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FINALS > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

1st line drug Mx for neuropathic pain

A

Amitriptyline, duloxetine, gabapentin, or pregabalin.

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2
Q

Opioid metabolism

A

In liver, involves CYP450 enzyme system.

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3
Q

Main opioid to use in palliative care?

A

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
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4
Q

Breakthrough morphine dose?

A

1/6th of daily morphine dose

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5
Q

What opioid if patient has mild-moderate renal impairment? Severe?

A
  • Mild/moderate: oxycodone
  • Severe: buprenorphine, fentanyl
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6
Q

Oral codeine or tramadol to oral morphine

A

divide by 10

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7
Q

Oral morphine to oral oxycodone

A

divide by 1.5-2 (2)

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8
Q

transdermal fentanyl 12ug (microgram) equates to what dose of oral morphine daily

A

30mg

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9
Q

transdermal buprenorphine 10ug patch equates to what dose of oral morphine daily

A

24mg

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10
Q

oral morphine to subcut morphine? to subcut diamorphine?

A
  • divide by 2
  • divide by 3
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11
Q

oral oxycodone to subcut diamorphine

A

divide by 1.5

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12
Q

Agitation and confusion?

A

Midazolam

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13
Q

Secretions?

A

Hyoscine butylbromide

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14
Q

Breathlessness?

A

Morphine sulfate

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15
Q

Nausea?

A

Haloperidol

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16
Q

Hiccups?

A

Chlorpromazine

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17
Q

Non-life threatening bleeds?

A

Exclude UTI, encourage fluids to prevent clot retention, etamsylate 500mg qds. Tranexamic acid avoided as promotes formation of hard clots.

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18
Q

Superior vena cava obstruction: features?

A

dyspnoea, headache worse in morning, swelling of face neck and arms, visual disturbance, pulseless jugular venous distension.

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19
Q

SVC causes and management?

A
  • small cell lung cancer and other malignancies, aortic aneurysm, mediastinal fibrosis
  • endovascular stenting for symptom relief and glucocorticoids.
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20
Q

Nausea due to reduced gastric motility?

A
  • ?opioid related, related to serotonin (5HT4) and dopamine (D2) receptors
  • metoclopramide
21
Q

Nausea: chemically mediated?

A
  • due to opiods, chemo or hypercalaemia
  • haloperidol
22
Q

Nausea: raised ICP, vestibular or cortical (due to anxiety or pain)?

A
  • 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)
23
Q

Mx headaches due to ICP?

A

Dexamethasone

24
Q

CXR pulmonary oedema?

A
  • 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
25
Q

Suspected heart failure first line Ix?

A

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

26
Q

What is B-type natriuretic peptide (BNP)?

A

hormone produced by LV myocardium in response to strain. High (>400) =poor prognosis. Raised (100-400)

27
Q

Factors that increase and decrease BNP levels?

A
  • 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
28
Q

Chronic HF management?

A

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

29
Q

HF with reduced ventriular ejection fraction?

A

<35-40%

30
Q

Causes of HF-rEF?

A

Typically systolic dysfunction eg. IHD, dilated cardiomyopathy, myocarditis, arrhythmias

31
Q

Causes of HF-pEF?

A

Diastolic dysfunction eg. hypertrophic obstructive cardiomyopathy, restrictive cardiomyopathy, cardiac tamponade, constrictive pericarditis

32
Q

Left sided HF?

A
  • 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
33
Q

Right sided HF?

A
  • 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
34
Q

High-output HF?

A

Normal heart unable to pump enough blood to meet metabolic needs of the body. Causes: anaemia, arteriovenous malformation, Paget’s, pregnancy, thiamine def, thyrotoxicosis

35
Q

Most common tumour causing bone mets

A
  • prostate
  • breast
  • lung
36
Q

Most common site of bone mets:

A
  • spine
  • pelvis
  • ribs
  • skull
  • long bones
37
Q

Features of bone mets?

A

Bone pain, pathological fractures, hypercalaemia, raised ALP

38
Q

Lung mets are due to what type of cancers?

A
  • breast
  • colorectal
  • renal cell
  • bladder
  • prostate
39
Q

Cannonball metastases?

A

Multiple round well-defined lung mets commonly seen with renal cell cancer, sometimes choriocarcinoma and prostate.

40
Q

Calcification in lung mets?

A

Uncommon except in chondrosarcoma or osteosarcome

41
Q

Ix for metastatic disease of unknown primary?

A
  • 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
42
Q

Metastatic bone tumours can be described as what?

A

Lytic (destroy bone), blastic (fill bone with extra cells) or mixed

43
Q

Risk of fracture in metastatic bone tumours?

A

Osteolytic lesions > osteoblastic for spontaneous fracture.
Most common site: peritrochanteric region.

44
Q

Management of spontaneous fracture with metastatic bone disease?

A

Use Mirel scoring system to then determine treatment

45
Q

Metastatic bone pain may respond to what?

A

Analgesia, bisphosphonate infusion or radiotherapy

46
Q

If pain with morphine not controlled, how much do you increase the dose?

A

30-50%

47
Q

What may be useful in reducing the discomfort associated with a painful mouth that may occur at the end of life?

A

Benzydamine hydrochloride mouthwash or spray

48
Q

Why are buprenorphine or fentanyl the opioids of choice for pain relief in palliative care patients with severe renal impairment?

A

They are not renally excreted and therefore are less likely to cause toxicity than morphine

49
Q

Syringe drivers: respiratory secretions & bowel colic may be treated by what?

A

Hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide

FINALS (34 decks)

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