Palliative Care COPY Flashcards
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
2
Q
Causes of pain
A
- Nociceptive
- Somatic
- Visceral
- Neuropathic
3
Q
Opioids for pain management
A
- 1st line = morphine
- Background and breakthrough
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.
5
Q
Monitoring
A
- Pain charts
- Individual dose titration
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
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.
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
9
Q
3 examples of palliative care emergencies
A
- Malignant hypercalcaemia
- Neutropenic sepsis
- Malignant spinal cord compression (MSCC)
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
11
Q
Malignant hypercalcaemia - treatment
A
- Fluid replacement (1-2L NaCl 0.9% over 24h)
- Given before bisphosphonates as nephrotoxic.
- Bisphosphonates: zolendronate or pamidronate
- Treatment effective for 2-4 weeks in 70-80% of pt
- Reduce dose in renal impairment
- Ca2+ levels fall after 48h and continue to decrease for 6/7 days
- Monitor
12
Q
Zolendronate
A
4mg/100ml in normal saline for 15 mins
13
Q
Pamidronate
A
- <3.5mmol/L = 60 mg
- > 3.5 mmol/L = 90 mg
- BOTH in normal saline over 2-4 hours
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
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
16
Q
Malignant hypercalcaemia - medical emergency
A
- > 4mmol/L
- Seizures
- Arrhythmias
- Untreated will die in a few days
17
Q
Malignant spinal cord compression
A
- Palliative care emergency - urgent referral for MRI
- Complications of cancer where metastases in spine
18
Q
MSCS - Symptoms
A
- Pain
- Motor deficits
- Autonomic deficits
- Sensory deficits
19
Q
MSCC - Treatment
A
- Dexamethasone 16mg OD ASAP
- Analgesia
- Radiotherapy
- Surgery
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.
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
Monitoring in neutropenic sepsis
- U&E
- FBC
- LFTs
- CRP
- Blood cultures
- Urine and sputum cultures
- Chest X ray
- Look for focus of infection - consider fungal
26
Late signs a patient is dying
- Agitation
- Decreased consciousness
- Mottled skin
- Cheyne-stokes breathing (very fast followed by quieter and slower breathing in a cycle)
- Noisy respiratory secretions
27
Early signs a patient is dying
- Fatigue
- Weight loss/loss of appetite
- Decreased mobility and performance
- Social withdrawal
- Changes in communication
28
Aim when a patient is dying
- Comfort and symptom management
- Stop unnecessary investigations, observations and medication
29
Common symptoms at end of life
- Pain
- Anxiety, agitation, delirium
- N+V
- Respiratory secretions
30
Malignant bone pain
- Localised, aching pain
- Secondary bone cancer:
- Osteoclasts break down too much bone
- Increased risk of fractures
- Causes malignant bone pain
31
Osteoblasts
Help build up new bone
32
Osteoclasts
Break down old bone
33
Treatment of malignant bone pain
- 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
N+V and management
- Determine root cause
- Look at neuronal pathways, find trigger
35
N + V caused by higher cortical centres
Benzodiazepines
- Stomach or small intestine: 5-HT3 antagonist
36
N + V caused by chemoreceptor trigger zone
- Histamine antagonist
- Muscarinic antagonist
- Dopamine antagonist
- Cannabinoids
37
What to give in n+v caused by cancer chemo or radiotherapy
* 1st line: ondan, dex
* Need to follow cancer guidelines
38
What antiemetic to give when N+V has uncertain cause
1st line: haloperidol and/or cyclizine
2nd line: levomepromazine
39
What to give in n+v caused by drugs/biochemical
1st line haloperidol
2nd line levomepromazine
40
Neuropathic pain
- Shooting, stabbing, electric shock-like sensation
- Occurs due to nerve damage caused by cancer
41
Neuropathic pain - amitriptyline
- 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
Neuropathic pain - gabapentin
- Binds to the A2D1 which normalises the NMDA-R targeting and inactivity
- Thus reduces neuropathic pain
- Neuropathic pain tend to have overexpression of A2D1
43
A2D1
Potentiates pre and post-synaptic NMDA-R activity of the spinal dorsal horn neurones.
Causes pain and hypersensitivity
44
Constipation
- Mild to very severe
- Very severe = faecal impaction or partial bowel obstruction
-
- Risk of intestinal obstruction
- Causes Pain
45
Causes of constipation
- 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
Management of constipation
○ 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
Are bulk forming laxatives e.g. magrogol given in opioid induced constipation
No
48
Confusion/agitation & causes
* Dementia
* Cerebral metastases
* Infection e.g. UTI
* Medication
* Electrolyte disturbances - high calcium, low sodium, low blood glucose
* Drug or alcohol withdrawal, psychological distress + pain
* Constipation or urinary retention
49
Treatment of confusion/agitation
- Consider reversible/ underlying cause
- Treat as for delirium:
- Benzodiazepines: midazolam, lorazepam
- Antipsychotics: low dose, e.g. haloperidol
50
Role of pharmacist in palliative care emergencies
- Early spotting of symptoms can improve outcomes
- Advice on dosing of medications and monitoring
51
What does the MDT do when a pt admitted to pallaitve care
- Medicine - remove uncessary meds/make switches
- Review pain levels
- Home situation:
- Hospice or home?
- If at home, provide appropriate bed/carer
52
Common symptoms and treatments for it at EoL
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
