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Ama - Part 4 PM4B > Palliative Care COPY > Flashcards

Palliative Care COPY Flashcards

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1
Q

Principles of pain management

A
  • Understand cause to optimize treatment
  • Appropriate level of WHO ladder
  • Use adjuvants where necessary
  • Use oral where possible
  • Assess regularly
  • Encourage patients to take an active role in the management of their pain
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2
Q

Causes of pain

A
  • Nociceptive
  • Somatic
  • Visceral
  • Neuropathic
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3
Q

Opioids for pain management

A
  • 1st line = morphine
  • Background and breakthrough
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4
Q

Breakthrough pain management

A
  • Regular opioid + Breakthrough opioid
  • Regular opioid = typically long acting 12 or 24 hour preparations.
  • Breakthrough = immediate release preparations, given PRN when pain worsens.
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5
Q

Monitoring

A
  • Pain charts
  • Individual dose titration
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6
Q

Syringe drivers

A
  • SC
  • Steady plasma conc. of drug
  • Dose reviewed every 24 hours, titrated up/down as needed - dependent on symptoms/side effects.
  • May still require breakthrough doses
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7
Q

When are syringe drivers useful?

A
  • Intractable pain
  • Vomiting
  • Severe dysphagia (patient too weak to swallow or unconscious)
  • Several drugs can be combined into one syringe - management of multiple symptoms.
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8
Q

Compatibility charts

A
  • For syringe drivers
  • Summarises compatibility information available for drug combinations
  • Determines if drugs can be mixed or if they will precipitate
  • Maximum concentrations
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9
Q

3 examples of palliative care emergencies

A
  • Malignant hypoercalcaemia
  • Neutropenic sepsis
  • Malignant spinal cord compression (MSCC)
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10
Q

Malignant hypercalcaemia

A
  • Palliative care emergency
  • Sign that disease has significantly progressed (most paitnets with this die within a year)
  • Ca> 2.6mmol/Lt
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11
Q

Malignant hypercalcaemia - treatment

A
  1. Fluid replacement (1-2L NaCl 0.9% over 24h)
    • Given before bisphosphonates as nephrotoxic.
  2. Bisphosphonates: zolendronate or pamidronate
    • Treatment effective for 2-4 weeks in 70-80% of pt
    • Ca2+ levels fall after 48h and continue to decrease for 6/7 days
    • Reduce dose in renal impairment
    • Monitor
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12
Q

Zolendronate

A

4mg/100ml in normal saline for 15 mins

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13
Q

Pamidronate

A
  • <3.5mmol/L = 60 mg
  • > 3.5 mmol/L = 90 mg
  • BOTH in normal saline over 2-4 hours
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14
Q

Malignant hypercalcaemia - MoA

A
  • Due to parathyroid hormone-related protein
  • Normally expressed in cells but also secreted by tumour cells
  • PTHrP stimulates bone resorption, increasing osteoclast activity (breaks down old bones, releases calcium)
  • Also increases calcium reabsorption so decreases urinary excretion of calcium
  • Higher serum calcium
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15
Q

Malignant hypercalcaemia - Symptoms

A
  • Symptoms typically present with >3mmol/L
  • N+V
  • Drowsiness
  • Confusion
  • Constipation
  • Anorexia
  • Fatigue
  • Mood disturbances, delirium
  • Symptoms are general, so regular monitoring of Ca levels is essential
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16
Q

Malignant hypercalcaemia - medical emergency

A
  • > 4mmol/L
  • Seizures
  • Arrhythmias
  • Untreated will die in a few days
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17
Q

Malignant spinal cord compression

A
  • Palliative care emergency - urgent referral for MRI
  • Complications of cancer where metastases in spine
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18
Q

MSCS - Symptoms

A
  • Pain
  • Motor deficits
  • Autonomic deficits
  • Sensory deficits
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19
Q

MSCC - Treatment

A
  • Dexamethasone 16mg OD ASAP
  • Analgesia
  • Radiotherapy
  • Surgery
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20
Q

Spinal cord compression

A
  • Pressure on the spinal cord
  • Nerves in the spinal cord swell and slow down or their blood supply is blocked.
  • Nerves cannot function as normal.
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21
Q

Spinal cord compression - symptoms

A
  • Progressive pain in spine
  • Spinal pain aggravated by straining
  • Nocturnal spinal pain preventing sleep
  • Limb weakness
  • Difficulty walking
  • Bladder or bowel dysfunction
  • Sensory defecits
22
Q

Spinal cord compression - treatment

A
  • Dexamethasone
  • Reduces oedema
  • Inhibits inflammatory response
  • Delays onset of neurological symptoms
23
Q

Neutropenic sepsis

A
  • Medical emergency
  • Neutrophil count <0.5 x 10^9/L and a temperature >38, or any symptoms or signs or sepsis
  • Can occur in any pt who has received chemotherapy within the last 4 weeks
  • Rapid progression of symptoms - leads to shock and death
  • Rapid referral essential
24
Q

Treatment of neutropenic sepsis

A

Broad spectrum abx IV within one hour
e.g. tazocin 4.5g TDS + gentamicin 5mg/kg OD

25
Q

Monitoring in neutropenic sepsis

A
  • U&E
  • FBC
  • LFTs
  • CRP
  • Blood cultures
  • Urine and sputum cultures
  • Chest X ray
  • Look for focus of infection - consider fungal
26
Q

