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Adam's Weak Spots > Treatments > Flashcards

Treatments Flashcards

1
Q

Does the current evidence support “burst” doses of ketamine?

A

No.

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2
Q

What is the primary receptor action of ketamine? What is the normal neurotransmitter at that receptor?

A

N-Methyl-D-Aspartate (NMDA) antagonism

Normally activated by glutamate.

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3
Q

What non-NMDA receptors does ketamine interact with? (3)

A

Opioid partial agonist (esp. mu, maybe sigma)
AMPA agonist (role in depression)
Sympatheticomimetic/anticholinergic

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4
Q

What areas of the brain does ketamine affect, especially in its role in treating depression? (3)

A

anterior cigulate cortex
insula–default mode network connectivity

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5
Q

What are the 2 phases of ketamine distribution in the body?

A

Initial distribution into fatty tissues (e.g. CNS)
Second distribution into peripheral tissues

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6
Q

What are side effects of ketamine overdose and/or chronic use?

A

agitation –> sedation (dose dependent)
psychosis
ataxia
nystagmus
elevated BP/HR
ulcerative cystitis
hepatic injury

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7
Q

What are typical ketamine side effects in the healthcare setting?

A

NV
Sialorrhea
Psychosis/psychiatric symptoms
Laryngospasm
tachycardia/elevated BP (less commonly, the opposite)
elevated muscle tone

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8
Q

What are 4 containdications to ketamine in PC?

A

allergy
pregnancy or breastfeeding
acute ethanol intoxication (resp. depression)
psychotic mental illness
?elevated ICP–debatable

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9
Q

List 7 reminders when managing palliative care patients with OUD.

A
  1. The goals and attitudes remain the same as with all palliative patients
  2. Opioid doses are likely to be higher
  3. Opioid side effects are :. also likely to be worse
  4. Do not forget adjuvant analgesics!
  5. Do not forget psychosocial aspects of pain
  6. Long-acting formulations are less prone to abuse
  7. Taper opioids if pain is treated (e.g. post-XRT)
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10
Q

Name 2 scales for assessing inappropriate drug use.

A

CAGE
- cut down
- annoyed
- guilty
- eye opening

4 C’s
- loss of control
- compulsive use
- use despite consequences
- cravings

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11
Q

Which particular behaviour is especially concerning for OUD in palliative patients?

A

Repeatedly escalating doses, especially if they report inefficacy.

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12
Q

List the most important consideration with a patient suspected of OUD in the palliative setting.

A

What are the benefits/risks of continuing opioid therapy?
- e.g. are the more functional on opioids?
- e.g. is ongoing opioid treatment safe?

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13
Q

List 5 strong contraindications to cannabis use.

A
  1. Pregnancy
  2. Strong family history of psychosis
  3. Unstable cardiovascular or respiratory disease
  4. Allergy
  5. History of substance use disorder
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14
Q

List 4 relative contraindications to cannabis use.

A
  1. Active mood disorder
  2. Tobacco use
  3. Heavy alcohol / sedative medication use
  4. Cardiovascular risk factors w/o active disease
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15
Q

Which 2 important CYP enzymes does CBD inhibit?

A

CYP 3A4
CYP 2D6

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16
Q

List several drug classes that cannabis increases serum concentration of?

A
  1. SSRIs (not fluoxetine)
  2. PPIs
  3. TCAs (if smoked)
  4. SNRIs (if smoked)
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17
Q

List some drug classes that can increase cannabis serum concentration?

A
  1. Antifungals
  2. Grapefruit juice
  3. Macrolides
  4. Fluoxetine (not other SSRIs)
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18
Q

What classes of drugs can worsen the tachycardic side effects of cannabis?

A
  1. Prescription stimulants
  2. Caffeine
  3. Nicotine
  4. Anticholinergics
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19
Q

Name 7 acute reactions to blood transfusion

A
  1. Transfusion-related lung injury (TRALI)
  2. Transfusion-related fluid overload
  3. Acute hemolysis
  4. Anapylaxis
  5. Sepsis
  6. Allergic transfusion reactions
  7. Febrile non-hemolytic transfusion reactions
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21
Q

What is the mechanism of TRALI?

A

Endogenous neutrophil activation in pulmonary vasculature.

Caused by transfusion product anti-HLA or anti-neutrophil antibodies.

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21
Q

What is the management of TRALI?

A

Stop transfusion.
Quarantine all blood from donor.
Patient can receive blood from other donors.
Supportive management.

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22
Q

What is the mechanism of acute hemolytic transfusion reaction?

A

ABO incompatibility
Reaction to other RBC proteins.

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23
Q

What is the most common reason for acute hemolytic transfusion reaction?

A

Administrative error.

