Symptom Management Flashcards
Compare nociceptive vs neuropathic pain
nociceptive: functioning nervous system. The pain is localised
neuropathic: dysfunctional nervous system. The pain is generally tingling, it travels and it fluctuates
Describe the WHO pain ladder
- paracetamol, NSAIDs
- codeine, tramadol, dihydrocodeine
- morphine, diamorphine, oxycodone, fentanyl
What are some side effects of opioids?
constipation drowsiness dry mouth N&V respiratory depression
What analgesia is best to use in CKD?
Mild renal impairment: oxycodone
Severe renal impairment: fentanyl and buprenorphine
When would you consider up titrating a persons opioid?
> 3 PRN needed a day
How is someone’s new up titrated dose of morphine calculated?
BD dose + PRN doses used = TDD
New BD = TDD/2
New PRN = TDD/6
What does NICE recommend as a regime for an opiate naive patient?
Total daily dose of 30mg
Morphine sulphate 5mg immediate release preparation to be given four hourly
What is a typical starting regime for someone new to opioids?
15mg BD zomorph (modified release)
5mg PRN oramorph (immediate release)
Compare the side effect profile of oxycodone and morphine
oxycodone is more constipating however leads to less nausea and drowsiness and pruritis
What are the causes of vomiting in a cancer patient?
gastric dysmotility opioid and chemotherapy induced electrolyte disturbances - uraemia - hypercalcaemia - hyponatraemia anxiety induced RICP
How is chemotherapy induced N&V managed?
Ondansetron
How is metabolic derangement induced N&V managed?
haloperidol or levomepromazine
How is N&V due to reduced gastric motility managed?
Metoclopramide
How is N&V due to mechanical bowel obstruction managed?
Cyclizine
How is anxiety induced N&V managed?
Lorazepam
How is RICP in palliative care managed?
Cyclizine + dexamethasone + radiotherapy
What are some causes of breathlessness in palliative care?
anxiety pneumonia PE SVCO rib metastasis
How is breathlessness in palliative care managed?
Open windows and increase air flow Sit the patient up Talk about any anxieties they are having Breathing exercises and physiotherapy Morphine Benzodiazepines Oxygen
Pleural aspiration/chest drain for pleural effusion Anticoag for PE Analgesia for pain with breathing Diuretics for heart or renal failure Abx for infection Stenting
What causes hiccups in palliative patients?
Gastric distention
Phrenic nerve involvement
Uraemia
How are intractable hiccups managed?
Chlorpromazine
+/- haloperidol, gabapentin and dexamethasone
What causes constipation in palliative care?
Opioids Weakness to push Dehydration and malnutrition Immobility Hypercalcaemia Spinal cord compression
How is constipation in palliative care managed?
Co-danthramer (stimulant + softener)
Or
Lactulose + Senna
How does end stage lymphoedema present?
Non-pitting oedema
Chronic skin changes
How is lymphoedema managed?
Gradient compression bandaging
How should psychological distress associated with cancer/ palliation be managed?
How should it be managed in the terminal phase of illness?
Non-pharmacologically: breathing exercises, religious support, CBT
Haloperidol or chlorpromazine
Terminal phase: Midazolam
What are the drug options for respiratory secretions? What is the advantage of one vs the other?
Hyoscine hydrobromide: sedating
Hyoscine butylbromide: non-sedating
Antimuscarinics so causes
constipation, dizziness, drowsiness, dry mouth, flushing, headache, nausea
Can also use glycopyrronium - anticholinergic, causes dry mouth, n+v, dizziness, fatigue, blurred eyesight
What are the advantages and disadvantages of using a patch for analgesia?
+ Less constipating
- Analgesia requirements need to be stable to use
- Increased N&V
- Withdrawal symptoms
When should a dose be titrated for opioids?
If using their PRN dose more than 4 times a day, titrate their dose up:
o Total dose per day (PRN + scheduled doses) ÷ 2 = new BD dose
o Total dose per day (PRN + scheduled doses) ÷ 6 = new PRN dose
Over how long do zomorph and morphine sulphate act?
Over 12 hours
How must prescriptions for controlled drugs be written?
Prescriptions for controlled drugs must be written out fully and in block capitals
o Patient name, ID and address
o Drug form (tablets, capsules, bottles) – specify size/formulation (e.g.10mg/5ml solution)
o Amount needed (digits and words) – normally enough for 14 days
o Patient directions
What makes up the vomiting reflex?
