Palliative Care, ASPHO Flashcards
where is the vomiting centre located?
medulla
receptors in chemo trigger zone?
dopamine
5HT3=serotonergic
NK1…want to block these to prevent nausea
recptors in vomiting centre?
5HT2, 5Ht3, histamine, n-acetylcholine
causes of n/v in oncology?
- chemo, antibiotics, opioids
- mucositis, constipation
- pscych/anticipatory
- increased ICP
- hypercalcemia
non-pharm options for n/v?
provide small meals hypnoiss breathing techniques, guided imagery aromatherapy (ginger, peppermint) acupressure P6 point avoid discomforting smells
give 4 classes of pharm therapies for n/v and an example for each?
-serotonic 5-HT3 inhibitors: ondansetron, gran, palo
-anti-dopaminergics (D2)
metoclopramide
haloperidol
olanzapine
-anti-Histamine H1
diphenhydramine, dimehydrinate
cyproheptadine
-Acetylcholine blocker
scoplamine
-Neurokinin 1 antagonist (NK)
aprepitant (can’t give with cyclophos, ifos)
-Benzos
lorazapeam for anticipatory nausea
-steroids (dexamethasone)
-IVF
-THC: dronabinol
-octreotide for bowel obstruction, other constipation meds
high emetogenic risk: how do you determine meds?
-is dex permitted or no?
-child’s age? if >6 mos, can get aprepitant…
-getting chemo that interacts with aprep?
Therefore, end up with 5HT3 inhibitor, dex if you can give it, and aprep if you can give it…..if <6 mos, 5HT3 + dex alone….if dex contraindicated and >6 mos and chemo ok, give 5HT3+ aprep….and if can’t get aprep as well, then 5HT3 inhibitor alone (palonosteron)
mod emetogenic risk: how you determine?
if can give dex: dex + 5Ht3 inhibitor…if can’t, then try 5HT3 + aprep as long as can receive aprep…otherwise 5HT3 alone
low emetogenic risk: give what?
ondans or gran
if minimal emetogenic risk, give what?
5HT3 inhibitor as needed (don’t need ppx)
what is nociceptive pain?
neural tarnsmission activate by mechanical, chem, or thermal damage to the body tissue, produces phsyiological/endocrine presonse separate from cogntiive/emotional repsonse…eg: break your arm
neuropathic pain=?
results from abnormal nerve function due to nerve invasion or inflammation
2 ways to quantify pain in kids?
Visual analog scale
FLACC scale= face, leg, activity, cry, consolability
principles for managing nociceptive pain?
- if having pain all teh time, set up regular pain meds, not PRN
- adapt tx to the child and their needs
- give meds by appropriate route
- 2-step strategy: step 1= mild, step 2= mod-severe
step 1 pain: manage how?
ibuprofen and/or acetaminophen…maybe cox2 inhibitor=toradol= ketorlac
step 2 pain: manage how?
morphine or other opioid like fentanyl, hydromoprh
tramadol can’t give to whom?
<12 yrs; history of seizures
4 side effects of opioids? and ways to manage?
- constipation…give REGULAR meds, like senna
- sedation…wait it out (imporves with time), remove other sedating medications
- pruritus…tx with naloxone >antihistamine
- nausea…tx with dopamine antagonist or 5HT3 antagonist
- urinary retention: nalbuphine or bladder cath
- hyperalgesia: dose reductioni or reduction to diff opioid
- myoclonus: reduce or rotate opiod, give benzo
reasons to rotate opiods?
- renal failure (stop morphine/oxycodone and go to fentayl or methadone)
- too many side effects with poor pain control (otherwise if good pain control, go down on dose by 20%)
- opioid-induced hyperalgesia or myoclonus
tolerance?
need to increase dose of opioids over time (this is a physio process)
withdrawal symptoms for stopping opioid too fast? 5
sweating diarrhea restlessness rhinorrhea hypertension
neuropathic pain relief takes how long to tx with neuro meds?
4-6 weeks!
4 types of meds for neuropathic pain?
- gabapentinoids, eg gabapentin, pregabalin
- TCAs, eg amitriptyline, notryptyline
- SNRIs, eg venlafaxine, duloxetine
- Antiepileptic drugs, eg topiramate
- local anethestics, eg: lidocaine or ketamine
- opioids (methadone) if NOT affectively treated with other meds
non-med ways to manage pain? 5
- physical tehrapy
- acupuncture
- massage
- heat/cold
- guided imagery
- hyponosis
targeted drug therpaies for pain?
NSAIDs, bisphosphonates for bony mets
corticosteroids
msucle relaxants
interventional procedures for pain?
- regional nerve blocks
- epidural anesthesia
- nerve ablation for refractory pain
- palliative radiation for bony pain
types of sx palliative care team manages>
- fatigue
- pain
- dyspnea
- resp secretions
- n/v, constipation, diarrhea, poor appetitie
- agitation, anxiety, depression, sleep issues
- pruritus
- delirium
EOL symptoms? 5
somnolence, decreased appetite
- urinary retention
- labored breathing
- less walking/speaking
- waxy appearance
- secretions/gurgling
end of life meds and their classes? (4)
opioid (morphine)
benzo (lorazepam)
haloperidol= antipsychotic
atropine or hyoscyamine= anti-cholingeric
morphine treats what at end of life? 3
pain
dyspnea
cough
benzo treats what at end of life? 4
sz
anxiety
agitation
nausea
haloperidol treats what at end of life? 2
n/v
delirium
atoprine treats what at end of life?
secretions
pain at EOL: increase dose by how much?
mod: 30-50%
severe: 50-100%
rescue doses at EOL should be waht % of daily requirement
10%…or 50-100% of continuous dose if using patient guided analgesia
when switching drugs, need to do what?
decease dose by 25-50% (cross-tolerance)
patches best for ___ pain, not for what 2 things?
chronic; not for acute or end of life
which medication cannot be rapidly titreated and can only be increased q3-4 days?
methadone
is there data that pain meds hasten death?
no
is there a ceiling dose for pain management at EOL?
no
dyspnea is ___
subjective (ask pt or look at their face!…don’t look at O2 sat/retractions/RR)
dyspnea management?
- opioids (generally 1/3-2/3 pain dose…but if already on for pain just use pain dose)
- fan to face
- increased head of bed
- oxygen by nasal cannula IF HYPOXIC
- benzos can be helpful for aniety
- consdier stopping IVF
how to manage delirium?
- tx underlying cause if possible
- day/night and re-orientation
- if distressing, haloperidol…avoid benzos adn anticholingerics!
managing secretions at EOL?
- reassure family not distressing to patient (anticipate family’s concern…due to body’s muscle relaxation)
- stop unncessary IVF
- atropine 1% eye drops given SL
- hyoscyamine
what CAN families do for child at EOL?
- provide child with famiial voices, sounds, touch
- continue to bathe, position changes, watch for discomfort
- practice prayer rituals, etc
- massage and Reiki