:. always contact blood bank about AHTRs

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24
Q

What is the presentation of acute hemolytic transfusion reaction?

A

Fever
Rigors
Oozing at transfusion site
Flank pain

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25
Q

What is the most common cause of a febrile NON-hemolytic transfusion reaction?

A

Cytokines released by donor neutrophils.

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26
Q

What is the first step in diagnosing a non-hemolytic transfusion reaction?

A

Ruling out allergic and hemolytic reactions.

(it is a diagnosis of exclusion)

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27
Q

Which are the 4 potentially deadly transfusion reactions?

A

Hemolytic
Anaphylactic
Septic
TRALI
Cardiac overload

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28
Q

What are times to avoid PDE-5 inhibitors?

A

Nitrate use
a-blocker use (e.g. terazosin)
retinitis pigmentosa

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29
Q

What is the outcome of PDE-5 inhibition at a cell level?

A

Reduced degradation of cGMP
–> vessel dilation
–> healthier endothelium

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30
Q

How does ESLD affect drug metabolism?

A
  1. Reduced 1st-pass metabolism (portosystemic shunting)
  2. Increased Vd (less protein binding)
  3. Reduced metabolism in general (glucuronidation/oxidation)
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31
Q

What are the first-line drug classes for MDD in ESLD?

A
  1. SSRI
  2. SNRI
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32
Q

Indications for cardiac resychronisation therapy (CRT)?

A

CHF, EF <35% (at least 3mo on medical tx) AND any of…
1. QRS >130 with LBBB, NYHA II+
2. QRS >150 w/o LBBB, NYHA III+
3. Requiring frequent ventricular pacing

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33
Q

What is LVAD “destination therapy”?

A

Previously, LVADs were meant to bridge to heart transplant.

“Destination therapy” is when LVAD is inserted for symptoms/life prolongation without plan for transplant.

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34
Q

What are 4 physiological benefits of LVAD therapy?

A
  1. Improved end-organ perfusion
  2. Reduction in diastolic pressure
  3. Reduction in wall stress/heart O2 use
  4. Improved heart perfusion
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35
Q

What are 4 clinical outcomes improved by LVADs?

A
  1. Reduction in cardiogenic shock
  2. Reduction in pulmonary edema
  3. Reduction in symptoms of cardiac ischemia
  4. Reduction in infarct sizes
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36
Q

Name 3 types of LVAD-associated infection

A
  1. Driveline infection
  2. Extravascular component infection
  3. Intravascular component infection
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37
Q

List 4 risks of LVAD insertion

A
  1. Bleeding
  2. Clotting (stroke, limb ischemia)
  3. Death
  4. Infection
  5. Hemolysis
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38
Q

What is the leading cause of death related to LVADs?

A

Stroke

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39
Q

Name 4 settings where it is inappropriate to reduce for incomplete cross tolerance.

A
  1. Uncontrolled pain
  2. Methadone rotation
  3. Fentanyl rotation
  4. Low-dose (esp. starting doses)
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40
Q

List 7 possible side effects of ENT XRT.

A
  1. Xerostomia
  2. Mucositis
  3. Jaw necrosis
  4. Dermatitis
  5. Taste change / dysgeusia
  6. Trismus
  7. Dental complications
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41
Q

List 6 acute side effects of abdominal/pelvic XRT

A
  1. NVD (d/t entero/colitis)
  2. Dermatitis
  3. Cystitis
  4. Abdominal pain, esp. cramping
  5. Fatigue
  6. Mucositis (spec. vaginal)
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42
Q

List 7 contraindications to XRT.

A
  1. Collagen vascular disease
  2. Pregnancy
  3. Radiosaturation
  4. Pre-existing lung disease in thoracic XRT
  5. Pacemaker in field
  6. IBD
  7. Unable to lie still
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43
Q

List the indications to dialysis in CKD.

A
  1. eGFR <5 (almost all)
  2. eGFR 5-15 plus…
    a. uremic pericarditis/pleuritis
    b. uremic encephalopathy (rare if eGFR 5+)
    c. uremic anorexia/cachexia
    d. refractory volume overload
    e. uremic fatigue/malaise
    f. persistent PO4/K+ abnormalities

1 + 2a + 2b are absolute indications (others relative)

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44
Q

List 8 complications of hemodialysis.

A
  1. Hypertension
  2. Hypotension
  3. Chest pain and/or dyspnea
  4. Reaction to dialyser membrane
  5. Cramps
  6. Syncope
  7. Seizure
  8. NV
  9. Headache
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45
Q

List 4 causes of cramping during hemodialysis.

A
  1. Plasma osmolarity changes
  2. Plasma volume loss
  3. Tissue hypoxia
  4. Electrolyte shifts
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46
Q

How would one manage cramping in dialysis patients?

