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YR6 Rotations > Medicine - Palliative > Flashcards

Medicine - Palliative Flashcards

1
Q

What drug can be used to relieve bowel colic in palliative care?

A

Hyoscine butylbromide (anti-muscarinic)

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2
Q

List 4 potential causes of confusion in palliative patients

A

Hypercalcaemia
Infection
Urinary retention
Medication

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3
Q

What is the drug of choice for agitation in palliative care vs for terminal restlessness?

A

Agitation: Haloperidol (2nd line chlorpromazine)

Terminal restlessness: Midazolam

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4
Q

What is the first line for treating hiccups in palliative care? What else can be used?

A

Chlorpromazine
(Haloperidol, Gabapentin, Dexamethasone)

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5
Q

List 6 syndromes causing nausea and vomiting in palliative patients

A

Reduced gastric motility
Chemically mediated
Visceral/ serosal
Raised ICP
Vestibular
Cortical

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6
Q

Which are the 2 most common syndromes causing nausea and vomiting in palliative care?

A

Gastric stasis
Chemical disturbance

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7
Q

Give a potential cause of reduced gastric motility in palliative care

A

May be OPIOID related
Related to serotonin (5HT4) + dopamine (D2) receptors

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8
Q

Give 3 chemically mediated causes of nausea and vomiting

A

Hypercalcaemia
Opioids
Chemotherapy

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9
Q

Give 2 visceral/ serosal causes of nausea and vomiting

A

Constipation
Oral candidiasis

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10
Q

What is a cause of nausea and vomiting in a palliative patient in the context of cerebral mets?

A

Raised ICP

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11
Q

Describe the vestibular syndrome cause of nausea and vomiting

A

Related to activation of ACh + Histamine (H1) receptors
Most freq in palliative care is opioid related
Can be motion related/ due to base of skull tumours

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12
Q

Describe the cortical syndrome causing nausea and vomiting in palliative care

A

May be due to anxiety, pain, fear +/or anticipatory nausea
Related to GABA + histamine (H1) receptors in the cerebral cortex

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13
Q

What is the antiemetic of choice in palliative care for for nausea and vomiting that is due to gastric dysmotility and stasis?

A

Metoclopramide (dopamine D2 antagonist, pro-kinetic)
(Domperidone)

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14
Q

When should metoclopramide NOT be used?

A

When pro-kineses may negatively affect the GI tract e.g. complete bowel obstruction, GI perforation or immediately following gastric surgery

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15
Q

What is the anti-emetic of choice for patients with chemically mediated nausea?

A

If possible correct chemical disturbance 1st
Ondansetron
(Haloperidol, Levomepromazine)

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16
Q

What is the antiemetic of choice in palliative care for nausea and vomiting due to visceral/ serosal causes?

A

Cyclizine/ Levomepromazine

(anti-cholinergics such as Hycosine can be useful)

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17
Q

What is the antiemetic of choice in palliative care for nausea and vomiting due to raised ICP?

A

Cyclizine
(Dexamethasone)
(Radiotherapy if due to cranial tumours)

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18
Q

What is the antiemetic of choice in palliative care for nausea and vomiting due to vestibular disturbance?

A

Cyclizine
If refractory: Metoclopramide/ Prochlorperazine or atypical anti-psychotics e.g. Olanzapine

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19
Q

What is the antiemetic of choice in palliative care for anticipatory nausea? (cortical)

A

Lorazepam (short acting benzo)
If not ideal: Cyclizine

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20
Q

Which route should be used for administration of anti-emetics?

A

Oral if possible
If not; IV

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21
Q

Give 3 situations in which administration of oral anti-emetics may not be possible

A

Vomiting
Issues with malabsorption
Severe gastric stasis

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22
Q

What is the usual dose of cyclizine in palliative care?

A

50mg 8-hourly

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23
Q

In what patients is it inappropriate to prescribe cyclizine and why?

A

Cardiac cases
Can worsen fluid retention

24
Q

Recall 2 patient groups in which metoclopramide should be avoided

A 
Parkinson's disease 
Young women (risk of dyskinesia)
25
Q

What is the anti-emetic of choice in Parkinson’s?

A

Domperidone

26
Q

What is the starting dose of morphine in palliative care?

