Palliative Care Flashcards
The indications for corticosteroid
- Inflammation
- Cérébral oedema, metastasis
- NV
- SC compression
- Analgesic (nerve pain)
- SOB in COPD exacerbation (reduce anxiety
Conversion bw prednisolone and dexamethasone
6mg pred is 1 mg dexathamethasone
Conversion bw buprenophine patch to 24h oral morphine salt
Patch duration
Buprenophine 5’ is 12mg PO morphine salt
72h / 96h/ 7d
Given morphine dose /12 then x5
Conversion bw fentanyl patch to PO OD morphine salt
Fentanyl 12’ is 30mg morphine salt OD 25’ is 60mg 50’ is 120mg Available as 72h only Given morphine dose/60 then x25
Symptoms for hypercalcaemia
Dehydration NV Constipation Confusion Cardiac probs Polydipsia (thirsty) Pruritus Fatigue
Treatment for hyperca
Moa
Rehydration Bisphosphonates eg zoledronic acid If GFR< 30 ibandronic acid Inhibitis osteoclasts activity reduce bone resorption reduce ca release
What is Corrected calcium level
55% Of calcium in the blood is bound to albumin
45% free ca to be measured
Corrected calcium level takes into account of albumin and protein level
What is the normal range of calcium level
2.1-2.6 mmol/L
What are the ranges for hypercalcaemia
Mild
Moderate
Severe
2.6-3
3-3.4
>3.4
Treatment for restlessness and agitation
Induce sedation
BZ
Midazolam
AP- haloperidol, levomepromazine at high dose
What is death rattle
Excessive chest secretion
What are the treatment for secretion
Hyoscine butylbromide x BBB, poor BA
Hyoscine hydrobromide yesBBB
Glycopyrrodinium bromide xBBB anti muscarinic
Octreotide somatostatin analogue, reduce gi motility
What is anticipatory medicine what is in that just in case box
medicine given to patient to use at home for emergency symptom control. AM should be based on individual patient’s condition Anticipatory medicine for sc use Needle and syringes Prescribing guidance Rx PIL Contact details for advice
What did nice cg31 Care of the dying adult in the last day of life recommend
- Recognising Last few days of life
- Communicate and shared decision-making
- Clinically assisted hydration
- Meds for Pain,SOB,NV,anxiety,delirium,agitation,secretion
- Anticipatory prescribing
What’s the acronym IMPACT stands for in Symptom control of palliative care patient
I Identify concerns M make an accurate assessment P Plan your action A act C Continuously re-evaluate T Talk to other HCPS
What did nice guidelines recommend on pain relief for palliative care adult CG140
Communication
Start on strong opioid and titrate the dose-oral morphine
Use 1st line maintenance trt
Use transdermal patches if oral opioid not suitable
Use 1st line trt for BT pain in pt who can take oral opioid
Manage constipation.NV. Sedation
What is a typical total daily starting dose of Oral morphine
20-30mg OD
10-15mg BD
5mg (1/6-1/10 OD dose)BT
Inversion between oral morphine with: Tramadol/ codeine/ dijudrocodine IV morphine PO/ IV oxycodone IV diamorphine IV alfentanyl PO hydromirphine
X10 /2 /2, /2 /3 /30 /7.5 10mg morphine is 1.3mg hydroM
Fentanyl is x times more potent than P.O. morphine?
Why is it used as 2nd line
50-100 x more potent
Greater CNS distribution
BUT Not any more effective as analgesic than morphine
Treatment for bone pain
Bisphosphonates
Zoledronic acid/ pamidronate
If GFR<30 use Ibandronic acid
Treatment for neuropathic pain
Antidepressant: Amitriptyline50mg SSRI Fluoxetine Anticonvulsants: Sodium valproate carbamazepine Gabapetin Ketamine - dysphoria and delirium use BZ or midazolam Dexamethasone
Mental capacity act 2005 -5 principles
- A presumption of capacity
- Individual supported to make their own decision
- Unwise decisions
- Best interests
- Less restrictive option
Impaired Capacity to make decisions according to law
motor neurone disease -30% impaired Feeling a burden Depression and hopelessness are mutually reinforcing Major depression Medication changes can impair capacity
What do u need to make any decision
Accurate info
Capacity (decision specific capacity- the capacity you have for making that decision at that time)
Voluntary- Willingness
Points covered in Assisted dying proposed legislation to UK Parliament
Terminally ill Clear and settled wish Mental capacity Informed of options 2 doctors Self administer
Why might a patient need a syringe pump
- NV
- dysphagia can’t swallow tablet
- pill burden
- poor GI ab. Eg oleostomy/ stoma/ obstruction
- profound weakness / unconsciousness
Signs of problems with syringe driver
Skin irritations
Pain / leaking at injection site
Precipitation in driver
Discolouration of solution
How does ph affects diamorphines stability/ solubility
Diamorphine less stable, more likely to precipitate if the ph is high >6
What is the pH of injectable dexamethasone
What’s the implication and solution
Ph 7-9
Strong alkali
It will precipitate our other drugs eg diamorphine
Given as separate bolus inj as long t1/2
What are the sources of information for compatibility of syringe driver drugs
- BNF
- compatibility tables
- the synringe driver
- palliative durg.com
- PCF
- pallcare guidrlines
What are the two benefit of anticipatory prescribing
Easy access to care and medicine when needed at home
Helpful when deterioration occurs out of hours
When deciding which anticipatory medicines to offer take into account of (NG31)
- likelihood of specific symptoms occurring
- benefit and harm of rx ing or administering medicine
- B&H of not rx ing
- risk of sudden deteriorating for which urgent symptom control may be needed
- the place of care & time it would take to obtain medicines
What are the four main symptoms that are covered in anticipatory medicine
- agitation/ restlessness
- NV or agitation
- ex chest secretions
- pain
What are the four main medicines prescribed in anticipatory medicine in just in case box
Morphine sulfate - analgesic
Midazolam - anxiolytics sedative
Hyoscine butybromide - anti secretory
Levomepromazine or haloperidol - antiemetic and anxiolytics
Treatment for spinal cord compression
What’s the risk
Emergency MRI scan 16mg dexamethasone IV/PO stat 8mg dexamethasone BD PO ongoing until MRI results Stop or wean down asap Adrenal suppression
What are the main symptom burden is in palliative care
IS PANIC Immobility SOB Pain Anorexia NV Insomnia Constipation
Nice guidelines on managing side effects of strong opioids
Constipation: laxatives + adherence
NV: self résolve + antiemetic
Sedation: self resolve (only initiation/ dose increase) + ability to drive
When does patient need opioid rotation
Inadequate analgesia despite dose titration and adjuvant
CNS SE remain when dose reduced
What are the breakthrough pain alternatives to Liquid Morphine
Fentanyl lozenges / SL
ALfentanyl SL/ spray
Hydromorphone is X times more potent than P.O. morphine?
7.5 x
What class of drug is oxycodone
Kappa opioid rec agonist - dsyphoria / hallucinations-> midazolam or BZ
What class of drug is methadone What is it used for
A mixed pharmacology -
Miu agonist
NMDA antagonist (glutamatergic neu trans)
SSRI
Analgesic / opioid addiction / antidepressant
What are the characters of methodone
Long half life - risk of accumulation
In what form is methadone avalible jn
Tablet
Liquid
Injection
Suppository