A
  1. Gabapentin
  2. Amitriptyline
  3. Exercise between dialysis sessions
  4. Dietary sodium restriction
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47
Q

What are the mechanisms of hyperbaric O2 therapy?

A
  1. Increase O2 delivery because of higher partial pressure
  2. Reduces nitrogen bubble size
  3. Shorter CO biological half-life (breath out faster)
  4. Reduces local hypoxia at wounds and promotes healing
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48
Q

List 8 contraindications to hyperbaric O2.

A
  1. Untreated pneumothorax (absolute)
  2. Obstructive lung disease
  3. Pulmonary blebs
  4. Recent ENT/chest surgery
  5. Claustrophobia
  6. URTIs
  7. Bleomycin therapy
  8. Doxirubicin therapy

(only 1 is an absolute contraindication)

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49
Q

List 5 complications of hyperbaric O2 therapy.

A
  1. ENT barotrauma (middle ear, sinus)
  2. Myopia (resolves in days)
  3. Pulmonary barotrauma
  4. Pulmonary O2 toxicity
  5. Seizure
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50
Q

List 5 drugs often used in palliative care that can interact with HAART.

A
  1. Xa inhibitors / direct thrombin inhibitors
  2. Benzodiazepines
  3. Antipsychotics (e.g. quetiapine)
  4. Most opioids
  5. Dexamethasone
  6. Methadone
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51
Q

List 4 practical forms of physical rehabilitation.

A
  1. Acute inpatient
  2. Subacute inpatient
  3. Outpatient
  4. Home based
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52
Q

List 4 goals of physical rehabilitation.

A
  1. Prevention of decline
  2. Restoration of losses
  3. Support/preservation of function in inevitable decline
  4. Palliative to manage symptoms, reduce contractures, reduce pressure sores
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53
Q

4 malignant causes of hiccups.

A
  1. Cerebral lesions
  2. Brainstem lesions
  3. Gastroparesis
  4. Dexamethasone
  5. Platinum chemotherapy
  6. Thoracic lymphadenopathy/tumour
  7. Hypercalcemia
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54
Q

Define a “good death.”

A
  1. Patient is treated as a person
  2. Dignity
  3. Symptom free
  4. Familiar surroundings and/or with familiar people
  5. Not unexpected
  6. Preceded by ACP
  7. Cultural mores respected
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55
Q

How many categories does the Bristol stool chart have?

A

7

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56
Q

What Bristol category of stool would be easily-passed blobs with clear-cut edges?

A

Type 5

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57
Q

What Bristol category of stool would be a lumpy, consistent mass?

A

Type 2

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58
Q

What categories of Bristol stool are considered the goal of constipation treatment?

A

3-4

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59
Q

How many categories does the Victoria Bowel Performance Scale have?

A

9 (-4 to G to +4)
G = “Good”
negatives are constipated
positives are loose/incontinent/diarrhea

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60
Q

What are the 3 characteristics that the Victoria BPS assesses?

A
  1. Characteristics
  2. Frequency/Pattern
  3. Control

(in order of importance when scoring)
(when in doubt, go with 2/3)

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61
Q

What are the goal scores on the Victoria BPS?

A

+1, G, -1

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62
Q

List the 5 diagnositic criteria for delirium in the DSM-V.

A

A. Reduced attention
B. Acute onset
C. 1+ other cognitive disturbance (e.g. memory loss, disorientation, language)
D. A + C not explained by pre-existing disorder
E. Evidence that this is caused by one or more organic causes

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63
Q

What are the 4 components of the Confusion Assessment Method (CAM)? What is required to diagnose delirium?

A
  1. Acute onset and fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Altered LOC (hypo/hyperactive)

Diagnosis is 1 + 2 and either 3 or 4.

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64
Q

What is the role of Endicott depression scale in PC?

A

A depression scale that replaces the physical symptoms in standard depression diagnosis, given that they overlap with common palliative symptoms.

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65
Q

What are the 4 substitutions in the Endicott depression scale?

A
  1. Weight changes –> depressed affect
  2. Sleep changes –> social withdrawal
  3. Fatigue –> brooding/self-pity
  4. Cognitive changes –> blunted affect, cannot be cheered up
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66
Q

What are the 5 components of the Child-Pugh rating for liver failure?

A
  1. Ascites
  2. Bilirubin
  3. Albumin
  4. PTT or INR
  5. Encephalopathy
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67
Q

How do you grade hepatic encephalopathy?

A

A. Inattention, sleep disturbance
B. Asterixis, lethargy, hyporeflexia
C. Somnolence, hyperreflexia
D. Coma

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68
Q

List 3 opioids safe to use in ESLD with good monitoring.

A
  1. Fentanyl
  2. Hydromorphone
  3. Morphine
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69
Q

List 3 nonopioid analgesics that are safe to use with monitoring in ESLD

A
  1. Gabapentin
  2. Pregabalin
  3. Acetaminophen (2g/d)
  4. TCAs
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70
Q

List 5 possible precipitants for hepatic encephalopathy

A
  1. Increased protein intake
  2. GI bleeding (–> protein absorption)
  3. Constipation
  4. Dehydration
  5. Portosystemic shunting (iatrogenic or spontaneous)
  6. Portal vv thrombosis
  7. Benzodiazepines
  8. Alcohol
  9. HCC
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71
Q

Name a mnemonic for identifying socioeconomically at-risk individuals, and its components.

A

ITHELLPS

  1. Income (general/food security)
  2. Transportation
  3. Housing
  4. Education
  5. Location/Legal status (immigrant? indigenous?)
  6. Literacy
  7. Personal safety (relationships, housing)
  8. Supports (personal, social)
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72
Q

Name the 5 components of the PAINAD scale and its use.

A

Use: identifying pain in patients with dementia unable to report accurately.

  1. Breathing (apart from vocalisation)
  2. Negative vocalisations
  3. Facial expression/grimace
  4. Body language
  5. Consolability/distractibility
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73
Q

What are the 5 components of the Palliative Prognostic Index? What outcome does it predict?

A
  1. Functional status
  2. Oral intake
  3. Dyspnea
  4. Delirium
  5. Edema

Survival under 3 weeks or >6 weeks (less accurate in between)

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74
Q

What are the 6 components of the Palliative Prognostic Score? What outcome does it predict?

A
  1. Dyspnea
  2. Anorexia
  3. KPS
  4. Clinicial estimate of survival
  5. WBCs
  6. Lymphocyte %

30-day survival

75
Q

List 5 nonpharma treatments for BPSD (9)

A
  1. Routines
  2. Separate them from what upsets them
  3. Limit activities that upset them
  4. “Time travel” with them if they are not in the present
  5. Don’t argue with incorrect thoughts
  6. Speak slowly, calmly, without raising voice
  7. Redirect to activities/things they enjoy
  8. Leave, if you are upsetting them
  9. Validate their emotions
76
Q

Which 2 SSRIs are best in BPSD?

A

Citalopram
Sertraline

77
Q

When should antipsychotic therapy be started for BPSD?

A

Late
- they are not very effective
- they can increase mortality
- initiate only if patient/carer at risk of injury/unable to care for patient

78
Q

In which BPSD patients should antipsychotics largely be avoided?

A

Lewy Body Dementia

79
Q

Which 2 antipsychotics are first-line for severe BPSD?

A

Quetiapine
Olanzapine

80
Q

What is the ABCD of a terminal bleed?

A
  1. Assure patient you will treat and be there for them
  2. Be present (someone there at all times)
  3. Calm demeanour
  4. Dignity–avoid sight of blood, cleaning face especially
81
Q

List the 9 standard questions that form the core of dignity therapy.

A
  1. What was most important in your life? What are highlights?
  2. Are there particular things you want your loved ones to remember about you?
  3. What were the most important roles you played in your life? Why were they important?
  4. What are your biggest accomplishments?
  5. Are there any unsaid things you would like to say to loved ones?
  6. What are your hopes for your loved ones?
  7. What life advice do you have for others?
  8. Is there anything you would like to say to your loved ones to help them to prepare for the future?
  9. In creating a record of your life, what would you like included?
82
Q

What is the first-line treatment for carcinoid syndrome?

A

Somatostatin analogs
- lantreotide
- octreotide

83
Q

What intervention can help a selected population with functional NETs?

A

Management of extensive liver disease (as these tumours are functional)
- surgery
- embolisation

84
Q

What are second-line options for carcinoid syndrome?

A
  1. High-dose somatostatin analogues
  2. Radioactive somatostatin
  3. Antidiarrheals
  4. Teloristat (tryptophan hydroxylase inhibitor) to prevent serotonin production
85
Q

What is the first-line symptomatic treatment for a VIPoma?

A

Somatostatin analogues.

86
Q

What are some second-line options for VIPoma symptoms?

A
  1. Corticosteroids
  2. Clonidine
  3. Antidiarrheals
  4. Cinacalcet
87
Q

What is the first-line symptomatic treatment for a somatostatinoma?

A

Somatostatin analogues (weird, I know)

88
Q

What is the first-line symptomatic treatment for gastrinoma?

A

High-dose PPI

89
Q

What are the 3 initial treatments for symptomatic insulinoma?

A
  1. Diabetic diet
  2. Diazoxide (inhibits insulin release)
  3. Everolimus
90
Q

Which neurological paraneoplastic syndromes are likely to respond to treatment?

