Symptom Control in Palliative Care Flashcards
4 main Sx in last day of life
Respiratory secretions
Nausea/vomitting
Pain
Agitation
(NB drugs should be written up PRN before they’re needed in last days of life, once they become regular>SC syringe driver)
Mx of respiratory secretions in last day of life (3)
hyoscine hydrobromide
hyoscine butylbromide if still conscious (butyl-brain working)
glycopyrronium
Mx of nausea/vomitting in last day of life
haloperidol
Mx of pain in last day of life
diamorphine w. breakthrough dose 1/6th daily amount
Mx of agitation in last day of life
muscle fatigue so severe, unable to make adjustments to become comfortable
Rx w. midazolam
Drugs CI in syringe drivers
chlorpromazine
prochlorperazine
diazepam
all cause reaction at injection site
Prescribing a syringe driver
Infusions section of drug chart
up to 4 drugs in driver-CHECK INTERACTIONS
drugs replaced every 24hr, syringe every 72hrs.
Fill in boxes as below:
- infusion fluid: water for injection (or 0.9% saline)
- volume: 24ml
- duration: 24hrs
- rate: 1ml/hr
bracket drugs together to be in one syringe and write “made up to 24ml w. water for injection running via SC infusion at 1ml/hr”
make relevant dose conversions so it's SC: morphine>parenteral morphine: /2 morphine>parenteral diamorphine: /3 mild opioids>morphine: /10 tramadol: /5
Causes of nausea/vomitting in ca. pts. (15)
bowel obs gastroparesis blood in stomach faecal impaction gross ascites hypercalcaemia hyponatraemia brain mets raised ICP pain anxiety renal failure debility:cough, infection, constipation iatrogenic: chemo, RT, Abx, NSAIDS, opioids concurrent dyspepsia/peptic ulcer/alcohol-related gastritits
Mx of nausea/vomiting in ca. pts. (4)
First find cause and Rx any reversible causes:
- constipation:laxatives
- thrush: fluconazole
- infection: Abx
- pain: analgesia
non-drug:
-reducing food
drug therapy:
- most can manage on 1 anti-emetic
- take at least 30mins before eating
- any added anti-emetics should have different mechanism of action
Drip and suck
Anti-emetic drug types (4)
dopamine antagonists
5HT-3 antagonists
H2 receptor antagonists
anti-cholinergics
Dopamine antagonists examples(4), uses(6) and SEs(6)
examples:
-metoclopramide, domperidone, prochlorperazine, haloperidol
used for:
- GI causes
- neoplastic disease
- radiation sickness
- drug-induced vomitting
- GA
- cytotoxics
SEs:
- EPSEs
- Prokinetic: akathisia (restlessness, dystonia)
- hyperprolactinaemia
- hyper/hypotension
- rarely causes agranylocytosis and SVTs
- oculogyric crisis: Rx w. procyclidine or benztropine
5HT-3 antagonists examples(2), use and SEs(5)
ondansetron, granisetron
used for chemo/RT sickness
SEs:
- constipation
- flushing
- headache
- rash
- hypersensitivity reaction
H2 receptor antagonists examples (2), uses (4) and SEs (4)
cinnarizine, cyclizine
used for:
- vestibular disorders
- mechanical bowel obs
- raised ICP
- motion sickness
SEs:
- drowsiness
- dry mouth
- blurred vision
- QTc
Anti-cholinergics examples(1), uses(1) and SEs(4)
hyoscine bromide
used for motion sickness
SEs:
- drowsiness
- blurred vision
- dry mouth
- difficulty w. micturition
In summary, best anti-emetic for:
- chemo/RT
- raised ICP or mechanical bowel obs
- drug related or metabolic (high Ca, renal failure)
- for gastrostasis
- general ca. sickness
ondansetron for chemo/RT
cyclizine for raised ICP/mechanical bowel obs
haloperidol for drug related/metabolic
domperidone for gastrostasis
metoclopramide for general ca. sickness
Reversible causes of respiratory secretions (2)
HF
pneumonia
Mx of resp secretions (2)
non-drug:
- re-positioning
- suctioning
- reducing parenteral fluids
anticholinergics:
- hyoscine hydrobromide
- hyoscine butylbromide: brain working
- glycopyrronium
Reversible causes of breathlessness (10)
PE pleural effusion pulmonary oedema neuromuscular weakness airways obstruction increased demand anxiety pain infections secretions
Mx of breathlessness (5)
sit up and fan
supplementary O2
for sensation of breathlessness: morphine
for anxiety: diazepam, midazolam
dexamethasone nebs if bronchospasm or partial obstruction
Ix for breathlessness
look for pleural/pericardial effusion
Mx of pruritus (2)
emollients
cholestyramine
Mx of restlessness and confusion (2)
if terminal restlessness/agitation:
- midazolam 1st line
- levomepromazine(antipsychotic) 2nd line: NB lowers seizure threshold
- haloperidol
Mx of raised ICP (2)
headache responds to dex:
- give earlier to avoid insomnia
- give w. gastric protection-omeprazole
if related nausea:cyclizine
Rx of muscle spasm
diazepam
Mx of intractable cough (2)
moist inhalations-NaCl nebs
oral morphine
Mx of hiccups (2)
metoclopramide for gastric distension
baclofen
Mx of hypercalcaemia (2)
fluid resus
pamidronate IV if persistent
Mx of anorexia (2)
pred or dex
mirtazepine: also useful in depression
Mx of capillary bleeding
gauze soaked in adrenaline and tranexamic acid
Mx and prophylaxis of seizures (6)
(can be due to tumours or uraemia)
acutely:
- IV lorazepam
- buccal midazolam
prophylaxis:
- PO: phenytoin, carbemazepine
- SC: midazolam syringe driver
- IV: phenobarbitol
- Rectally: diazepam
Mx of dry mouth (2)
measures: gum, pineapple, ice, artificial saliva
if caused by candida: miconazole, nystatin, fluconazole PO
Mx of dysphagia
dex can help alleviate obstruction
Mx of oesophageal spasm
nifedipine
Mx of GI pain (5)
(pain caused by bowel colic)
loperamide (opioid receptor anagonist)
SC:
- hyoscine hydrobromide
- hyoscine butylbromide
- glycopyrronium
oxybutynin if bowel obs
Mx of anxiety and depression (3)
anxiety: lorazepam, diazepam
depression:
- citalopram 1st line
- fluoxetine 2nd line
Mx of hallucinations
haloperidol
Mx of DM
stop hypo agents e.g. insulin, gliclazide
relaxed control: 5-20
