Symptomatic treatment Flashcards
Symptoms of cancer
Breathlessness
Nausea and vomiting
Constipation
Causes of cancer related breathlessness (9)
Anaemia PE Congestive cardiac failure COPD Respiratory tract infection - pneumonia Pleural effusion Pericardial effusion SVCO Anxiety
Investigations for breathlessness
Anaemia - Bloods
PE - CTPA
Congestive cardiac failure - CXR, BNP
COPD - Spirometry
Pneumonia - Bloods, culture, CXR
Pleural effusion - CXR
Pericardial effusion - CXR, CT
SVCO - CXR
Anxiety - Bloods
Treatment for breathlessness
Anaemia - treat cause e.g. iron supplements or transfusion
PE - Enoxaparin (LMWH or DOAC)
Congestive cardiac failure - Diuretics, ACEi
COPD - bronchodilators
Pneumonia - abx
Pleural effusion - aspiration, chest drain (pluerodesis)
Pericardial effusion - paracentesis, corticosteroids
SVCO - Stent, radiotherapy or steroids
Anxiety - CBT, benzodiazepines, SSRIs
General management of breathlessness
Consider oramorph 1 - 2mg PRN
If anxiety - sublingual lorazepam
Common causes of nausea and vomiting
Infection
- UTI
- pneumonia,
- gastro-enteritis
- thrush
Metabolic
- renal impairment
- hepatic impairment
- hyponatraemia
- hypercalcaemia
- sepsis
- tumour toxins
- stopping steroids quickly
Drug related
- opiods
- abx
- NSAIDs
- diuretics
- digoxin
- SSRIs
- chemo
Gastric stasis
- pyloric tumours
- ascites
- hepatomegaly
- opioids
- anticholinergics
- DKA- pancreatic cancer
GI disturbance
- constipation
- gastritis
- ulceration
- obstruction
Organ damage
- distention
- obstruction
- radiotherapy
Neurological
- raised ICP
- motion sickness
- meningeal disease
Psychological - anxiety/ fear
Raised ICP symptoms
Headaches
Confusion
Visual disturbances
Worse in the morning
Symptoms of hypercalcaemia
Headaches Constipation Bone pain Nausea Dark urine
Receptors in the chemo trigger zone
D2 - Dopamine receptors
NK1 - natural killer receptors
5HT3 - Serotonin receptors
Receptors in the vomiting centre
Achm - Acetylcholine receptors
H1 - histamine receptors
5HT2 - Serotonin receptors
Receptors in the VIII nucleus
Achm - Acetylcholine receptors
H1 - histamine receptors
What triggers the chemo trigger zone
Toxins in blood
What triggers the vomiting centre
Higher centres - anxiety/ fear/ pain
Autonomic afferents
Medication for nausea and receptors
Haloperidol - D2
Metoclopramide - D2, 5HT3
Domperidone - D2
Cyclizine - Ach, H1
Levomepromazine - D2, 5HT2, Ach, H1
Ondansetron - 5HT3
Hyoscine hydrobromide - Ach
Prochlorperazine - D2, Ach, H1
Aprepitant - NK1
Feature of prochlorperazine
Weak antiemetic
Used in GP
Which anti-emetics cause sedation
Levomepromazine
Hyoscine hydrobromide
Which antiemetic is used for chemical causes of nausea
Haloperidol or metoclopramide if gastric stasis
Features of chemical nausea
Persistent Often severe Unrelieved by vomiting aggravated by the sight and smell of food Drowsiness and confusion
Which antiemetic is used for gastric stasis causes of nausea
Metoclopramide
Domperidone
Features of gastric stasis nausea
Fullness and regurgitation
Reduced appetite
Large volume of vomit
Vomiting relieves nausea
Epigastric discomfort
Hiccups
Which antiemetic is used for functional causes of nausea (bowel obstruction)
Cyclizine
Features of functional nausea due to bowel obstruction
High obstruction - regurgitation, forceful vomiting of undigested food
Low: colicky pain, feculent vomit, visible peristalsis
Which antiemetic is used for raised ICP intracerebral causes of nausea
Cyclizine and dexamethasone to reduce cerebral oedema
Features of nausea due to raised ICP intracerebral
Nausea worse in the morning
Projectile vomiting
Worse with head movements
Headache
Which antiemetic is used for anxiety causes of nausea
Benzodiazepines
Features of nausea due to anxiety
Anxiety
Fear
Anticipation
Which antiemetic is used for nausea caused by post op or post radiotherapy
Ondansetron
Which antiemetic is used for nausea caused by constipation
Laxatives
Metoclopramide
Features of nausea due to constipation
Feculent vomit
Abdominal distension
Risk factors associated with chemotherapy induced N+V
Female
Age < 50 yo
Past Hx of N+V with pregnancy, chemo or motion sickness
Side effects of aprepitant
Constipation
Headache
Route and regime of antiemetics
Often given SC due to poor oral absorption
Given before, morning off and after chemotherapy
Use regularly
Can combine anti-emetics with different MOA
Features of constipation
Hard faeces which is difficult to pass
Reduced frequency
Sense of incomplete evacuation
Faecal incontinence
Colicky abdo pain and abdo distension
Flatulence
N+V
Causes of constipation
Disease related - immobility, reduced food intake, intra-abdominal and pelvic disease
Fluid depletion - poor fluid intake, fluid loss e.g. vomiting
Weakness - inability to raise intra-abdominal pressure e.g. cardiac failure
Intestinal obstruction - recurrence, adhesions, surgery
Medication - opioids, diuretics, anticholinergics, 5HT antagonists
Biochemical - hypercalcaemia, hypoklaemia
Other - pain when defecating, diverticulitis
Stimulant laxatives
Senna
Bisacodyl
Reduce bowel transit times
Softener laxative
Docusate
Increase water penetration of stool
Stimulant/softener laxative
Sodium picosulfate
Osmotic laxatives
First line
- Lactulose
- Movicol
- Laxido
Holds water in the gut lumen
Side effects of osmotic laxatives
Flatulence
Bloating
Suppositories
Glycerin - softner
Bisacodyl - stimulant
Types of malignant bowel obstruction
Mechanical - due to tumour within the gut or outside bowel wall
Functional - infiltration of myenteric plexus
Treatment of malignant bowel obstruction
Surgical intervention:
- Endoscopic stenting
- Venting gastrostomy to decompress
- Cautious use of prokinetics
If inoperable:
- IV fluids - correct electrolytes
- NG tube
- Trial of dexamethasone
- Analgesics
Broad spectrum anti-emetic
Levomepromazine