A
  1. Lambert-Eaton myaesthenia
  2. Myaesthenia gravis
  3. Certain encephalitides

(any encephalitis related to SURFACE protein reactivity)

91
Q

What is the treatment approach to SIADH?

A
  1. Ensure euvolemia (incl. IVF if needed)
  2. Fluid restriction
  3. Demeclocycline (vasopressing antag.)
92
Q

List 2 screening scales for substance use disorder that can be used in PC.

A

Opioid Risk Tool
Screener and Opioid Assessment for Patients with Pain (SOAPP)

93
Q

List an initial approach to managing substance use disorder early in PC.

A
  1. Screen all ambulatory patients.
  2. Single prescriber
  3. Establish shared goals for symptom management
  4. Clear rules around lost rx, early refills, etc.
  5. Expect and plan for relapse
94
Q

List 4 approaches to ongoing management of substance use disorder in palliative care.

A
  1. CBT if available
  2. Frequent clinic visits/shorter refills
  3. Co-prescription of naloxone
  4. Maximise non-habit-forming adjuvants
  5. Consider referral to addiction services
  6. Consider buprenorphine/methadone
95
Q

Name a model for managing sexual health, and its components.

(not unique to palliative care)

A

PISSIT
1. Give “permission” to be sexual/talk about it
2. Information (that this is expected/normal)
3. Specific Suggestions for issues raised
4. Intensive Therapy for difficult cases

96
Q

List 4 examples of “specific suggestions” in the PISSIT model.

A
  1. Lubricants
  2. Planning ahead/switching time of day
  3. Try different positions to conserve energy
  4. How to maintain privacy
  5. Managing distracting symptoms (e.g. pain, fatigue)
  6. Managing partner’s needs
  7. Reestablishment of emotional intimacy (e.g. cuddling, massage, touch)
  8. PT for range of motion if it is limiting
97
Q

List 4 sexual issues specific to palliative care.

A
  1. Fatigue
  2. Dyspnea
  3. Depression
  4. Medications (antidepressants, opioids)
  5. Cancer therapy
  6. Body changes (cachexia, wounds)
  7. Medical interventions (colostomies, feeding tubes, tracheostomies)
98
Q

What hormone interventions can improve sexuality in PC?

A
  1. Testosterone + estrogen in women
  2. Testosterone alone in men
  3. Topical estrogen for vaginal atrophy if lubricants ineffective
99
Q

List 4 indications for intrathecal analgesia.

A
  1. Severe chronic pain, nociceptive and/or neuropathic
  2. Refractory to/intolerant of systemic analgesia
  3. No alternative interventions (e.g. surgery)
  4. Pain below the neck, ideally locoregional
  5. Success with temporary epidural
  6. Highly symptomatic pathological # close to death
100
Q

List 4 contraindications to IT analgesia.

A
  1. Local infection or sepsis
  2. Uncorrected coagulopathy
  3. Elevated ICP
  4. Pregnancy/Breastfeeding
  5. Logistical barriers (e.g. confused patient, $)
101
Q

What score can be used to assess motor blockade in IT analgesia?

A

Bromage Score

  • based on hip flexion strength
102
Q

List 6 nonpharmacological treatment options for neuropathic and or chronic pain.

A
  1. CBT
  2. Mindfulness-based-stress-reduction
  3. Pain neurophysiology education
  4. Therapeutic exercise/PT
  5. Acupuncture
  6. Massage
103
Q

List 8 nonpharmacological management strategies for delirium.

A
  1. Orientation (clocks, calendars, windows, reminders)
  2. Cognitive stimulation (games, visits)
  3. Sleep hygiene
  4. Early mobility / minimal restraints
  5. Hearing aids/glasses
  6. Maintain nutrition/hydration
  7. Quiet/consistent environment
  8. Do not challenge hallucinations/delusions
104
Q

In one European study, how what % of cancer patients were using CAM?

A

40% overall

105
Q

What population of cancer patients uses CAM the most?

A

Women with gyne/breast ca.
60-90%

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736076/

106
Q

Of doctors, nurses, and patients, which population has the strongest belief in CAM?

A

Nurses (90% endorse)
MDs (70% endorse)
Patients (50% endorse)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736076/

107
Q

In a 2018 systematic review, which CAM approaches showed benefit for symptoms over placebo?

A
  1. Massage/meditation in HIV for function
  2. Music therapy for pain
  • no good studies
  • most studies negative
108
Q

Describe the 4 criteria for palliative sedation
outlined in the Calgary Guidelines

A
  1. Terminal disease (<2 weeks)
  2. Refractory symptom
  3. DNR/MOST 1
  4. Informed patient/SDM consent
  • ideally this is established by PC expert
  • document every step
109
Q

List other considerations in palliative sedation beyond the 4 core criteria.

