Palliative Care PPT Flashcards
What is the first line anticipatory drug for nausea and vomiting and why?
haloperidol - because it’s once a day, long acting, and covers a large range of N&V
what route could you use in a cachectic person instead of IM?
subcutaneous route - unlicensced for most drugs
Which of the below would you discontinue at EOL?
Statins, treatment dose LMWH, prophylactic LMWH, opioids, iron?
statins, prophylactic LMWH, iron
name two common indications for a syringe driver
persistent N&V and severe dysphagia
do oral and subcutaneous doses have the same effect?
they should do as long as the patient is absorbing things properly
how strong is codeine in comparison to morphine?
codeine is 1/10th the strength of morphine
What is the mechanism of action of pregabalin?
acts on calcium channels to stop calcium coming into the cell whcih hyperpolarises the cell making it harder for an action potential to be formed
what class of drug is clonazapam?
benzodiazepine
what is the mechanism of action of clonazapam?
increases chloride in teh cell through GABA receptors.
Why might benzodiazepines make people sleepy?
because they are decreasing lots of neural pathways in teh brain and not just the pain pathway
what is the mechanism of action of opioids in terms of their pain relief effects?
they open potassium channels via G-protein coupled receptors, making them more negative (hyperplolarises cell) whcih reduces the chance of an action potential forming
name four ways in which opioids can cause harm
- Excessive side effects
- toxic by-products (metabolites)
- opioid induced hyperalgesia
- poorly informed patients and professionals
Name 3 GI side effects of morphine
constipation, xerostomia, N&V, delayed gastric emptying, GORD, constriction of the sphincter of Oddi
name 4 neurological effects of opioids
analgesia, delirium, hallucinations, sedation, myoclonus, hyperalgesia, seizures, headahces, euphoria, dysphoria, dependency
name two cardiovascular effects of opioids
bradycardia, hypotension
name 2 pulmonary effects of opioids
respiratory depression, decresased cough reflex, non-cardiogenic pulmonary oedema
name two urological effects of opioids
urine retention, decreased urine production
name an endocrinological effect of opioids
hypognoadism/sexual dysfunction, osteoporosis
what effect are opioids thoeught to have on immunity
thought to decrease immunity.
opioid induced bowel dysfunction causes what 3 effects?
cramps, slow bowel transit, dry hard stool
what are the two most common causes of opioid toxicity in EOL patients
poor prescribing/wrong dose given, pt has gone into renal failure (most opioids are excreted renally)
Name 4 of the most common side effects of opioid toxicity?
sedation, hallucinations, confusion/delirium, myoclonus, respiratory depression with hypoxaemia
in opioid-induced respiratory depression, what two things do you need to see on observation for this to be the cause?
decreased resp rate (<8) AND subsequent decreased sats (<90%)
how should you initially manage treating respiratory depression in a pt who is on morphine for cancer pain or EOL?
try shaking pt, high flow O2 if sats are low.
What is the best antiemetic to use for chemotherapy induced N&V?
ondansetron.
surgery, chemo and radiotherapy can cause the release of serotonin from intestinal enterochromaffin cells. ondansetron might help with this as it is a 5-HT3 receptor antagonist
What is a concerning side effect of high dose or long-term metoclopramide?
extra-pyramidal toxicity
What is the mechonism of action of metoclopramide and domperidone?
5-HT4 and D2 antagonists
which causes less side extrapyramidal side effects domperidone or metoclopramide?
domperidone as it doesn’t cross the BBB. however, can prolong QTc causing Torsades de point
what is the mechanism of action of haloperidol? What situations is it a good anti-emetic to use?
D2 antagonist antiemetic that works on the CTZ.
good for when emesis is caused by chemicals, metabolites or drugs
what is the MOA of levomepromazine and when is it a good anti-emetic to use?
5-Ht2, AChm, D2, H1 antagonist.
broad-spectrum antiemetic, often used second-line, or first-line when aetiology is uncertain or due to multiple causes
what is the MOA of cyclizine?
H1 and AChm antagonist
name 4 situations where cyclizine would be the antiemetic of chioce
bowel obstruction, motion sixkness, pharyngeal irritation, raised ICP.
name two side effects of cyclizine
sedation, dry mouth, constipation etc.
what are teh only two indications for using steroids (dexamethasone) as an antiemetic?
for N&V induced by chemotherapy or raised ICP
name a somatostatin analogue that can be used to manage emesis caused by bowel obstruction by reducing secretions from the intestine and pancreas
octreotide
in cancer patients who are anorexic and cachectic but who have something important to do i.e. father of the bride speech, what could you prescribe them temporarily that will help stimulate appetite and reduce fatigue?
dexamethasone 4-6mg per day (in morning to prevent insomnia)
PRN dose of opioid for breakthrough pain tends to be what dose of the dose of the opioid they’re on?
1/6th of the dose of the opioid they’re on
how much more potent is fentanyl than morphine?
~100x
what pharmacoloigcal class of drugs could be given to reduce respiratory tract secretions in palliative patients?
anti-muscarinics e.g. glycopyroonium
what drug is first line for restlessness or agitation in palliative care?
midazolam
what is ssecond line drug for restlessness or agitation in palliative care? what is the main side effect?
levomepromazine - but it is very sedating
what pharmacological thearpy whould you use first line for delirium?
haloperidol
after giving haloperidol t a pt with delirium, if this hasn’t worked, what drug can you add in second line?
midazolam
name 5 acute side effects of radiotherapy
fatigue, skin redness and itching, N&V, diarrhoea, abdo: cystitis, proctitis. oesophagus: oesophagitis, odynophagia, dysphagia.
Lung: cough, SOB due to pneumonitis.
Head and neck: hoarse voice, dysphagia, mucositis, skin pigmentation.
Brain: fatigue, hair loss
name 5 late side effects of radiotherapy (occuring 6 months after)
fibrosis in skin causing thinning and lack of elasticity.
fibrosis in bowel causing strictures, stenosis, decreased motility.
deranged organ function. salivary glands affected can cause dry mouth.
pelvic radiotherapy can cause rectal bleeding and haematuria.
soft tissue necrosis and mucosal ulceration in severe cases.
brain: hypopituitarism, short term memory impairment.
secondary cancer.
what are some of the long-term side effects of radiotherapy in children
growht retardation, hypoplasia of organ irradiated, secondary cancer
what symptom is radiotherapy good for palliating?
bone pain caused by bone mets.
in the palliative care setting. if N&V is thought to be due to reduced gastric mobility, what is first-line?
pro-kinetic agents such as metoclopramide and domperidone
if N&V is chemically mediated and chemical distrubances have tried to be corrected, what are the best antiemetics to use?
ondansetron, haloperidol, levomepromazine
what is the recommended antiemetic for N&V due to intracranial disease?
cyclizine or dexamethasone
what is the first line antiemetic for N&V casued by vestibular disturbance?
cyclizine
what antiemetics can be used for refractory vestibular causes of N&V?
treat alternatively with metoclopramide or prochlorperazine.
olanapine or risperidone could also be used
what is the best antiemetic to use for N&V caused by anxiety, pain, fear and/or anticipatory nausea
short acting benzo such as lorazepam can be useful. if not, cyclizine. then can trial ondansetron and metoclopramide
