Palliative Care Flashcards
1st line drug Mx for neuropathic pain
Amitriptyline, duloxetine, gabapentin, or pregabalin.
Opioid metabolism
In liver, involves CYP450 enzyme system.
Main opioid to use in palliative care?
Oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain.
-If no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain eg. 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
- laxatives should be prescribed for all patients initiating strong opioids
Breakthrough morphine dose?
1/6th of daily morphine dose
What opioid if patient has mild-moderate renal impairment? Severe?
- Mild/moderate: oxycodone
- Severe: buprenorphine, fentanyl
Oral codeine or tramadol to oral morphine
divide by 10
Oral morphine to oral oxycodone
divide by 1.5-2 (2)
transdermal fentanyl 12ug (microgram) equates to what dose of oral morphine daily
30mg
transdermal buprenorphine 10ug patch equates to what dose of oral morphine daily
24mg
oral morphine to subcut morphine? to subcut diamorphine?
- divide by 2
- divide by 3
oral oxycodone to subcut diamorphine
divide by 1.5
Agitation and confusion?
Midazolam
Secretions?
Hyoscine butylbromide
Breathlessness?
Morphine sulfate
Nausea?
Haloperidol
Hiccups?
Chlorpromazine
Non-life threatening bleeds?
Exclude UTI, encourage fluids to prevent clot retention, etamsylate 500mg qds. Tranexamic acid avoided as promotes formation of hard clots.
Superior vena cava obstruction: features?
dyspnoea, headache worse in morning, swelling of face neck and arms, visual disturbance, pulseless jugular venous distension.
SVC causes and management?
- small cell lung cancer and other malignancies, aortic aneurysm, mediastinal fibrosis
- endovascular stenting for symptom relief and glucocorticoids.
Nausea due to reduced gastric motility?
- ?opioid related, related to serotonin (5HT4) and dopamine (D2) receptors
- metoclopramide
Nausea: chemically mediated?
- due to opiods, chemo or hypercalaemia
- haloperidol
Nausea: raised ICP, vestibular or cortical (due to anxiety or pain)?
- ICP: cerebral mets
- Vestibular: activation of acetylcholine and histamine (H1) receptors, opiod or motion related
- Cortical: GABA and histamine (H1) receptors in cerberal cortex
- Cyclizine (anything like head related)
Mx headaches due to ICP?
Dexamethasone
CXR pulmonary oedema?
- interstitial oedema
- bat’s wing appearance
- upper lobe diversion (increased blood flow to the superior parts of the lung)
- Kerley B lines
- pleural effusion
- cardiomegaly if cardiogenic cause
Suspected heart failure first line Ix?
N-terminal pro-B-type natrieretic peptide (NT-proBNP).
- if high (>2000) specialist assessment (incl transthoracic echo) within 2w
- if raised (400-2000) then within 6w
What is B-type natriuretic peptide (BNP)?
hormone produced by LV myocardium in response to strain. High (>400) =poor prognosis. Raised (100-400)
Factors that increase and decrease BNP levels?
- Increase= LV hypertrophy, ischaemia, tachy, RV overload, hypoxaemia (PE), GFR <60, sepsis, COPD, diabetes, >70yrs, liver cirrhosis
- Decrease= obesity, diuretics, ACEin, BB, Angiotension 2 receptor blockers, aldosterone antagonists
Chronic HF management?
1) ACEI + BB
2) + spironolactone (aldosterone antagonist)
3) specialist eg. digoxin for HF with sinus rhythm
If preserved ejection fraction, just manage comorbidities eg. HTN
HF with reduced ventriular ejection fraction?
<35-40%
Causes of HF-rEF?
Typically systolic dysfunction eg. IHD, dilated cardiomyopathy, myocarditis, arrhythmias
Causes of HF-pEF?
Diastolic dysfunction eg. hypertrophic obstructive cardiomyopathy, restrictive cardiomyopathy, cardiac tamponade, constrictive pericarditis
Left sided HF?
- Due to increased LV afterload (eg. arterial HTN or aortic stenosis) or increased LV preload (eg. aortic regurg resulting in backflow to LV)
- pulmonary oedema= dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, bibasal fine crackles
Right sided HF?
- Increased RV afterload (pulmonary HTN) or increased RV preload (tricuspid regurg)
- peripheral oedema (ankle/sacral), raised juglar venous pressure, hepatomegaly, weight gain due to fluid retention, cardiac cachexia
High-output HF?
Normal heart unable to pump enough blood to meet metabolic needs of the body. Causes: anaemia, arteriovenous malformation, Paget’s, pregnancy, thiamine def, thyrotoxicosis
Most common tumour causing bone mets
- prostate
- breast
- lung
Most common site of bone mets:
- spine
- pelvis
- ribs
- skull
- long bones
Features of bone mets?
Bone pain, pathological fractures, hypercalaemia, raised ALP
Lung mets are due to what type of cancers?
- breast
- colorectal
- renal cell
- bladder
- prostate
Cannonball metastases?
Multiple round well-defined lung mets commonly seen with renal cell cancer, sometimes choriocarcinoma and prostate.
Calcification in lung mets?
Uncommon except in chondrosarcoma or osteosarcome
Ix for metastatic disease of unknown primary?
- FBC, U&E, LFT, calcium, urinalysis, LDH
- CXR
- CT of chest, abdomen and pelvis
- AFP and hCG
- Sometimes: myeloma screen (if lytic bone lesions); endoscopy; PSA (men); CA 125 (women with peritoneal malignancy or ascities); testicular US (men with germ cell tumours); mammography
Metastatic bone tumours can be described as what?
Lytic (destroy bone), blastic (fill bone with extra cells) or mixed
Risk of fracture in metastatic bone tumours?
Osteolytic lesions > osteoblastic for spontaneous fracture.
Most common site: peritrochanteric region.
Management of spontaneous fracture with metastatic bone disease?
Use Mirel scoring system to then determine treatment
Metastatic bone pain may respond to what?
Analgesia, bisphosphonate infusion or radiotherapy
If pain with morphine not controlled, how much do you increase the dose?
30-50%
What may be useful in reducing the discomfort associated with a painful mouth that may occur at the end of life?
Benzydamine hydrochloride mouthwash or spray
Why are buprenorphine or fentanyl the opioids of choice for pain relief in palliative care patients with severe renal impairment?
They are not renally excreted and therefore are less likely to cause toxicity than morphine
Syringe drivers: respiratory secretions & bowel colic may be treated by what?
Hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide
