Symptom Control in Palliative Care

Question 1

4 main Sx in last day of life

Answer 1

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)

Question 2

Mx of respiratory secretions in last day of life (3)

Answer 2

hyoscine hydrobromide

hyoscine butylbromide if still conscious (butyl-brain working)

glycopyrronium

Question 3

Mx of nausea/vomitting in last day of life

Answer 3

haloperidol

Question 4

Mx of pain in last day of life

Answer 4

diamorphine w. breakthrough dose 1/6th daily amount

Question 5

Mx of agitation in last day of life

Answer 5

muscle fatigue so severe, unable to make adjustments to become comfortable

Rx w. midazolam

Question 6

Drugs CI in syringe drivers

Answer 6

chlorpromazine
prochlorperazine
diazepam

all cause reaction at injection site

Question 7

Prescribing a syringe driver

Answer 7

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

Question 8

Causes of nausea/vomitting in ca. pts. (15)

Answer 8

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

Question 9

Mx of nausea/vomiting in ca. pts. (4)

Answer 9

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

Question 10

Anti-emetic drug types (4)

Answer 10

dopamine antagonists
5HT-3 antagonists
H2 receptor antagonists
anti-cholinergics

Question 11

Dopamine antagonists examples(4), uses(6) and SEs(6)

Answer 11

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

Question 12

5HT-3 antagonists examples(2), use and SEs(5)

Answer 12

ondansetron, granisetron

used for chemo/RT sickness

SEs:

• constipation
• flushing
• headache
• rash
• hypersensitivity reaction

Question 13

H2 receptor antagonists examples (2), uses (4) and SEs (4)

Answer 13

cinnarizine, cyclizine

used for:

• vestibular disorders
• mechanical bowel obs
• raised ICP
• motion sickness

SEs:

• drowsiness
• dry mouth
• blurred vision
• QTc

Question 14

Anti-cholinergics examples(1), uses(1) and SEs(4)

Answer 14

hyoscine bromide

used for motion sickness

SEs:

• drowsiness
• blurred vision
• dry mouth
• difficulty w. micturition

Question 15

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

Answer 15

ondansetron for chemo/RT

cyclizine for raised ICP/mechanical bowel obs

haloperidol for drug related/metabolic

domperidone for gastrostasis

metoclopramide for general ca. sickness

Question 16

Reversible causes of respiratory secretions (2)

Answer 16

HF

pneumonia

Question 17

Mx of resp secretions (2)

Answer 17

non-drug:

• re-positioning
• suctioning
• reducing parenteral fluids

anticholinergics:

• hyoscine hydrobromide
• hyoscine butylbromide: brain working
• glycopyrronium

Question 18

Reversible causes of breathlessness (10)

Answer 18

PE
pleural effusion
pulmonary oedema
neuromuscular weakness
airways obstruction
increased demand
anxiety 
pain
infections
secretions

Question 19

Mx of breathlessness (5)

Answer 19

sit up and fan

supplementary O2

for sensation of breathlessness: morphine

for anxiety: diazepam, midazolam

dexamethasone nebs if bronchospasm or partial obstruction

Question 20

Ix for breathlessness

Answer 20

look for pleural/pericardial effusion

Question 21

Mx of pruritus (2)

Answer 21

emollients

cholestyramine

Question 22

Mx of restlessness and confusion (2)

Answer 22

if terminal restlessness/agitation:

• midazolam 1st line
• levomepromazine(antipsychotic) 2nd line: NB lowers seizure threshold
• haloperidol

Question 23

Mx of raised ICP (2)

Answer 23

headache responds to dex:

• give earlier to avoid insomnia
• give w. gastric protection-omeprazole

if related nausea:cyclizine

Question 24

Rx of muscle spasm

Answer 24

diazepam

Question 25

Mx of intractable cough (2)

Answer 25

moist inhalations-NaCl nebs

oral morphine

Question 26

Mx of hiccups (2)

Answer 26

metoclopramide for gastric distension

baclofen

Question 27

Mx of hypercalcaemia (2)

Answer 27

fluid resus

pamidronate IV if persistent

Question 28

Mx of anorexia (2)

Answer 28

pred or dex

mirtazepine: also useful in depression

Question 29

Mx of capillary bleeding

Answer 29

gauze soaked in adrenaline and tranexamic acid

Question 30

Mx and prophylaxis of seizures (6)

Answer 30

(can be due to tumours or uraemia)

acutely:

• IV lorazepam
• buccal midazolam

prophylaxis:

• PO: phenytoin, carbemazepine
• SC: midazolam syringe driver
• IV: phenobarbitol
• Rectally: diazepam

Question 31

Mx of dry mouth (2)

Answer 31

measures: gum, pineapple, ice, artificial saliva

if caused by candida: miconazole, nystatin, fluconazole PO

Question 32

Mx of dysphagia

Answer 32

dex can help alleviate obstruction

Question 33

Mx of oesophageal spasm

Answer 33

nifedipine

Question 34

Mx of GI pain (5)

Answer 34

(pain caused by bowel colic)

loperamide (opioid receptor anagonist)

SC:

• hyoscine hydrobromide
• hyoscine butylbromide
• glycopyrronium

oxybutynin if bowel obs

Question 35

Mx of anxiety and depression (3)

Answer 35

anxiety: lorazepam, diazepam

depression:

• citalopram 1st line
• fluoxetine 2nd line

Question 36

Mx of hallucinations

Answer 36

haloperidol

Question 37

Mx of DM

Answer 37

stop hypo agents e.g. insulin, gliclazide

relaxed control: 5-20