A
  1. Adequate documentation!!!
  2. Indwelling catheter
  3. Educate around nutrition/hydration
  4. Stop po medications
  5. Positioning to keep airway open
  6. Continue analgesia
110
Q

List the 3 drugs most commonly used
in palliative sedation

A
  1. Methotrimeprazine
  2. Midazolam
  3. Barbiturates (esp. phenobarbital)
111
Q

What is the relative potency of
midazolam : diazepam

A

Sedative–3x
Antiseizure–2x

112
Q

What is the mean T1/2 of midazolam?

A

3h

113
Q

Which drugs INCREASE
blood [midazolam]

A

SSRIs
Fluconazole

114
Q

Which drugs DECREASE
blood [midazolam]

A
  • phenytoin
  • phenobarbital
  • carbamezapine
  • dexamethasone
115
Q

What is the typical starting dose
of a midazolam infusion for PS?

A

0.5-1mg/h following 2.5-5mg bolus

116
Q

What are appropriate midazolam
titration instructions for PS?

A

Increase by 1mg/h q30min prn

117
Q

When should you consider adding
phenobarbital to midazolam?

A

If requiring midazolam >5mg/h, or definitely >10mg/h

118
Q

What is the serum T1/2 of phenobarb?

A

4-6 days

119
Q

What are typical phenobarb doses?

A

30-120mg subq bid-tid

120
Q

How would you titrate propfol for palliative sedation?

A

Increase 10mg/h q15min to effect

all changes take <10min to act

121
Q

What is the initial propofol dose
in palliative sedation?

A

5-10mg/h IV

Consider 20mg IV bolus

122
Q

What is a typical maximum
propofol dose for palliative sedation?

A

70mg/h

123
Q

What are the complications
of acute oral problems in PC?

A
  • Pain
  • Reduced po intake
  • Local / systemic infections
  • Delay/discontinue cancer therapy
124
Q

Which 2 populations are most
at -risk of iatrogenic mucositis?

A

Head/neck radiation patients
Myelosuppressive chemotherapy

  • Esp. for hematological malig.
125
Q

What are the 2 main modalities of oral care?

A
  1. Mechanical plaque disruption
  2. Mouth rinses
126
Q

Advise approach to oral hygiene
in the cancer patient

A
  1. Extra-soft nylon brush softened in hot water
  2. Flavour-free fluoride paste
    * Consider with added secretagogue
    * Consider 0.5% saline if pt can’t tolerate toothpaste
  3. Rinse mouth regularly
  4. Floss if no bleeding risk
127
Q

What are some oral cleaning methods to avoid?

A
  • Foam sticks / toothettes
  • Glycerine
  • Lemon swabs
128
Q

Are mouth rinses an essential part of oral care?

A

No—brushing/flossing usually enough

129
Q

When are mouth rinses indicated?

A
  • Xerostomia
  • Pain management
  • Infection tx
130
Q
A
131
Q

What is a good homemade
mouth rinse recipe?

A

Three options:
a. 5g NaCL + 1000mL water
b. 5g NaCO3 + 250mL water
c. 2.5g NaCl + 30g NaCO3 + 1000mL

132
Q

What setting are H202 rinses useful?

A

Fucibacterium infection

133
Q

What is the role of
chlorhexidine rinses?

A
  • Anti-plaque
  • Anti-microbial
  • Mildly anti-fungal

However, minimal evidence of benefit for prevention/treatment of mucositis

134
Q

Describe adequate denture care

A
  • Do not wear 24h/d
  • brush/soak every day w. right tools
  • Rinse before wearing
135
Q

How to manage dentures in suspected thrush infection?

A

Overnight soak in bleach solution
* 1:80 ratio of 1% bleach in water
* Rinse after soaking

Nystatin applied to inside of denture

136
Q

Why might dentures not fit in the palliative patient?

A

Loss of oral fat pads
Dry mouth

  • Need professional relining
  • Can consider short-term OTC relining
137
Q

List 5 causes of xerostomia
in the palliative patient

A
  1. Medications
  2. Head/neck radiation
  3. Mouth breathing
  4. O2 therapy
  5. Dehydration
138
Q

List 5 classes of medication that commonly cause dry mouth

A
  • TCas
  • Neuroleptics (esp. phenothiazines)
    E.g. Nozinan
    E.g. Prochlorperazine
    E.g. Chlorpromazine
  • Antihistamines (esp. H1)
  • Anticholinergics
  • Opioids
139
Q

Describe an approach
to xerostomia (7)

A
  1. Medication review
  2. Oral hygiene education
  3. Keep mouth moist
  4. Small sips sugar-free juice/liquid
  5. Sugarless gum/candies
  6. Saliva substitutes, esp. Gels
  7. Water-based lip balms
  8. Sparing application of olive oil
  9. Maintain room humidity
140
Q

What is the primary medication to treat xerostomia?

