Palliative care

Question 1

Domperidone / Metoclopramide receptor & complications

Answer 1

D2 (Dopamine antag)

Long QT
Extrapyramidal symptoms

Question 2

Ondansetron receptor & complications

Answer 2

5HT (Serotonin antag)

Headache
Consipation
Long QT

Question 3

Cyclizine receptor & complications

Answer 3

H1 (Antimuscarinic)

Drowsiness
Dry mouth
constipation

Question 4

Pain treatment goals

Answer 4

Good nights sleep

Pain free at rest and movement

Question 5

Types of pain

Answer 5

Nociceptive (tissue damage/distortion)

Neuropathic (nerve damage/compression/infiltration)

Question 6

WHO pain ladder
1
2
3

Answer 6

1) non-opioid ± adjuvant (NSAID)
2) Mild Opioid ± non-opioid ± adjuvant
3) Strong Opioid ± non-opioid ± adjuvant

Question 7

Simple analgesics and precautions

Answer 7

Para (Liver impairment, cachexia)

NSAIDs (renal impair, low pt. CI in GI bleed and asthma - prostaglandins)

Question 8

Weak opioids and Precautions

Answer 8

Codeine, Tramadol, Dihydrocodeine

Constipation, Ceiling effect - replace with strong opioid rather than adding it to it

Question 9

Strong opioids

Answer 9

Morphine, Diamorphine, Oxycodone, Buprenorphine, Fentanyl

Renal impair, Constipation, Resp

Warn of driving

Question 10

Specialist palliative analgesia

Answer 10

Alfentanil
Methadone
Ketamine

Question 11

Codeine/Tramadol Vs Morphine potency

Answer 11

Codeine and Tramadol = 1/10th of Morphine

Question 12

Oxycodone Vs Morphine

Answer 12

Morphine is half as strong as Oxycodone (e.g. Oxycontin)

Question 13

How much morphine PRN

Answer 13

1/6th of 24 hour dose

Question 14

SE of morphine & managing

Answer 14

Constipation, Resp depression, sedation, nausea, dry mouth

Stimulant laxatives (Senna, Sodium Picosulfate) + PRN antiemetics (nausea should pass)

Question 15

Oral Vs Subcut/IV morphine

Answer 15

Oral is half as strong as SC/IV

Question 16

When to give Naloxone

Answer 16

Only if RR is less than 8 AND ALSO SpO2 under 92%

Question 17

Fentanly Vs Morphine

Answer 17

Morphine is 1/3 as strong as fentanyl

Question 18

When is fentanyl good

Answer 18

Poor oral route - given as a patch

Renal impairment

Question 19

Adjuvant analgesics for:

Neuropathic pain

Muscle spasm

Compression symptoms

Bone pain

Answer 19

• Amitryptaline (tricyclic), Pregab/Gabapentin (antiepileptics - NMDA CA channel block)

Diazepam (Benzos), Baclofen (Antispasminogenic)

Dexamethasone (steroid)

Zolendronic acid (Bisphosphonates)

Question 20

What things need to be discussed in dying patient?

Answer 20

Preferred place

Medical interventions (IV Abx, PEG etc

DNACPR

Question 21

Key symptoms to control in dying patient

Answer 21

Pain (PRN morphine)
Breathlessness (Opioid SC)
Respiratory secretions (buscopan)
Nausea and vomiting (Halopaeridol - D2, domperidone/metoclopramide)
Distress/agitation (Midazolam - Benzo - GABA effect)

Question 22

Alternative to SC meds (patient unable to take oral meds)

Answer 22

Syringe driver

Question 23

Palliative care emergencies

Answer 23

Malignant spinal cord compression
(Dex IV)

SVC obstruction
(Dex)

Malignant hypercalcaemia - breast/lung/MM
(IV zoledronic acid)

Opioid overdose/toxicity

Acute bleeding - headband neck/GI cancers + quick death
(Pain, green blankets, Morphine and midazolam to relax