PC FastFacts Random questions Flashcards
Test for oral candidiasis
KOH staining
First line option for thrush management (not nystatin)
Clotrimazole troche 10mg 5x/d
Treatment for esophageal thrush suspected
Fluconazole
Diagnosis if thrush not improving with fluconazole
Resistant candidiasis (rare)
2 other azole’s aside from Fluconazole
Voriconazole
Itraconazole
Mirtazapine mechanism of action
5HT2 antagonist
5HT3 antagonist
H1 antagonist (inverse agonist)
alpha-2 adrenergic antagonist
Mirtazapine class of drug
NaSSA - noradrenergic and specific serotonin antidepressant
2 treatments for dysgeusia (medications/ supplements)
Zinc
Alpha-lipoic acid
Dronabinol
Key rationale for parenteral nutrition in advanced cancer
Give some examples
Where death from starvation would be expected sooner than through illness progression:
- Dysfunction of GI tract (short gut, obstruction, etc.)
- Needs to be in line with goals
- Prognosis should be in range of several months (>3-6 in ESMO guideline)
Key facets / diagnostic criteria for cancer cachexia
- Systemic inflammation
- Weight loss (>5%) OR >2% if sarcopenic or BMI <20.
List key outcomes for megesterol acetate in cancer anorexia/cachexia
- Weight gain (fat)
- Appetite stimulation (equal to dex)
- No improvement in QOL or survival
- Higher risk of thrombotic events
- Other - adrenal insuff., hypertension, edema, hyperglycemia, uterine bleeding, n/v/d
Benefit of Corticosteroid to MGA in cancer anorexia/cachexia
Improvement in QOL and fatigue with Dex
3 benefits of Dex in comparison to other steroids
multiple routes
long half life
low mineralocorticoid effect
which steroid is not preferred in liver failure and why?
prednisone
needs to be converted to prednisolone via liver metabolism
list 3 early and 3 late s/e of steroids
early:
- hyperglycemia
- fluid retention
- mental disturbances (insomnia, agitation, paranoia)
late:
- myopathy
- infection risk (immune compromise)
- GI bleed risk
dosing parameter allowing for stopping of steroid without a taper (various guidelines)
2 benefits of dosing steroids in AM (and before 2PM as a latest dose)
less insomnia
less HPA axis suppression
Dex to prednisone ratio
1:4-5
List the 2 key complications of stopping immune suppressants in transplant patients at EOL
List 2 options for management if these medications need discontinuing
- acute rejection (days to weeks)
- graft failure
- substitute with steroids
- manage symptoms
Depression in advanced ca.
What criteria is used to substitute somatic criteria with psychological criteria?
Endicott
Which question has the highest sensitivity and specificity for depression screening in advanced illness
Are you feeling down, depressed, or hopeless most of the time over the last two weeks?”
Which patients benefit from tube feeding in advanced illness?
- proximal GI obstruction
- undergoing XRT compromising swallowing (reversible)
- some HIV patients
- some ALS patients
Does tube feeding prevent aspiration pneumonia?
no robust data to support that it does
Does tube feeding improve QOL?
Only when used to address existing hunger and thirst
Median survival of cancer patients with KPS <40
3 months
5 categories in PPS assessment
Ambulation
Activity / evidence of disease
Consciousness
Intake
Level of Consciousness
2 aspects of mGPS (modified glasgow prognostic scale)
albumin
CRP
7 steps in the serious illness conversation guide
1) Set up the conversation
- introduce, purpose, permission
2) Assess illness understanding and information preferences
3) Share prognosis and explore emotions
4) Explore key topics
- goals, fears, strength, critical abilities, trade-offs, family
5) Close conversation
- summarize, recommendations, commitment
6) Document
7) Communicate (with team)
Acronym: SASECDC
What are potential consequences of naloxone used inappropriately?