A

Pilocarpine

h/e has GI side effects

141
Q

How can you modify diet
to reduce xerostomia? (6)

A
  • Soften foods with tasty liquids
  • Butter, milk, gravy, milk etc.
  • Puree foods
  • Avoid dry/crumbly foods
  • Avoid caffeine
  • Avoid alcohol
142
Q

Distinguish stomatitis from mucositis

A

They are often used interchangeably, but distinguishing them can be helpful:

  • Stomatitis = infectious or autoimmune oral inflammation (e.g. HSV, bacterial)
  • Mucositis: inflammatory lesions caused by oncological treatment. Not just in mouth.
143
Q

What bugs cause oral thrush?

A

Candida albicans (+++ most common)
Other Candida species
Aspergillus spp

144
Q

List risk factors for oral thrush

A
  1. Iatrogenic immunosuppression
    * Steroid tx
    * Cancer tx
    * antibiotics
  2. HIV/AIDS
  3. Uncontrolled DM
  4. Poor oral hygiene
  5. Oral appliances (e.g. dentures)
  6. Poor nutritional status
  7. Iron deficiency
145
Q

Name 4 patterns of oral candidiasis’ clinical presentation

A
  1. Pseudomembranous (i.e. thrush)
  2. Acute erythematous
  3. Chronic atrophic
  4. Chronic hyperplastic

NB: these presentations can coexist in the same patient at the same time

146
Q

Describe pseudomembranous candidiasis

A
  • White/yellow plaques
  • Plaques can be wiped/scraped off (esp. palate, bucca, dorsal tongue)
  • Mucosa red/prone to bleeding
147
Q

Describe acute erythematous oral fungal infection

A
  • Similar to pseudomembranous
  • Lacks plaques but erythema persists
148
Q

Describe “denture stomatitis”

A

AKA chronic atrophic candidiasis
* Chronic edema/erythema
* “Velvet” texture where dentures fit

149
Q

Describe chronic hyperplastic oral fungal infection

A
  • Looks like leukoplakia
  • Plaques cannot be removed
    a. Bucca
    b. Lateral tongue
  • Usually painful
150
Q

How to treat oral candidiasis?

A
  1. Most forms can be treated topically
  2. Hyperplastic form requires systemic tx
  • Nystatin 500K u s/s qid
    a. No rinsing x 20 min post-swish
    b. Contains sucrose
  • Clotrimazole 10mg lozenge qid
  • Fluconazole 200mg/100mg x 7 days
    a. Major cytochrome interactions
151
Q

Name 6 principles of
oral mucositis pain management

A
  1. Keep a broad DDx
  2. Reduce irritating factors
  3. Good oral hygiene management
  4. Treat local/systemic infections
  5. Standard analgesia
  6. RD advice on maintaining oral intake
152
Q

Name some local treatments for oral mucositis pain

A
  1. Bland rinses
  2. Topically applied local anesthetics
    a. Do not swallow
    b. Do not eat if throat numb
  3. Morphine oral rinses +/- swallowing
    a. 15mL morphine 2% solution q4h prn
  4. Many magic mouthwashes
    a. Minimal evidence for any of these
153
Q

Name some drug/classes that can cause itching.

A
  1. Opioids
  2. Erythromycin
  3. Clavulin
  4. Estrogen
  5. Androgenic hormones
  6. Anabolic steroids
154
Q

What is the mechanism of the itch triggered by these medications?

A

Cholestasis

(although opioids, esp. morphine, are also histaminergic)

155
Q

List the nonpharmacological
management techniques for itch

A
  • Avoid hot showers/baths/swimming
  • Reduce sweating (e.g. loose clothing)
  • Moisturising creams/oils
  • Short nails
156
Q

Which class of cancers are most
strongly associated with itching?

A

hematological (esp. Lymphoma, MM)

157
Q

What are pharmacological options for itching management?

A
  1. H1-blockers, esp. 2nd-generation
  2. 1st-generation antihistamines
    a. (these likely work as much from anxiolysis as actual antipruritic action)
  3. Doxepin (2* antihistamine effect)
  4. Topical steroid therapy
  5. Anxiolysis in extreme cases
158
Q

List medications that may work for cholestatic itch

A
  1. Antihistamines
  2. Naloxone/naltrexone
  3. Ondansetron
  4. Rifampicin
  5. Paroxetine
  6. Mirtazapine
  7. Thalidomide (hah)
159
Q

What commonly-rx medication is not
typically used for itch in PC?

