Palliative Medicine Flashcards
Cancer pain occurs in what % of patients?
80%
Bone pain is described as what type of pain?
Dull pain often worse on weight bearing/with movement
Bone pain is treated with what?
NSAIDs
Radiotherapy
Bisphosphonates - pamidronate
Deep seated tenderness over a particular organ can be a sign of which type of pain?
visceral
Hyoscine butylbromide can be used to treat what type of pain?
Colicky pain - e.g. intestinal obstruction
A dull headache worse on leaning forward is treated with what agents?
Raised ICP headache
16mg dexamathasone to reduce oedema + cyclazine
NSAIDS & paracetamol
Pregabalin can be used to treat what type of pain?
Neuropathic
Liver capsule pain is a type of what pain? And how is it managed?
Visceral pain
Analgesic ladder
What is neuropathic pain?
Area of abnormal sensation - pins & needles, numbness, pallor/sweating
Abnormal pain due to damaged nerves
What does TENS stand for? And what is it used to treat?
Transcutaneous electrical nerve stimulation
Nerve pain where amitriptyline is inappropriate
What fraction of your 24 hour dose of morphine should the PRN dose be?
1/6
If morphine is not tolerated or ineffective, what is the alternative opioid?
Oxycodone - 2x more potent than morphine
How many times more potent is diamorphine SC compared to PO morphine?
3x
What opioids are available transdermal? And for how long does they last?
Fentanyl - 72 hours
Buprenorphine
What should always be prescribed in conjunction with an opioid?
Laxative
Name 3 preparations of co-codamol
8/500 2x QDS max
30/500 2x QDS max - is this doesn’t work, don’t increase codeine due to constipation
Instead move up ladder
Which patients should amitriptyline be avoided in and why
Cardiac patients - risk of arrhythmias
What are the strong opioids?
Morphine
Fentanyl
Oxycodone
Buprenorphine
Which weak opioid is rarely used in treatment of cancer pain?
Tramadol
Which antiemetic is used to counteract opioid N&V?
Haloperidol
When does drowsiness usually occur when taking opioids & when is it abnormal?
When starting or changing dose
Should subside in 48 hours - if prolonged then this is abnormal
If respiratory depression occurs due to opioid overdose, what is the management?
Naloxone
What are the signs of opioid toxicity?
Persistent N&V Persistent drowsiness Confusion Visual hallucinations Myoclonic jerks Respiratory depression - late sign
What are the 2 types of morphine?
Immediate release
Modified/slow release
MST & Zomorph are what type of morphine and what is the duration of action?
Modified release
Lasts up to 12 hours - therefore take BD
Oromorph is what type of morphine & what is the duration of action?
Normal/ immediate release
Works within 20-30 minutes & lasts 4 hours
Used as PRN
What is the normal starting dose of MST?
15-20mg
What is the maximum no. of doses you can take of PRN oromorph?
6 doses per day
Each dose = 1/6 of max dose in 24 hours
How many times more potent is parenteral MST compared to oral morphine?
2x more common
Therefore divide max dose by 2 when converting PO to SC
How can MST be delivered to someone not tolerating oral tablets?
Syringe driver over 24 hours
What step of the analgesic ladder is oxycodone?
Step 3 - 2nd line after morphine
What are the 2 preparations of oxycodone?
Oxynorm - immediate release
Oxycontin - slow release
What is the medical term for dry mouth?
What are some causes?
Xerostomia
Palliative meds - antiemetics, antidepressants
Reduced intake of oral fluids - e.g. due to opioid N&V
Radiotherapy of head & neck
What can be used to treat anorexia caused by opiate use?
Dexamethasone 4mg OD - effect wears off after 2-3 weeks
Megestrol acetate - 160mg OD - can cause fluid retention
What are the 4 main causes of vomiting?
Toxic
Gastric
Cerebral
Vestibular
N&V caused by ascites pressing on the stomach can be treated with which antiemetic?
Gastric cause - use metaclopramide
Or domperidone
Posseting & retching is a sign of which type of N&V?
Which antiemetic should be used to treat this?
Toxic causes
Haloperidol - 1.5-5mg PO/sc nocte (at night)
Or levomoperizine
Cyclamen is used to treat which type of N&V?
Raised ICP
What are the side effects of metaclopramide?
EPSEs
Prolactinaemia
Diazepam is used to treat what type of nausea? When can it occur?
Anticipatory nausea
E.g. before chemo/rx
Consultations/ bad news
Fybogel is what type of laxative?
Bulk forming
What are the softener laxatives?
Lactulose
Sodium docusate
What is a side effect of lactulose?
Bloating
What are the stimulant laxatives?
Senna
Danton
Sodium picosulphate
What are the combination laxatives?
Movicol
Co-danthramer
Which laxative causes orange urine?
Co-danthramer
Which type of cancers most commonly cause intestinal obstruction?
Ovarian & bowel
What are the symptoms of intestinal obstruction?
N&V
Abdominal pain & distention
Constipation/ overflow diarrhoea
Colicky pain
What non-surgical treatment can be used for intestinal obstruction? How does it work?
Buscapan - hyosine butylbromide
Reduces bowel movement & pain
What can be used to treat breathlessness in palliative patients?
Opioids to reduce respiratory effort
What are common acute causes of breathlessness?
Asthma - bronchodilators
Pulmonary oedema - diuretics & diamorphine
PE - anticoagulants
What if someone develops SoB over several days, what may be the cause?
Pneumonia - abx
COPD - abx & bronchodilators
SVCO obstruction - dex + & PPI + stent
Bronchial obstruction - dex + PPI +stent
Name some causes of gradual onset SoB
Heart failure - digoxin, diuretics, ACE-i Anaemia Pleural effusion - aspiration Ascites Lymphangitis carcinomatosis
What is lymphangitis carcinomatosis
Inflammation of the lymph vessels caused by malignancy
Causes gradual onset SoB
What are the 3 main causes of cough in palliative patients?
Excessive mucous production
Inhaled foreign body
Abnormal stimulation of bronchial receptors
How can dry cough be treated pharmacologically?
Opioids - cough suppressants
E.g. codeine linctus
What are the benefits of telling someone when they are palliative?
Reduces fear
Allows them to make non-medical decisions
Allows them to make preparations
What is the gold standards framework and who is it for?
Patients in last year of life
Assesses current & future possible clinical needs
Plans for cross-boundary care
i.e. gives relevant contacts etc
What does the AMBER in amber care bundle stand for?
Assessment Management Best practice Engagement Recovery uncertain
Who is the AMBER care bundle for?
Those likely to die in the next 2 months
Aims for early conversation with carers & reduced hospital readmissions
