Symptom control 1 Flashcards
Agitation / Secretions / Hiccups / N+V / Nutrition
What should you look for if confusion [6]
Infection Dehydration Retention Medication Hypercalcaemia Electrolyte imbalance
Where are sources of information for reasons for confusion
Nurse Relative NEWS Drug cardex Blood results 4AT
What examination can you do in a palliative patient presenting with confusion [4]
Chest
Abdo
Neuro
PEARL
What can you use if specific Rx fails
Haloperidol = 1st line
Chloropromazine
What is used in terminal phase of agitation / restless
Midazolam
What is licensed for intractable hiccups
Chloropromazine
What is also used for intractable hiccups [3]
Haloperidol
Gabapentin
Dexamthasone - hepatic
What are common in final days of life
Secretions
More troubling for family
What is conservative Rx for secretions
Avoid overload - stop IV or SC fluid
Educate family that patient is not troubled
What is medical management of secretions?
MOA?
SE profile [2]
Hyoscine hydrobromide
Centrally acting anti-muscarinic also used in motion sickness
SE:
- central anticholinergic syndrome (excitement, ataxia, hallucinations, behavioural abnormalities, drowsiness)
- anti-muscarinic side effects
When is hycosine butyl bromide indicated? [2]
What are contraindications of hycosine? [3]
Bowel colic
Excessive respiratory secretions
Contraindications:
- GI obstruction,
- myasthenia gravis
- BPH, urinary retention
What can cause nausea in palliative care [7]
Metabolic Drugs Infection Intra-cranial Abdominal Psychological SE chemo therapy
What are metabolic causes of nausea [3]
Uraemia
Hyperclacaemia
Circulating Ig
What drugs cause nausea [7]
Opioids NSAID Chemo Abx SSRI Iron Digoxin
What abdominal causes of nausea [3]
Gastric outlet obstruction
Constipation
Mass
What is useful if intra-cranial lesion causing N+V [2]
Dexamethasone
Haloperidol
What are RF of chemo related N+V [4]
Anxiety
<50
Concurrent use of opioids
What is used if low risk of N+V Sx in chemo
Metoclopramide
What is added if doesn’t work or if high risk [2]
5HT3 receptor antagonist - ondansetron
Dexamethasone
What are used as anti-emetics [5] (class of drugs)
Neurotransmitter blockers Dopamine antagonist Anti-histamine Anti-cholinergic 5HT3 antagonist
What are dopamine antagonist and what are they useful for [3]
Haloperidol - N+V in palliative care
Metoclopramide - gut peristalsis
Levomepromazine - sedative
What anti-cholinergic
Hyoscine hydrobromide
Eg of 5HT3 antagonist
What is it useful for [4]
Ondanstron Post op use Chemo Gastroenteritis Vestibular causes of nausea
What is downside of 5HT3 antagonist [2]
Very constipation inducing
Expensive
What happens to calcium in a sick person [2]
Albumin is low
Ca levels may be normal but ionised Ca will be too high
What are consequences of malnutrition [6]
Impaired immune Poor wound healing Muscle wasting and weakness Impaired organ function Altered drug Poor response to Rx
What is cancer cachexia [2]
Unintential body and lean tissue wasting
Metabolic abnormality results in increased energy, fat and oxidation
What does it lead too [3]
GI disturbance
Anorexia
Undernutriton
How do you treat [2]
Adequate replacement and supplements
Appetite stimulates
MUST screening on admission and weekly
What replacement feed options do you have [6]
Energy and protein dense diet Food fortification Oral supplement NGT PEG TPN
What stimulates appetite? [3]
Megace
Dexamethasone
Alcohol
Indications for metoclopromide or domperidone (pro-kinetics) [3]
Contraindications [3]
SE [3]
Ind:
- N&V from clinical toxicity (metoclopramide only)
- motility disorders
- migraine
CI:
- post-GI haemorrhage
- obstruction, perforation
- pheochromocytoma
SE:
- extra-pyramidal symptoms
- hyperprolactinaemia
- GI upset
Haloperidol Class of drug Indications [3] Contraindication [2] SE [3] Interactions [3]
D2 receptor antagonist (plus anticholinergic and alpha adrenergic effects)
Ind:
- N&V due to clinical toxicity in palliative care
- anti-psychotic
- hiccups in palliative care
CI: coma, pheochromocytoma
SE:
- extrapyramidal symptoms, hyperprolactinaemia
- anti-cholinergic effects (constipation, urinary retention, dry mouth)
Interactions:
- potentiate effects of alcohol and sedatives, beta blockers
Ondansetron
Contraindication [1]
SE [3]
Interactions [3]
CI: congenital long QT syndrome
SE:
- constipation, headache, abdo pain, drowsiness
- QT prolongation, arrhythmia
- injection site reaction
Interactions:
- anti-arrhythmic, beta blockers, avoid in any drugs that cause QT prolongation
Cyclizine MOA Indications [2] SE [2] Interactions [2]
Anti-histamine (blocks histamine receptor blockers) in vestibular system and VC
Ind: vestibular causes, ICP
SE: drowsiness, anticholinergic effects
Interactions: alcohol, BDZ
Levomepromazine
MOA
Indications [2]
Contraindications [3]
Phenothiazine (dopamine, 5HT2, alpha 1 adrenergic, histamine and ACh antagonist) so broad spectrum anti-emetic
Ind:
- N&V post-op
- refractory or multifactorial N&V in palliative care
CI: coma, pregnancy, breastfeeding
Levomepromazine SE [6]
Interactions [1]
Education [1]
SE:
- hypotension
- neuroleptic malignant syndrome
- GI SE, respiratory depression
- extra-pyramidal SEs
- anti-muscarinic effects
- prolonged QT interval
- Interactions: avoid in any drugs that cause QT prolongation or drugs which have similar effects
- Education: alcohol may potentiate effects