A

15mg morphine MR PO BD
5mg oromorph IR PO PRN
Can start with IR + when pain controlled –> MR

27
Q

Give 3 side effects of MR morphine

A

Nausea (most common): Usually transient, offer anti-emetic if persists
Drowsiness: usually transient, dose adjust if persists
Constipation: usually persistent

28
Q

What should be prescribed to all patients initiating strong opioids?

A

Laxatives

29
Q

How much should a breakthrough dose of morphine be?

A

1/6th of total morphine
(inc. breakthrough doses)

30
Q

What opioid is best to use for palliative patients with a GFR of 30-60? (mild-moderate renal impairment)

A

Oxycodone

31
Q

What opioids are best to use for palliative patients with a GFR of <30? (severe renal impairment)

A

Alfentanil
Buprenorphine
Fentanyl

32
Q

Recall 3 ways in which bony met pain can be managed

A

Analgesia
Bisphosphonates
Radiotherapy

33
Q

How should opioid doses be increased?

A

Increase by 30-50%

34
Q

In addition to strong opioids, bisphosphonates and radiotherapy, what can be used for metastatic bone pain?

A

Denosumab

35
Q

100mg codeine is equivalent of how many mg of morphine?

A

10mg
Codeine to Morphine: Divide by 10

36
Q

Oral tramadol to oral morphine

A

Divide by 10

37
Q

How do the side effects of oxycodone differ to morphine?

A

Oxycodone: less sedation, vomiting + pruritis than morphine but more constipation.

38
Q

Oral morphine to oral oxycodone

A

Divide by 1.5-2

39
Q

What does a transdermal fentanyl 12 microgram patch equate to in oral morphine?

A

30mg oral morphine daily

40
Q

What is the equivalent of 30mg IR morphine in a MR formulation?

A

15mg
prescribe half when doing MR

41
Q

Oral morphine to SC morphine

A

Divide by 2

42
Q

Oral morphine to SC diamorphine

A

Divide by 3

43
Q

Oral oxycodone to SC diamorphine

A

Divide by 1.5

44
Q

Describe conservative management of secretions in palliative care

A

Avoiding fluid overload: particularly stopping IV or SC fluids
Educating family that patient is likely not troubled by secretions

45
Q

Recall the 1st and 2nd line drugs used for secretions in palliative care

A
  1. Hyoscine hydrobromide/ Hycosine butylbromide
  2. Glycopyrronium bromide
46
Q

Which drug for managing secretions is less sedating? Why is this?

A

Hycosine butylbromide
Does not cross BBB thus less likely to cause CNS SE
(Neither does Glycopyrronium bromide)

47
Q

When is a syringe driver considered in palliative care?

A

When unable to take oral medication due to nausea, dysphagia, intestinal obstruction, weakness or coma

48
Q

What are the 2 types of syringe driver in the UK?

A

Graseby MS16A (blue): delivery rate is given in mm per hour
Graseby MS26 (green): delivery rate is given in mm per 24h

49
Q

What is the most common side effect of cyclophosphamide?

A

Haemorrhagic cystitis

50
Q

What are the toxicities of cisplatin?

A

Ototoxic, nephrotoxic, hypomagnasaemia

51
Q

Which chemotherapy agent is associated with SIADH?

A

Cyclophosphamide

52
Q

In a patient with cord compression due to spinal mets who is too frail for surgery, what is the treatment of choice?

A

External beam radiotherapy

53
Q

What is the treatment of choice for headaches caused by raised ICP due to brain cancer/ mets? How does this work?

A

Dexamethasone
Reduces surrounding oedema + thus reduces the pressure burden.

54
Q

What is the drug of choice in palliative care for reducing discomfort of a painful mouth?

A

Benzydamine hydrochloride mouthwash

55
Q

What is mucositis? Give a risk factor for development

A

inflammation of oral mucosa often accompanied by painful ulcerations
RF: radiation to head + neck

56
Q

List 3 risk factors for nausea and vomiting due to chemotherapy

A

Anxiety
Age <50y
Concurrent use of opioids

57
Q

Which drugs should be used to prevent nausea in patients undergoing chemotherapy?

A

Low risk: Metoclopramide

High-risk: Ondansetron (5HT3 receptor antagonist) + Dexamethasone

YR6 Rotations (22 decks)

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