Palliative care Flashcards
method of opioid administration in palliative care?
Start low and titrate up with regular dose of immediate release and PRN, switching to modified release when pain is controlled.
S/Es of opioids in palliative care?
- N&V - self limiting but metoclopramide/haloperidol useful for anti-emesis
- Itch - doesn’t respond to anti-histamines as it is CNS
- Constipation - prophylactic laxatives used
- Drowsiness - usually self-limiting and for first few days otherwise reduce dose
Opioid toxicity symptoms?
- Myoclonic jerks
- Agitation
- Visual hallucinations
- Confusion
- Pinpoint pupils
- Respiratory depression
Management of opioid toxicity?
- Dose reduction
- Switching opioids
- Opioid antagonist – naloxone
What opioids are safer for sue in renal failure?
Oxycodone and fentanyl
Symptoms of malignant hypercalcaemia?
Mild:
- N&V
- Anorexia
- Constipation
- Thirst and polyuria
Severe:
- Gross dehydration
- Drowsiness
- Confusion & coma
- Abnormal neurology
- Arrhythmias
Management of malignant hypercalcaemia?
1) Rehydrate with IV 0.9% saline
2) After at least 2L, give bisphosphonate infusion
3) Measure U&Es every day, correcting with IV fluids (Ca normalisation takes 3-5 days)
Options for antiemetics in palliative care?
Haloperidol
Cyclizine
Levopromazine
Metaclopramide
Mechanism of action of Haloperidol, and uses?
Dopamine antagonist - acts at the CTZ
Best used for chemical causes, e.g. drugs, renal failure, hypercalcaemia
Mechanism of action of Cyclizine, and uses?
Antihistamine and anticholinergic with acts at the vomiting centre
Used in complete bowel obstruction, raised ICP, motion sickness
Mechanism of action of Metaclopramide, and uses?
Peripheral DA antagonist and 5HT4 agonist, and a central 5HT3 antagonist
Helps to control acid reflux (prokinetic)
Mechanism of Levopromazine, and uses
Acts at multiple receptors
- many S/Es, broad spectrum
Causes of bowel obstruction in palliative care patient?
Extrinsic compression e.g primary tumour, omental masses, malignant adhesions, fibrosis
Intraluminal occlusion from tumour
Motility disorders (tumour infiltrating muscle)
Management of complete bowel obstruction in the palliative care patient?
- Pain control
- Improve motility (laxatives, maybe steroids or prokinetics)
- Anti-emetics
- Reduce colic if present
- Reduce gastric secretions (anticholinergic/somatostatin analogue)
- NG tube (often last resort in palliation)
Antispasmodic antisecretory agents?
Hyoscine butylbromide (Buscopan) – Ach antagonist
Octreotide = somatostatin analogue
Palliative surgical procedures for bowel obstruction?
- Venting gastrostomy (tube from stomach to outside of abdomen)
- Duodenal/rectal stent
- Surgical palliative bypass
When might you use continuous subcutaneous infusions in palliative care?
- Intractable vomiting (treatment resistant)
- Severe dysphagia
- Poor GI absorption
- Too weak to swallow oral medications
Metastases that can compress the spinal cord?
- Lung
- Breast
- Prostate
- Kidney
- Melanoma
- Multiple myeloma
- Lymphoma
Regions of the spinal cord that can be compressed?
- Cervical (breast)
- Thoracic (lung, breast, prostate)
- Lumbosacral (GI, prostate)
- Below L1/L2 = cauda equina syndrome
Signs and Symptoms of spinal cord compression?
Symptoms:
- Back pain (often band-like)
- Tingling and numbness – often starts in feet and goes
- Myelopathy – rapid onset
- Bladder/bowel symptoms are typically late and so indicate poor prognosis
Signs:
- Sensory change (possibly with a level)
- Hypo/hyperreflexia
- Weakness
- Perianal sensory changes/loss of sphincter tone
Management of spinal cord compression?
- High dose dexamethasone (2 separate 16mg doses)
- Radiotherapy and/or surgery
- MDR approach to rehab
Management of neuropathic pain?
- TCAs e.g. amitriptyline
- Anticonvulsants e.g. gabapentin
- Steroids e.g. dexamethasone
What is total pain, what aspects make up total pain?
All the pain a patient may be experiencing, including:
Physical pain
Social pain
Pyschological pain
Spiritual pain
Common causes of vomiting?
Mouth and pharynx - Taste, secretions, candida
GI - stasis, obstruction, gastritis, constipation
Drugs
Metabolic e.g. hypercalcaemia
Toxic, infection
Raised ICP
Balance
Anxiety/fear
Compression below the level of L1/2 is called what?
Cauda equina syndrome
Most common level of spinal cord compression?
Thoracic
