Flashcards in Oncology - Palliative care Deck (25):
How should hiccups be managed in a palliative care setting?
Chlorpromazine is licensed for the management of hiccups in palliation.
Haloperidol and gabapentin are also used.
Dexamethasone is used particularly if there are hepatic lesions.
How is agitation and confusion in end of life care managed?
Underlying causes of confusion and agitation should be looked for and treated as appropriate - e.g. hypercalcaemia, infection, urinary retention, and medication. If specific treatments fail then the following can be applied:
- first line: haloperidol
- other options: chlorpromazine, levomepromazine
In the terminal phases of illness, agitation or restlessness is best treated with midazolam.
How should opiates be started for palliative patients?
NICE recommend that patients with advanced or terminal diseases should be offered regular oral modified release (MR) or oral immediate release morphine depending on patient choice, with oral immediate release morphine for breakthrough pain.
If there are no co-morbidities, use 20-30mg of MR a day with 5mg for breakthrough pain. For example, 15 mg modified release morphine BD with 5 mg breakthrough oral morphine solution PRN.
What else should patients receiving opioids be prescribed?
Laxatives should be prescribed alongside opiates. Patients should be advised that drowsiness with morphine is often transient, but if this persists then an antiemetic should be offered.
What do the SIGN guidelines recommend about breakthrough pain?
The breakthrough dose of morphine should be one sixth of the daily dose of morphine. All patients receiving morphine should be prescribed laxatives.
What alternatives can be used for opioid based pain relief in patients with kidney disease?
Morphine should be used with caution in patients with CKD. Alfentanyl, buprenorphine, and fentanyl are preferred.
How should opiate doses be increased in the palliative setting?
When increasing the dose of opiates, the next dose should be increased by 30-50%.
Transient side effects of opiates are nausea and drowsiness. Constipation is usually a persistent side effect.
How do you convert oral codeine to oral morphine?
A useful hint: to convert either oral codeine or oral tramadol to oral moprhine divide the dose in each case by 10.
How do you convert oral morphine to oral oxycodone?
Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation. To convert oral morphine to oral oxycodone divide the dose of morphine by 1.5-2 because oral oxycodone is roughly twice as strong as oral morphine.
Patients generally require lower doses of subcutaneous opioides compared to oral doses. How do you convert oral morphine to a subcutaneous dose?
Oral morphine to subcutaneous morphine, divide by 2.
Oral morphine to subcutaneous diamorphine, divide by 3.
Oral oxycodone to subcutaneous diamorphine, divide by 1.5
When should a palliative patient be considered for a syringe driver?
Syringe drivers allow continuous subcutaneous injection of medication. They should be considered in palliative care when the patient is unable to take oral medication due to nausea, vomiting, dysphagia, intestinal obstruction, weakness or coma. In the UK there are two main types of syringe drivers:
- Graseby (blue) - gives infusion rate in mm per hour
- Graseby (green) - gives infusion rate in mm per 24 hour
Which drugs are best delivered in syringe drivers using 0.9% sodium chloride rather than water for injection?
What agents are best used to reduce respiratory secretions and bowel colic in the palliative setting?
Respiratory secretions: hyoscine hydRobromide
Bowel colic: hyoscine Butylbromide
There doses are also VERY different!
What compatibility issues can there be with using syringe drivers?
Some drugs are incompatible when mixed together for continuous sub cut infusion. Diamorphine (the preferred opiate of choice for pain relief can be mixed with most drugs). Cyclizine (an anti-emetic) CANNOT be mixed with some drugs. These include:
What are the causes of nausea and vomiting in palliative patients?
Causes include chemotherapy, constipation, GI obstruction, drugs, severe pain, cough, oral thrush, infection and uraemia. Management should aim to treat reversible causes, e.g. with laxatives, fluconazole, analgesia or antibiotics. Consider the likely cause and base anti-emetic choice on mechanism of nausea and site of drug action. Give drugs orally if possible.
What receptor types do anti-emetic agents target?
This is a simple way of recalling anti-emetics and their mechanism of action:
- histamine (H1)
What anti-emetics target histamine (H1) receptors and when should they be used?
Cyclizine and cinnarizine target H1 receptors.
Cyclizine is useful for GI causes of nausea and can be given PO/ IV/ IM.
Cinnarizine is useful for vestibular causes and can only be given orally.
What anti-emetics target dopamine D2 receptors and when should they be used?
Metoclopramide - GI causes, also prokinetic
Domperidone - also prokinetic
Prochlorperazine - vestibular/ GI causes
Haloperidol - chemical causes (e.g. opioids)
Domperidone has a peripheral anti-dopaminergic effect so causes no acute dystonic side effects. Metoclopramide blocks central CTZ.
What is the only anti-emetic that acts on 5-HT3 receptors?
Ondansetron. This can be given by slow IV infusion or PO but it is very useful for chemotherapy induced nausea.
What should hyoscine hydrobromide not be prescribed alongside?
Hyoscine hydrobromide is antimuscarinic and therefore is anti-spasmodic and antisecretory so should not be prescribed with a prokinetic agent.
How is constipation managed in the palliative setting?
Constipation is a very common SE with opiates and is better prevented that treated. It may also be due to raised calcium or dehydration. Use bisacodyl at night or combine a simulant with a softener (e.g. co-danthramer). Macrogols are useful in resistance. Try glyercol suppositories or an enema if oral therapy fails.
What is the WHO analgesic ladder?
This is a stepwise approach to pain relief.
Rung 1 = non opioid, e.g. paracetamol, NSAIDs
Rung 2 = weak opioid, e.g. tramadol, codeine, dihydrocodeine
Rung 3 = strong opioid, e.g. morphine, diamorphine, oxycodone, fentayl, buprenorphine (+/- adjuvant analgesics)
What are the most common tumours causing boney metastasis?
What is the most common site for bone metastasis?
5) Long bones