 hourly PO

20mg up to hourly PRN SC

60-300mg/24hCSCI

68
Q

what are 6 side effects of hyoscine butylbromide and hyoscine hydrobromide?

A

constipation
urinary retention
tachycardia
hypotension
blurred vision
drowsiness/confusion

69
Q

what is the dose for hyoscine hydrobromide for nausea and vomiting?

A

400 micrograms PRN SC 4 hourly

1.2-2mg/24 hour CSCI

70
Q

what is the dose of glycopyronium bromide for bowel colic and resp secretions?

A

200 micrograms every 4 hours PRN

0.6-1.2 mg/24 hours CSCI

71
Q

what are a type of antiemetics that are licenced for prevention of chemo related n+v?

A

Neurokinin- receptor
antagonists

72
Q

what are 2 examples of Neurokinin- receptor
antagonists used as antiemetics?

A

aprepitant - oral
fosaprepitant - IV

73
Q

what is usually the 1st line antiemetic for chemo nausea?

A

Ondansetron from your oncologist

74
Q

what antiemetics are used for neuro causes of nausea?

A

Haloperidol for you head

Cyclizine
Dexamethasone

75
Q

what are 6 signs of dying?

A

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
Q

what always needs to be prescribed with a syringe driver?

A

water for injection or Sodium chloride 0.9%

77
Q

what should always be prescribed with opioids?

A

laxatives - senna (simulant laxitive) first and then osmotic (lactulose, macrogol)

78
Q

what are 3 medications that can be helpful for hiccups?

A

prokinetics - metoclopramide
antiflatulents - peppermint oil
PPIs

79
Q

what medication can be given in palliative care for breathlessness?

A

morphine

benzodiazapines for anxiety related

80
Q

what medication can be used for bowel colic in palliative care?

A

hyoscine butylbromide

81
Q

what are 5 reasons cancer can cause constipation directly?

A

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
Q

what is the 1st line pharmological management of palliative constipation?

A

Stimulant laxative - sena

83
Q

what is 2nd line management of constipation in palliative care?

A

ADD osmotic laxative - lactulose or macrogol
OR
Surface wetting laxative - docusate (if ado colic is a problem)

84
Q

what is the 3rd line management of constipation in palliative care?

A

Soft stool - bisacodyl OR sodium citrate suppository

Hard - glycerol suppository

VERY hard - arachis oil enema over night

85
Q

what are 2 laxatives types that should be avoided in palliative care?

A

Bulk forming
Phosphate enemas - can cause electrolyte disturbance

86
Q

who should not get rectal constipation interventions?

A

people on chemo who may be neutropenic

people with thrombocytopenia

rectal or anal disease

87
Q

what medication can be used for agitation in palliative care?

A

haloperidol

88
Q

what antidepressant is good for patients with nausea, insomnia or reduced appetite?

A

mirtazapine

89
Q

what is the first line medication for seizure in palliative care?

A

levetiracetam

90
Q

what antiepileptic is generally used in CSCIs due to compatibility?

A

midazolam

91
Q

what are 2 medications that can be used for respiratory secretions in palliative care?

A

hyoscine butylbromide
glycopyrronium bromide

92
Q

what are 2 medications that can be given in pruritus?

A

levomenthol cream
antihistamines

93
Q

what 4 medications are commonly in a syringe driver and what doses?

A

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
Q

what is multiple organ dysfunction syndrome?

A

a hypometabolic, immunodepressed state with clinical and biochemical evidence of the failure of 2 or more organ systems

95
Q

what are 6 common causes of multiple organ dysfunction syndrome?

A

sepsis
traumatic injury - burns, blood loss
pancreatitis
MI
Liver failure
toxic injury/poisoning

96
Q

what medications can be used to suppress cough?

A

Opioids
soothing agents - syrups

97
Q

what are 3 antiemetics that are good for chemically induced nausea?

A

Haloperidol
Metoclopramide
Levomepromazine

98
Q

what 2 antiemetics are good for nausea due to raised ICP?

A

Cyclizine - if just intracranial disease

Dexamethasone - if raised

99
Q

what antiemetic is used 1st line for vestibular disease and motion sickness?

A

cyclizine

100
Q

what are 4 antiemetics which are good for vestibular disease?

A

Hyoscine hydrobromide
Cinnarizine
levomepromazine
prochlorperazine

Phase 4 (22 decks)

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