Abrupt increase in sympathetic activity
- pulmonary edema
- cardiovascular collapse
Approach to narcotization in palliative care:
- indications for naloxone
- dosage
- supportive strategies
indications:
- decr. LOC, RR<8 with evidence of inadequate ventilation (hypoxia, hypotension)
dose:
- naloxone 0.04mg IV q1min PRN
- consider other cause if no response with 0.8mg
supportive:
- ask patient to breathe in (can often do this voluntarily)
Ways to differentiate preparatory grief from depression
- grief comes in waves, depression is pervasive
- self worth not commonly affected in grief
- anhedonia less common in grief
- death wish less common in grief
What is the bioavailability of sublingually administered morphine and hydromorphone
10-20%
3 tasks necessary for a patient to be deemed “decisional”
(decision making capacity)
1) Receive information
2) Evaluate and manipulate the information
- look for understanding, logic, and consistency
3) Communicate the information
2 factors that decision making is contingent on:
- task specific
- the greater the potential harm of the treatment, the more certain one needs to be about capacity
- time specific
What is the BATHE approach to create an empathic milieu?
B - background
A - affect (name and acknowledge the emotion)
T - troubles (what frightens/worries you?)
H - handle (how are you handling it?)
E - empathy (seek to understand, support)
List pharmacological treatments for myoclonus
- clonazepam (and other benzodiazepines)
- valproic acid
- baclofen
- gabapentin
levetiracetsm
List the potential benefits of psychostimulants in palliative care
- mood elevation (cochrane analysis)
- energy (improvement in CRF)
- opioid related sedation
- improvement in cognition
- potentiation of opioid analgesic effect
Relative contraindications to methylphenidate use
- CV disease and HTN (associated arrythmia, MI, HTN)
- Psychiatric d/o (mania, psychosis)
- Delirium
Things to look for in an addictions (substance abuse) assessment:
- Loss of control over drug use
- Compulsions
- Use despite harm (life consequences)
- Drug seeking behavior (lost meds, street use)
- Abuse of other drugs (current or past)
- Exposure to drug culture (family, friends)
- Not cooperative with treatment plans
Most sensitive test for respiratory insufficiency in ALS
What other tests might be helpful?
MIP (maximal inspiratory pressure) - most sensitive
or SNIP (those with facial weakness)
Other:
- Vital capacity
- Nocturnal oximetry (or full polysomnogram)
What is the difference between Dronabinol and Nabilone
Dronabinol - synthetic THC
Nabilone - THC analog
Which agents have evidence in management of RT enteritis induced diarrhea?
- ASA and Cholestyramine
- Metamucil
What is loperamide’s mechanism of action?
Peripherally acting opioid
Dose 4mg once, then 2mg with each loose stool
Max 16mg/d
List 6 aspects of an insomnia history
- sleep hygiene
- sleep chronology (onset, pattern, duration)
- sleep environment (change, disturbance etc)
- physical symptoms
- medical conditions (including medications)
- spiritual / existential concerns
What spiritual concern often causes insomnia?
Fear of dying
(falling asleep and not waking up)
What is the major benefit of continuing HAART therapy in HIV patients nearing EOL?
Prevention of retroviral syndrome
Which symptoms correlate with viral load in HIV?
neuropathy
constitutional - fatigue, weight loss etc.
HAART also directly inhibits opportunistic infection
How long after stopping HAART do symptoms manifest?
1-2months
What are common side-effects of HAART’s?
GI intolerances
fatigue
headache
peripheral neuropathies
List some components of sleep hygiene
- keep a regular sleep schedule
- avoid daytime naps
- avoid EtOH, caffeine
- avoid stimulating activities and bright lights before bed
3 behavioral therapies for sleep:
- relaxation therapy
- stimulus control therapy (use the bedroom for sleep only)
- cbt
- sleep restriction therapy
- psychotherapy
- exercise
Which treatment has the strongest evidence for management of chronic insomnia?
CBTi
4 major classes of medications used for insomnia
- benzodiazepines (and BZRA’s)
- dual orexin receptor antagonists (DORA’s)
- histamine receptor antagonists (doxepin)
- melatonin (and MRA’s)
- anti-depressants
List etiologies for secondary myoclonus
1) Drugs
- opioid
- psych meds (SSRI,TCAs)
- antibiotics (penicillin, cephalosporin)
- anti-epileptics
- levodopa
2) Metabolic
- renal, hepatic failure
- hyperthyroid
- hypoxia, hypercarbia
- hyponatremia, hypoglycemia
3) CNS or PNS
- stroke, trauma, neurodegenerative etc.