A

Cholestyramine
2* diarrhea, malabsorpion, taste

160
Q

List some rx options for uremic itch (6)

A
  1. Antihistamines
  2. Mirtazapine
  3. Naloxone/naltrexone (mixed evidence)
  4. Ondansetron (mixed evidence)
  5. Thalidomide
  6. EPO when given for renal anemia
161
Q

List some medications effective for malignancy-induced itch

A
  1. Cancer-modifying therapy
  2. Mirtazapine
  3. Steroids
  4. ASA 81mg
  5. Paroxetine
  6. Antihistamines
162
Q

List rx options for managing
opioid-induced itch

A
  • Reducing/rotating opioids
  • Ondansetron
  • Paroxetine
  • Mirtazapine
  • Careful use of opioid antagonists
163
Q

Describe initial management of
febrile neutropenia

A
  1. Align approach to GOC
    a. If GOC medical, this is emergent
  2. Cultures: blood/urine
  3. CXR
  4. CBC/lactate
  5. IV antibiotics (ceftriaxone/Tazocin)
164
Q

Describe management of
paraneoplastic/tumour-related fever

A
  1. Disease-modifying treatment
  2. Acetaminophen
  3. NSAIDs
  4. Steroids (prednisone 15-30mg/d)
165
Q

List drug options for malignant hyperhidrosis

A
  1. NSAIDs
  2. Anticholinergics
    a. Esp. scopolamine/Buscopan
  3. Olanzapine
  4. Beta-blockers if there is anxiety contributing
166
Q

Name a drug option rarely used
for fever with rigors

A

Meperidine 25mg IV slowly

167
Q

Name 2 rx options for hot flashes in women

A
  1. Estrogens preferred
  2. Progesterone if tumour is estrogen-sensitive
    a. Megesterol 20mg po bid
168
Q

Describe 3 nonhormonal options for hot flashes

A
  1. High-dose venlafaxine
  2. Paroxetine
  3. Fluoxetine
169
Q

Which two antibiotics can be given subcutaneously?

A

Ceftriaxone
Cefipime

170
Q

How long will the typical patient die after stopping fluids?

A

3-14 days

171
Q

List 4 nonoral routes of fluids

A

IVF
SubQ (hypodermoclysis)
Enteral (via NG/PEG/PEJ)
Rectal (proctoclysis)

172
Q

What are some arguments against
parenteral fluids in palliative care?

A
  1. Comatose patients unlikely to feel
  2. Dry mouth not improved with fluids
  3. Thirst not improved with fluids
  4. Reduces voiding
  5. Reduces terminal secretions risk
  6. Reduces pulmonary edema risk
  7. Reduces effusion/ascites accumulation
  8. Reduces medicalisation at EOL
173
Q

What are some arguments for parenteral fluids in PC?

A
  • Some patients thirsty at EOL
  • Can treat opioid neurotoxicity
  • Can treat electrolyte abn (esp. Na/Ca)
  • No evidence this prolongs dying
  • Relieves family/cultural anxiety
174
Q

What are contraindications to parenteral fluids in PC?

A
  1. Short days/hours of life
  2. Excessive peripheral edema
  3. Excessive terminal secretions
  4. Accumulation of ascites/effusions
  5. Pulmonary edema
  6. Request of patient/SDM to stop
175
Q

What are indications for parenteral
fluids in palliative care?

A

These assume patient is conscious and prognosis likely >days

  • Symptomatic hyperNa+ or hyperCa++
  • Delirium expected to respond
  • Strong patient/SDM preference despite education around limitations
  • Time-limited trial
176
Q

Describe a serum-Na approach to beginning parenteral fluids

A

Fluid deficit can be divided into:

  • Dehydration (always hyperNa)
  • Volume deficit (any Na state)

Treat dehydration w. fluids
Treat volume deficit according to cause

177
Q

What is a usual volume of fluid daily
required by a terminal patient?

A

700-1000mL

178
Q

What are the advantages of IVF?

A
  • Rapid onset
  • High volumes
  • High bioavailability
  • Allows IV-only drugs
179
Q

What are the disadvantages of IVF?

A
  1. Venous access issues
  2. Limits patient mobility
  3. Frequent site changes
  4. Higher infection risk
  5. Higher cost
  6. Requires trained personnel
  7. Ties patient to medical location
180
Q

What are the advantages of HDC?

A
  • Easy tissue access
  • Catheter can remain up to 7 days
  • Minimal training required
  • Lower bleeding/infection risk
  • Patient can remain mobile
  • Cheaper
181
Q

What are the disadvantages of HDC?

A

Sites can get irritated
More work than no fluids

(BUT generally superior to IVF in PC)

182
Q

What equipment is best for HDC?

A

Teflon > steel catheters
Insert at 45* angle to skin, then tape
Pump or gravity infusion

183
Q
A

Adam's Weak Spots (8 decks)

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