Late signs a patient is dying

A
  • Agitation
  • Cheyne-stokes breathing (very fast followed by quieter and slower breathing in a cycle)
  • Decreased consciousness
  • Mottled skin
  • Noisy respiratory secretions
27
Q

Early signs a patient is dying

A
  • Fatigue
  • Weight loss/loss of appetite
  • Decreased mobility and performance
  • Social withdrawal
  • Changes in communication
28
Q

Aim when a patient is dying

A
  • Comfort and symptom management
  • Stop unnecessary investigations, observations and medication
29
Q

Common symptoms at end of life

A
  • Pain
  • Anxiety, agitation, delirium
  • N+V
  • Respiratory secretions
30
Q

Malignant bone pain

A
  • Localised, aching pain
  • Secondary to bone cancer:
    • Osteoclasts break down too much bone
    • Increased risk of fractures
    • Causes malignant bone pain
31
Q

Osteoblasts

A

Help build up new bone

32
Q

Osteoclasts

A

Break down old bone

33
Q

Treatment of malignant bone pain

A
  • Denosumab - human Mab
  • Targets RANKL protein which is needed for new osteoclasts to be made and function
  • Stops production of osteoclasts
  • Prevent further breakdown of bone, reduces bone pain, reduces risk of fractures
34
Q

N+V and management

A
  • Determine root cause
  • Look at neuronal pathways, find trigger
35
Q

N + V caused by higher cortical centres

A

Benzodiazepines
- Stomach or small intestine: 5-HT3 antagonist

36
Q

N + V caused by chemoreceptor trigger zone

A
  • Histamine antagonist
  • Muscarinic antagonist
  • Dopamine antagonist
  • Cannabinoids
37
Q

What to give in n+v caused by cancer chemo or radiotherapy

A
  • 1st line: ondansetron, dexamethasone
  • Need to follow cancer guidelines
38
Q

What antiemetic to give when N+V has uncertain cause

A

1st line: haloperidol and/or cyclizine
2nd line: levomepromazine

39
Q

What to give in n+v caused by drugs/biochemical

A

1st line haloperidol
2nd line levomepromazine

40
Q

Neuropathic pain

A
  • Shooting, stabbing, electric shock-like sensation
  • Occurs due to nerve damage caused by cancer
41
Q

Neuropathic pain - amitriptyline

A
  • Increases NA in spinal cord, which directly inhibits neuropathic pain through the A2 adrenergic receptors
  • Increased NA also acts on local coeruleus and improves function of descending neurogenetic inhibitory system
  • Dopamine and serotonin can reinforce noradrenergic effects to inhibit the neuropathic pain
42
Q

Neuropathic pain - gabapentin

A
  • Neuropathic pain tend to have overexpression of A2D1
  • Binds to the A2D1 which normalises the NMDA-R targeting and inactivity
    • Thus reduces neuropathic pain
43
Q

A2D1

A

Potentiates pre and post-synaptic NMDA-R activity of the spinal dorsal horn neurones.
Causes pain and hypersensitivity

44
Q

Constipation

A
  • Mild to very severe
  • ## Very severe = faecal impaction or partial bowel obstruction
    • Risk of intestinal obstruction
    • Causes Pain
45
Q

Causes of constipation

A
  • Poor food and liquid intake
  • Lack of exercise
  • Lack of privacy - off putting for patients to pass stool
  • Drugs
    • Opioids
    • Ondansetron, octreotide, iron
  • Hypercalcaemia
  • Hypokalaemia
  • Hypokalaemia
46
Q

Management of constipation

A

○ Address diet
- Increase fluid + fibre intake if possible,
- Increase mobility
- Good toilet hygiene/privacy
- If on opioids give regular laxatives:
- Combination
- Softener and stimulant e.g. macrogol with senna, docusate with sodium picosulfate

47
Q

Are bulk forming laxatives e.g. magrogol given in opioid induced constipation

A

No

48
Q

Confusion/agitation & causes

A
  • Cerebral metastases
  • Constipation or urinary retention
  • Dementia
  • Drug or alcohol withdrawal, psychological distress + pain
  • Electrolyte disturbances - high calcium, low sodium, low blood glucose
  • Infection e.g. UTI
  • Medication
49
Q

Treatment of confusion/agitation

A
  • Consider reversible/ underlying cause
  • Treat as for delirium:
  • Benzodiazepines: midazolam, lorazepam
  • Antipsychotics: low dose, e.g. haloperidol
50
Q

Role of pharmacist in palliative care emergencies

A
  • Early spotting of symptoms can improve outcomes
  • Advice on dosing of medications and monitoring
51
Q

What does the MDT do when a pt admitted to pallaitve care

A
  • Medicine - remove uncessary meds/make switches
  • Review pain levels
  • Home situation:
    • Hospice or home?
    • If at home, provide appropriate bed/carer
52
Q

Common symptoms and treatments for it at EoL

A

Pain
- Morphine, diamorphine (more potent)

Anxiety, agitation, delirium
- Midazolam

N+ V
- Haloperidol

Respiratory secretions
- Hyoscine antimuscarinic dries out the secretions
- Poor oral availability - SC injection
- 20mg PRN or put in syringe driver

Ama - Part 4 PM4B (69 decks)

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