Treatments for myoclonus (pharmacological)
- benzodiazepine (1st line)
- clonazepam and lorazepam
- anti-epileptics (VPA and keppra)
- dantrolene
What kind of scales are most helpful for assessing pain in infants and children <3yrs?
Behavioural observational scales
List 3 scales used for pain assessment in peds:
Younger kids:
FLACC - face, legs, activity, crying, consolability
Self report for older kids:
VAS - visual analogue scale
Wong-baker faces scale
Most common chemo agents causing mucositis
5-FU
doxorubicin
cytarabine
etoposide
MTX
grades of chemo mucositis
1 - injection, mild pain
2 - patchy mucositis, serosanguinous d/c, moderate pain
3 - confluent fibrinous mucositis, severe pain possible
4 - ulceration, necrosis, hemorrhage
5 - death from mucositis
ECOG scale
0 - fully active
1 - some restriction, ambulatory, light work
2 - ambulatory, self care but not work, up >50% of day
3 - limited self care, chair/bed >50% of day
4 - bedbound, total care
5 - dead
What does the PaP (Palliative prognostic score predict)?
What are the components of its assessment?
What is a unique feature of this model?
30 day survival
Criteria:
- dyspnea
- anorexia
- WBC
- lymph percentage
- KPS
- clinician prediction / gestalt (unique feature)
The PaP is valid in which populations?
- Adult oncology
- Pediatric oncology
- Reliable in various non-cancer areas, as well (?published)
What is D-PaP
Variant of PaP which includes delirium
(performs slightly better in cancer setting)
What is the PPI?
What does it assess? which population?
What are the criteria assessed?
Palliative Prognostic Index
Survival (>3 or >6weeks)
Cancer patients
PPS
intake
edema
dyspnea
delirium
5 aspects of the PPS
Intake
Activity / evidence of disease
Ambulation
Self Care
Consciousness
What is PPS valid for?
Survival prediction of cancer patients (tested in outpatient setting)
Tracking needs of Palliative care patients
Features that assist in evaluating pain in those with cognitive impairment:
- facial expression
- posturing
- vocalization
- interactivity
- appetite / intake
- breathing
- consolability
List 2 tools for assessment of pain in cognitively impaired
PAINAD - pain assessment in advanced dementia
Checklist of non-verbal pain indicators
Specific elements of PAINAD
breathing
vocalization
facial expression
body language
consolability
List key approach points to a patient with substance use disorder in palliative care:
1) thorough review of substance use history
2) screen risk formally (ORT)
3) consider addictions consult / collaboration, referral to recovery programs
4) create a plan
- optimize use of non-opioid
- written opioid agreement
- strategic opioid use (safe intervals, long acting formulation)
5) address psychosocial and spiritual aspects
- shown to reduce illicit drug use
6) close monitoring
7) compassion, always
5 aspects of the opioid risk tool
How is it scored? (unique feature)
1) family hx. substance abuse
2) personal hx. substance abuse
3) age
4) history of pre-adolescent sexual abuse
5) psychological illness / disorder
Scored differently for males vs. females
(family hx. counts more for males, sexual abuse for females)
What can a bedside swallow test not rule out?
silent aspiration
List some strategies for prevention of oral mucositis (and complications) prior to chemo/RT:
- dental care - extractions / revisions of prosthesis
- good oral hygiene
- antiseptics (baking soda/salt, povidine iodine, chlorhexidine to reduce bacterial overgrowth)
- avoid drying, caustic foods
List treatments for oral mucositis (considerations)
1) infection assessment / treatment
- low threshold for viral and fungal culture
2) pain management
- benzydamine
- viscous lidocaine
- topical opioid
When does carcinoid syndrome typically present in carcinoid cancers?
- sufficient concentration of hormones to reach systemic circulation (typically in patient with liver mets)
S/S of carcinoid syndrome complex:
- flushing
- diarrhea, n/v, abdominal cramping
- bronchospasm and cyanosis
- r. sided heart failure
- plaque like fibrous deposits on valves, cardiac chambers
- humoral substances inactivated by lung (l. heart safe)
List specific treatments for carcinoid
1) Somatostatin analogs (Octreotide)
Specific
Diarrhea - Cyproheptadine
Wheeze - Bronchodilator
CHF - Diuretics
What are the unique facets of children’s grief
- in spurts
- re-grieving at different developmental stages
- more behavioural manifestations / emotional
Grief manifestations (0-2 years)
- no concept of death
- separation anxiety
- developmental regression possible
Grief manifestations (2-6 years)
- concrete, literal understanding of the world
- death may be seen as temporary
- correlation, not cause (may think they brought it on)
- magical explanations
Grief manifestations (6-8years)
- understanding of death as final, less of understanding this could occur to them
- psychological and somatic symptoms manifest
Grief manifestations (8-12 years)
- adult understanding of death
- abstract thinking developing
- more curious about existential implications
- independent expressions and thoughts need space
What is the classic measure of severity in COPD?
