Palliative care Flashcards
why is it important that analgesics are given regularly
more effective in preventing pain than relieving established pain
what can be used to control the pain of bone mets? (2)
bisphosphonates
strontium isotopes
1st and 2nd line for nueropathic pain?
tricyclic intidepressant (TCA) antiepileptic (pregab, gabapent)
Other options include ketamine
How to treat neuropathic pain due to nerve compression
corticosteroid such as dexamethasone (reduces oedema around the tumour)
Also consider nerve blocks & regional anesthesia (e.g. epidural) if pain is localised
frequensy of morphine:
immediate release
modified release
immediate 4 hourly
modified 12 hourly
how long before an activity that causes pain should a breakthrough pain dose be given
30 mins
dose for breakthrough pain should be …
how often to reapeat dose?
1/10 to 1/6 of total 24 hour dose
2-4 hourly, up to hourly in needed
if they need breakthrough dose. ……. times a day the regular dose should be reviewed
2
increments of increase of morphine should not exceed
one half to one third of total 24 hour dose
how to transfer patient from immediate release to modified release morphine
four hours after immediate release dose give the modified release dose (with same 24 hour total dose)
when adjusting morphine do we adjust the dose or the frequency
dose
oral to parenteral morphine convertion
parenteral is about half oral dose
what is the route of admin of syringe driver
SC
why is diamorphine sometimes preferred in syringe driver
more soluble
equlvilent S/C dose of diamorphine is about ……. of the dose of oral morphine
a third
transdermal route is not suitable for what sort of pain
acute and pt who analgesic requirements are variable
when switching to transdermal patch due to opioid induced hyperanalgesia how much should the dose be reduced by?
1/4 to 1/2
anorexia symptom control treatment (2)
dexamethasone or prednisolone
symptom relief for bowel colic and repiratory recretions
S/c hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium (antimuscurinics)
(4 hourly up to hourly)
symptom treatment - capillary bleeding (3)
tranxeamic acid PO
or tranexamic acid or adrenaline solution soaked gauze to affected area
vit k ( for liver disease)
opioid induced constipation in palliative care
PREVENTATIVE -codanthramer (peristaltic stimulant & fecael softener) -lactulose and senna also -methylnaltrexone
prophylactic treatment for convulsions in palliative care
phenytoin or carbamazapine PO
rectal diazepam
phenobarb injection
midazolam syringe driver
dry mouth non pharma treatment
sucking ice, chewing gum, sucking pinapple chunks
artificial saliva
what to consider as a cause of dry mouth
too much antimuscurinic (e.g. hyoscine) candida infection (nystatin, miconazole, fluconazole treatment)
dysphagia caused by obstruction with tumour could be treated with
dexamethasone
breathlessness can be relieved with
PO morphine
diazepam if due to anxiety
corticosteroid if bronchospasm/obstruction
fungulating tumours treated with
dressings
metronidazole systemically for malodour
GI pain / colic may be relieved by
Loperamide
Also hyoscine hydrobromide sc/IV, hyoscine butyl bromide, glycopyrronium
Abdominal distension due to pressure on the stomach may be relieved by …. And ….
Antacid and antiflatulent and prokinetic before meals
Three prokinetic drugs
Domperidone,metoclopramide, erythromycin
Hiccup may be caused by …. And treated with ….
Also second line ….
Gastric distension. Preparation incorporating antacid and antiflatulent. Or if this fails Metoclopramide Baclofen Nifedipine
Insomnia should be treated by
Treating the cause eg. Discomfort, cramps.
If this fails BZs could be considered such as temazepam
Intractable cough should be treated with ….
And you should NOT treat with …
Treat with PO morphine
Don’t treat with methadone because of long duration of action - accumulation,
2 treatments for muscle spasm
Diazepam or backofen
Opioid induced N&V usually only lasts … Days
4/5
Opioid induced N&V first line (2)
Haloperidol and metoclopramide
General first line category of antiemetic.?
Prokinetic
Drugs with ….. Action antagonise prokinetic effect
Antimuscurinic
What is used for metabolic causes of nausea eg. Renal failure , hypercalcemia
Haloperidol
What is used for nausea associated with gastritis, gastric statis and functional bowel obstruction
Metoclopramide
Treatment for nausea due to increase intracranial pressure, motion sickness and mechanical bowel obstruction
Cyclizine
Main treatment for puritus ……
And if it is due to obstructive jaundice also try ….
Emollients
Cholestyramine
Headache due to raised intracranial pressure can be treated with …..
Dexamethasone … Before 6pm to prevent insomnia
Restless and confusion antipsychotic of choice 2
Haloperidol and levomepromazine
Levomepromazine is also licenced to treat pain in what circumstances
Palliative care, unresponsive pain
Route of a syringe driver is ….
Subcutaneous
Three indications for syringe driver
- unable to take medication by mouth
- does not wish to take meds by mouth
- in malignant bowel obstruction to avoid insertion of NG tube or IV admin
Hyoscine hydrobromide can cause paradoxical ….
Agitation
Which is more sedative haloperidol or levomeprmazine
Levomepromazine
Uraemia puts patients another risk of …..
Convulsions
Problems with putting cyclizine or metoclopramide in a syringe driver
Cyclizine - likely to percipitate
Metoclopramide - skin reaction
Use of octreotide
Stimulates water and electrolyte absorption and inhibits water secretion in the small bowel …
Reduces GI secretions to reduce vomitting due to bowel obstruction
Pain control of choice for syringe driver …
Diamorphine
3 medications that are contraindicated via SC
Chlorpromazine
Prochlorperazine
Diazepam
Indication for need of change of syringe driver injection site
Pain and inflammation.
But not necessarily firmness or swelling
