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Symptom Management Flashcards

1
Q

Compare nociceptive vs neuropathic pain

A

nociceptive: functioning nervous system. The pain is localised
neuropathic: dysfunctional nervous system. The pain is generally tingling, it travels and it fluctuates

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2
Q

Describe the WHO pain ladder

A
  1. paracetamol, NSAIDs
  2. codeine, tramadol, dihydrocodeine
  3. morphine, diamorphine, oxycodone, fentanyl
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3
Q

What are some side effects of opioids?

A 
constipation 
drowsiness
dry mouth 
N&V
respiratory depression
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4
Q

What analgesia is best to use in CKD?

A

Mild renal impairment: oxycodone

Severe renal impairment: fentanyl and buprenorphine

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5
Q

When would you consider up titrating a persons opioid?

A

> 3 PRN needed a day

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6
Q

How is someone’s new up titrated dose of morphine calculated?

A

BD dose + PRN doses used = TDD

New BD = TDD/2
New PRN = TDD/6

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7
Q

What does NICE recommend as a regime for an opiate naive patient?

A

Total daily dose of 30mg

Morphine sulphate 5mg immediate release preparation to be given four hourly

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8
Q

What is a typical starting regime for someone new to opioids?

A

15mg BD zomorph (modified release)

5mg PRN oramorph (immediate release)

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9
Q

Compare the side effect profile of oxycodone and morphine

A

oxycodone is more constipating however leads to less nausea and drowsiness and pruritis

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10
Q

What are the causes of vomiting in a cancer patient?

A 
gastric dysmotility 
opioid and chemotherapy induced 
electrolyte disturbances
- uraemia 
- hypercalcaemia 
- hyponatraemia 
anxiety induced 
RICP
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11
Q

How is chemotherapy induced N&V managed?

A

Ondansetron

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12
Q

How is metabolic derangement induced N&V managed?

A

haloperidol or levomepromazine

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13
Q

How is N&V due to reduced gastric motility managed?

A

Metoclopramide

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14
Q

How is N&V due to mechanical bowel obstruction managed?

A

Cyclizine

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15
Q

How is anxiety induced N&V managed?

A

Lorazepam

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16
Q

How is RICP in palliative care managed?

A

Cyclizine + dexamethasone + radiotherapy

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17
Q

What are some causes of breathlessness in palliative care?

A 
anxiety 
pneumonia 
PE
SVCO
rib metastasis
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18
Q

How is breathlessness in palliative care managed?

A 
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
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19
Q

What causes hiccups in palliative patients?

A

Gastric distention
Phrenic nerve involvement
Uraemia

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20
Q

How are intractable hiccups managed?

A

Chlorpromazine

+/- haloperidol, gabapentin and dexamethasone

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21
Q

What causes constipation in palliative care?

A 
Opioids
Weakness to push 
Dehydration and malnutrition 
Immobility 
Hypercalcaemia 
Spinal cord compression
22
Q

How is constipation in palliative care managed?

A

Co-danthramer (stimulant + softener)
Or
Lactulose + Senna

23
Q

How does end stage lymphoedema present?

A

Non-pitting oedema

Chronic skin changes

24
Q

How is lymphoedema managed?

A

Gradient compression bandaging

25
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
26
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
27
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
28
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
29
Over how long do zomorph and morphine sulphate act?
Over 12 hours
30
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
31
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
32
What class is haloperidol, some side effects, usual dose?
Dopamine antagonist Acts on CTZ Extrapyramidal signs Restlessness/sedation 0.5-5mg PO or SC
33
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
34
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
35
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
36
What class is aprepitant, some side effects, usual dose?
NK1 antagonist Acts mainly centrally Constipation, headache Use to augment 5-HT3 antagonists
37
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
38
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 ```
39
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 ```
40
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
41
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
42
What symptoms can be experienced in opiate naive patients?
30% experience nausea Constipation Drowsiness
43
What types of pain have a good response to analgesics?
Nociceptive pain - soft tissue pain, visceral pain
44
What types of pain can have a moderately good response to analgesia?
Bone pain
45
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
46
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
47
What combination preparations are available?
Co-codamol 30/500 - codeine phosphate 30mg and paracetamol 500mg Co-dydramol - dihydrocodeine 20 or 30mg with paracetamol 500mg
48
What formulations is codeine available as?
15mg, 30,g or 60mg tablet
49
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
50
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
51
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%
52
What drugs are good to prescribe for neuropathic pain?
Amitriptyline Gabapentin Pregabalin

Cancer Care (15 decks)

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