What is one validated prognostic tool?
FEV1
BODE index
B - BMI
O - Obstruction (FEV1)
D - Dyspnea (mMRC)
E - Exercise (6min walk distance)
What factors outside BODE index correlate with prognosis in COPD
- inflammation - CRP
- PaO2
in hospital:
- requiring ventilation
- PaCO2
- comorbidities
- low albumin
- low hemoglobin
Give 2 mechanisms for opioid induced hyperalgesia
- toxic effect of metabolites (M3G etc.)
- central sensitization (opioid activation of NMDA receptors)
How to bronchodilators help with secretions?
- open airways
- increase ciliary activity
how does guaifenesin work on secretions?
expectorant
stimulates cough reflex
vagally mediated increase in airway secretions
how does NAC work on secretions?
mucolytic
lowers mucus viscosity (severs disulphide bonds of glycoproteins in mucus)
List 4 non-pharmacological techniques to clear respiratory secretions
- suctioning
- postural drainage / chest physiotherapy
- OPEP
- vibration vest (chest wall)
What are 3 alternatives to euthanasia in a patient that wishes to hasten their death?
- withdrawal of life-sustaining intervention
- sedation for severe intractable symptoms
- voluntary stopping of eating and drinking
Safest opioids in renal failure
methadone
fentanyl
bup
key different between hydromorphone vs. morphine metabolites in renal failure
HM metabolites - dialysable
What are the 5 steps to Advance Care Planning?
1) Think - what are your values and wishes about care and interventions
2) Learn - your condition, interventions - pros/cons
3) Choose - your SDM / agent
4) Talk - discuss your values with your healthcare team and those important to you
5) Record - your wishes
What is therapeutic privilege?
aka therapeutic non disclosure
Principle that physicians may withhold information from patients if they believe this would harm the patient
What is the legal standard for informed consent?
Inform the patient according to what a reasonable person would want to know
(some use according to what a reasonable physician should provide)
What basic information needs to be provided as part of informed consent?
- diagnosis
- risks/benefits of proposed treatment
- risks/benefits of alternatives
- risks/benefits of foregoing treatment
Outline the pharmacotherapeutic approach to patients with Alzheimer’s dementia
1) cholinesterase inhibitors (donepezil, galantamine etc)
- mild-mod disease
- severe disease (relative efficacy but small absolute improvement to be expected)
2) NMDA antagonist (memantine)
- mod-severe disease
3) aducanumab
- scam
What are 3 structural classes of opioids?
phenanthrenes - morphine, hydromorph, oxy, codeine
phenylpiperidine - fentanyl
diphenylheptane - methadone
Mechanism of lidocaine
non-selective na channel blocker
conservative management of xerostomia
oral care
avoid toothpaste with sodium lauryl sulfate
alcohol free mouthwashes
saliva substitute
sugarless gum, candy, citrus
humidifiers
hydration
distinguish type 1 vs. type 2 HRS
type 1 - acute onset (doubling Cr <2weeks), inciting event, mortality in order of weeks
type 2 - insidious onset, incr. portal pressures, diuretic resistant ascites, median survival 6mo.