Vomiting centre in the medulla causes reflex
Fed in from
Higher cortical centres - memory, fear, sensory
Chemoreceptor trigger zone - chemo, anaesthetics, opioids
Drugs - histamine, muscarinic and dopamine antagonists
Stomach and small intestine drugs - 5HT3 antagonists
What class is haloperidol, some side effects, usual dose?
Dopamine antagonist
Acts on CTZ
Extrapyramidal signs
Restlessness/sedation
0.5-5mg PO or SC
What class is metoclopramide, some side effects, usual dose?
Dopamine antagonist - 5-HT3 antagonist
Prokinetic
Acts on CTZ
Extrapyramidal side effects
Avoid antimuscarinics
10mg TDS PO 30mg/day SC
What class is ondansetron, some side effects, usual dose?
5-HT3 antagonist
Inhibits serotonin released by bowel injury, chemo, radio
Constipation, headache
Reduce dose in renal failure
Can cause serotonin syndrome
4-8mg TDS
8-16mg day SC
What class is levomepromazine, some side effects, usual dose?
Phenothiazine
Acts at vomiting centre and chemoreceptor trigger zone
Drowsiness
6.25-12.5mg/day PO or SC
What class is aprepitant, some side effects, usual dose?
NK1 antagonist
Acts mainly centrally
Constipation, headache
Use to augment 5-HT3 antagonists
What are some examples of adjuvants used in palliative care?
Antidepressants - amitriptyline, duloxetine
Anti-convulsants - gabapentin, pregabalin
Benzodiazepines - diazepam, clonazepam
Steroids - dexamethasone
Bisphosphonates for bony pain
What are examples of treatable causes of breathlessness?
Anaemia PE COPD CCF Respiratory tract infection Pleural effusion Pericardial effusion SVCO Anxiety Transfusion LMWH, DOAC Diuretics, ACEi Bronchodilators Aspiration, pleurodesis
What are common symptoms at the end of life?
Pain and discomfort Agitation Delirium Nausea and vomiting Breathlessness, Cheyne Stokes breathing - Respiratory tract secretions Mouth care - sips, foam sticks, vaseline to lips Drinking and eating care Bladder care Skin integrity Emotion/spiritual/psychological needs
What is used for the relief of breathlessness?
Morphine sulphate for the relief of the sensation of breathlessness
Midazolam for the relief of anxiety associated with breathlessness
What might be some causes of restlessness and agitation, and how can it be treated?
Uncontrolled pain
Full bladder, full rectum
Breathlessness
Anxiety, fear resolve where possible
If cannot otherwise be relieved - give midazolam 2.5-5mg STAT and PRN by subcutaneous injection
What symptoms can be experienced in opiate naive patients?
30% experience nausea
Constipation
Drowsiness
What types of pain have a good response to analgesics?
Nociceptive pain - soft tissue pain, visceral pain
What types of pain can have a moderately good response to analgesia?
Bone pain
Why might extra pain management be required for breakthrough pain?
Exacerbations of pain
Pain occurring before the next dose of opioid pain is due
Incident pain - due to specific actions e.g. movement or coughing
What are the types of opioids?
Weak opioids - codeine, dihydrocodeine
Tramadol classed by BNF as strong opioid
Strong: morphine, diamorphine, oxycodone, hydromorphine, fentanyl, alfentanil, methadone
What combination preparations are available?
Co-codamol 30/500 - codeine phosphate 30mg and paracetamol 500mg
Co-dydramol - dihydrocodeine 20 or 30mg with paracetamol 500mg
What formulations is codeine available as?
15mg, 30,g or 60mg tablet
How can immediate release morphine be given?
Every 4 hours
Immediate release available e.g. 10mg/5ml
Once controlled, then converted to oral morphine modified release given twice a day
What is a typical starting dose for an opiate naive patient?
20-30mg in divided doses e.g. 10-15mg every 12 hours
And 5mg immediate release oral doses
How can altering the dose of morphine be calculated?
Add up total dose of morphine received in 24 hours, including regular and as required doses
Divide dose into 2 12 hourly preparations
Prescribe new as required dose - usually 1/6th
Or - if the patient is in pain, increase dose by approx 30%
What drugs are good to prescribe for neuropathic pain?
Amitriptyline
Gabapentin
Pregabalin