What factors correlate with mortality in dialysis patients
- age
- albumin levels
- functional status
- comorbidities (Charlson Comorbidity Index)
- the surprise question carries some weight in this population…
Define developmental disability
persons with impaired social functioning, ability to comprehend complex/new information, or to learn skills
disability must have developed before age 18
List barriers to medical / palliative care for those with DD
- communication challenges (missed dx, symptoms, suffering)
- lack of clarity around decision makers / decision making
- lack of comprehension around illness
- social and psychological neglect
- suboptimal preventative care
List important considerations around decision making and ACP for those with developmental disabilities
- engaging those who can express wishes and values
- ensuring guardian’s goals are aligned with patient
- being aware of QOL biases
- ensuring risks/benefits of treatments are best understood
- understanding the patient as best possible to make recommendations
imaging study of choice for osteonecrosis
MRI
can start with XR or CT
(bone scan - high false negative rate)
risk factors for ON of jaw in patients on bisphosphonates
- prior RT
- IV bisphosphonate rather than PO
- poor dentition / periodontal disease / dental bone surgery
- age >65
- caucasian
- myeloma
Most common chemo agents to cause CIPN
platinums
taxanes
vinka alkaloids
most common pattern of CIPN
- loss of deep tendon reflex -> sensory neuropathy -> motor neuropathy
CIPN usually decreases after treatment in most cases, except with this agent:
platinum agents
“coasting effect”
oxaliplatin can cause this specific acute neuropathy:
cold induced paresthesias
vincristine can cause this unique neuropathy
pharyngeal myalgias
Which agent has best evidence for management of CIPN?
- Duloxetine
- Venlafaxine (some positive data)
Others (less evidence):
- Topical amitriptyline/ketamine
- Topical menthol, capsaicin
- Gaba/pregabalin - no significant benefit in trials
key features of huntingtons disease
inheritance
progressive movement d/o
psychiatric manifestations
behavioral abnormality
cognitive decline
autosomal dominant
natural hx. of huntingtons
onset 30s-40s
most die by 60’s
often institutionalized
no disease modifying therapies
greatest psychosocial challenge in huntingtons
family stress
young children
fear of inheriting
motor manifestations in huntingtons
chorea
dystonia
rigidity
myoclonus
tremor
gait and balance abnormalities
psych manifestations in huntingtons
depression - common
emotional lability
psychosis
anxiety
routines are helpful
most common complication of vertebro/kyphoplasty
cement extravasation
PE - bone marrow displacement
bleeding
infection
list the best agents for the management of the following issues in patients discontinuing dialysis
- RLS
- muscle cramps
- pruritis
- RLS - clonazepam
- muscle cramps - clonazepam
- pruritis - antihistamine or ondansetron
What are some suicide risk factors in patients with cancer?
psychiatric comorbidity
uncontrolled pain
older age
male sex
family history
AIDS diagnosis
certain cancers: head and neck, pancreatic, lung
Why is cancer incidence higher in HIV?
immune dysfunction
higher environmental RF’s
greater incidence of infection with oncogenic viruses
classification of malignancies in HIV:
ADM - aids defining (KS, cervical ca, NHL)
NADM - non-aids defining
Outline an approach to asking about cultural beliefs in palliative care
C - communication (preferences - how much, with whom etc.)
U - unique cultural values
L - locus of decision making (communal vs. individualistic)
T - translator (use when needed)
U - understanding (go the extra mile to confirm you and patient understand each other)
R - rituals and rites
E - environment at home (incl. openness to support)
RLS is more common in which 2 disease processes
parkinsons
renal failure (on hemodialysis)
Pathophysiology of RLS
disorder of central or peripheral dopaminergic pathways
Which drugs can worsen RLS?
neuroleptics
SSRI’s
antihistamines
4 key characteristics of RLS
urge to move legs
relief with movement
worse in evening / night
worse with inactivity / rest
1st line drug treatment for RLS
dopamine agonists - pramipexole, ropinirole
Problem with using levodopa in RLS
augmentation
2nd/3rd line options for RLS
benzodiazepines
anticonvulsants - gabapentin
opioids
4 strategies for wound odor management
necrotic tissue - debride
infection - control
adsorbents - charcoal, pet litter
aromatics - essential oils, coffee grounds candles
list 3 agents for wound infection control:
antibiotics (oral or topical metronidazole)
silver sulfadiazine (antibiotic)
cadexomer iodine (absorbent, bactericidal)
- aka iodosorb
honey (bactericidal)
Steps to managing family request not to disclose medical information to a patient
1) open and calm - don’t judge
2) understand the family perspective and their rationale
3) clarify what the patient knows
4) clarify whether patient has expressed information preferences, and whether this request conflicts or agrees with their preference
5) empathize with family concerns
6) provide your open, balanced an honest view (incl. professional obligations to ask patient how much they want to know)
7) brainstorm possible approaches and solutions (collaboratively)
8) negotiate a solution (ideally that both HCP and family should respect the patient’s decision)
List steps in preparing for a family meeting:
1) review the data / case
- medical: diagnosis, history, treatments, options, prognosis - including consultations where needed for clarity
- goc/acp: personal directives, goals etc. especially if patient lacks capacity
- psychosocial: understand and anticipate family issues / dynamics, cultural/religious aspects
2) formulate professional impression and approach
3) determine who would be helpful at the meeting (professionals and family members)
4) invite relevant parties (with consent from the patient)
5) choose an appropriate setting (calm, quiet, round table etc)
6) pre-meeting with healthcare team (clarify impressions, goals, lead, potential challenges to anticipate)
General approach to starting a family meeting
1) introductions and setting goals, build rapport
2) determine what the family / patient know
3) seek permission, then provide the medical update and review
(summarize with a bottom line statement)
4) provide silence for reflection, processing and questions
5) respond to emotions (next card)
Outline steps on responding to emotions in a family meeting
1) understand your role - to support and meet emotional needs
2) acknowledge the emotion (or presence of discomfort/distress)
3) legitimize the emotion
4) explore the emotion more deeply
5) empathize (if you can genuinely feel it)
6) explore strengths and coping mechanisms (can defer)
- “what are you hoping for now?”
- “what has helped you cope through previous challenges?”
- “where do you find your strength?”
what are the most common reasons for conflict in a family meeting?
1) information gaps
- genuine uncertainty vs. communication gap / misunderstanding
2) confusion around treatment goal
- lack of clarity, different opinions and goals
3) emotions
- fear, grief, anxiety, guilt, anger, hope
4) family/team dynamics
5) relational challenge - patient/family to provider
- lack of trust, values conflict etc.
List the approach to assist surrogates in making healthcare decisions
1) ensure condition and prognosis are clearly understood
2) bring the patient’s voice into the deliberation / decision
- review and share ACP document with decision maker
3) outline the goals as a framework to guide the plan
4) once goals are clear, offer to make a recommendation based on understanding. avoid burdening.
5) acknowledge and respond to emotions
6) reframe, rather than challenging, statements for aggressive care. leave room for a miracle.
7) hold hope with “I wish” statements. affirm what can be done, rather than reiterating what can’t be done.
8) provide space to think, process, and do grief work. offer formal grief support.
Review approach to goal setting and future planning in a family meeting
1) establish patient goals
- hopes, values, people to see, things to do, where to live
2) recommend a care plan
- specifics: GOC, readmission, interventions (blood, abx. etc), disposition, care needs etc.
3) allow space for “long shot” goals, but emphasize prepare for the worst, and present symptom control
4) end meeting
5) document, discuss, debrief
NIPPV is appropriate for which palliative care patients?
1) patients wanting to prolong life for a specific goal
2) symptom control of dyspnea (particularly for the patient wanting to avoid sedating effect of opioid)
3) patients with acutely reversible complications (COPDe or CHFe)
What are the predictors of poor neuro outcome in anoxic ischemic brain injury
Poor outcome: death, vegetative state, severe disability (total care) at 6mo.
Usual life expectancy in down’s syndrome
60yrs
List causes of morbidity more common (compared to general population) in Down’s syndrome
- cardiovascular (congenital cardiac defects)
- childhood leukemia
- dementia (40-50’s)
- seizure disorders (can signify more rapid decline)
other: hearing loss, cataracts, sleep apnea, recurrent resp. infections, thyroid dysfunction
What are some specific psychosocial issues to acknowledge in Down’s (esp. EOL)
- toll of lifelong care / complications / challenges
- isolation, grief and loss can be challenging (living in facilities, little contact with deceased parents)
- decision making may be challenging for those with lifelong cognitive impairment
- EOL may be recognized late and after precipitous decline
what are the general guidelines for driving while on opioids
- must have no cognitive / neurological s/e
- on stable dose for 1 week
Management of tracheostomy complication:
Acute dyspnea
likely due to partial / complete blockage - secretions
cough
suction
Management of tracheostomy complication:
Bleeding
early complication
minor bleed - gauze, compression, cautery/suture
massive bleed - innominate artery erosion (likely)
- gloved finger into trach and direct pressure (pulsatile mass)
- could overinflate cuff
- urgent OR
Management of tracheostomy complication:
Accidental decannulation
- if fresh trach <5d, tract may not be established - ET tube
- if tract established, reinsert cannula with obturator following path of airway (stop if resistance)
How does capsaicin work?
TRPV1 receptor activation on C fibres and some A-delta fibres
- prolonged activation causes loss of receptor functionality
- higher concentration causes temporary neurolysis
(re-innervation weeks after cessation of drug)
NOT substance P depletion (as previously thought)
2 formulations of capsaicin
cream - 0.025-0.075% TID
patch 8% - apply only for 60mins. repeat q 3mo.
some areas of evidence for capsaicin use
post herpetic neuralgia
peripheral neuropathy (diabetic, HIV)
post-mastectomy neuropathic pain syndrome
Blood glucose parameters at end of life
Keep BG between 10-20 to avoid hypoglycemia
Reasonable to continue insulin/monitoring in T1DM even if hours to days as DKA can develop rapidly.
Which phase of liver metabolism is less affected in cirrhosis
Glucuronidation
hep C infection stimulates with CYP enzyme?
a4
Describe the pathophysiology of CF
What is the median survival?
autosomal recessive d/o
defect in CFTR (cystic fibrosis transmembrane conductance regulator) gene -> abnormalities in chloride and sodium transport -> incr. viscosity of secretions
median survival ~50 years (47 years)
Which organ systems are affected in CF?
Which issue causes the most morbidity?
Lungs
Pancreas
Hepatobiliary
Sweat glands
Reproductive tract
Greatest morbidity from respiratory dysfunction
- cough, dyspnea
- obstructive lung disease and chronic bronchitis ->bronchiectasis
- recurrent infections
What are key considerations around ACP for those with CF?
- prediction of short term mortality is difficult
- ongoing complications can be exhausting
- repeated recovery establishes a pattern of expecting the same
- CF patients generally report high QOL, but chronic anxiety and depression can be common
One risk that prevents up titration of buprenorphine
(max 20mcg/h approved by FDA)
QT prolongation
buprenorphine can be beneficial as an analgesic in which populations?
patients with low opioid requirements +
- elderly / frail
- intolerance of opioid s/e
- chronic kidney disease
what is the general approach to breakthrough dosing in patients on buprenorphine patch?
- normal approach in those on low doses (5-10mcg/h)
- in those on higher doses
- consider agent with higher mu receptor affinity (HM, fent)
- dose higher or more frequently
- buprenorphine not shown to antagonize effects of other opioids at doses up to 70mcg/h
what degree of hypoglycemia = significant seizure and death risk?
<2.2
Compare CPR outcomes for in-hospital cardiac arrest vs. peri-operative cardiac arrest
Outcomes are generally better in peri-op arrest
asystole 30.5% vs. 10%
pulseless electrical activity 26.4% vs 10%
pulseless VT/VF 41.9% vs approximately 34%
what approaches can be taken to reconsideration of DNR status around surgical procedures?
- rescind the DNR for the procedure
- uphold the DNR
- modify the DNR to include more interventions within reason
- patient allows operating team to use clinical judgement in determining which interventions might be appropriate
(no one fits all policy)
what are common etiologies of bladder spasms?
infection - UTI
chemical irritant - caffeine, diet soda
obstruction - bladder outflow tract, constipation
irritation of detrusor - tumor, stone, catheter
neurogenic - disinhibition from UMN lesion
meds - opioids, anticholinergic, benzo
outline a general approach to working up bladder spasm:
- determine if bladder is emptying properly
- rule out UTI
- address easily reversible causes (meds, constipation)
- search for other contributors
3 pharmacological agents for bladder spasms
1) bladder muscle relaxants
- anticholinergic (1st line) - oxybutynin, tolterodine, solifenacin
- B-3 agonist - mirabegron
2) bladder emptying agents (neck relaxation)
- alpha 1 antagonist - tamsulosin
3) calm surface irritation (analgesic and anaesthetic actions)
- phenazopyridine (analgesic and local anaesthetic)
- rectal opioid (O+B supp)
- rectal benzodiazepine (diazepam)
normal urine PVR
50-100cc
PVR associated with obstructive renal failure
> 300cc
