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Flashcards in Palliative care Deck (26):
1

method of opioid administration in palliative care?

Start low and titrate up with regular dose of immediate release and PRN, switching to modified release when pain is controlled.

2

S/Es of opioids in palliative care?

• N&V - self limiting but metoclopramide/haloperidol useful for anti-emesis
• Itch - doesn’t respond to anti-histamines as it is CNS
• Constipation - prophylactic laxatives used
• Drowsiness - usually self-limiting and for first few days otherwise reduce dose

3

Opioid toxicity symptoms?

- Myoclonic jerks
- Agitation
- Visual hallucinations
- Confusion
- Pinpoint pupils
- Respiratory depression

4

Management of opioid toxicity?

• Dose reduction
• Switching opioids
• Opioid antagonist – naloxone

5

What opioids are safer for sue in renal failure?

Oxycodone and fentanyl

6

Symptoms of malignant hypercalcaemia?

Mild:

• N&V
• Anorexia
• Constipation
• Thirst and polyuria

Severe:

• Gross dehydration
• Drowsiness
• Confusion & coma
• Abnormal neurology
• Arrhythmias

7

Management of malignant hypercalcaemia?

1) Rehydrate with IV 0.9% saline
2) After at least 2L, give bisphosphonate infusion
3) Measure U&Es every day, correcting with IV fluids (Ca normalisation takes 3-5 days)

8

Options for antiemetics in palliative care?

Haloperidol

Cyclizine

Levopromazine

Metaclopramide

9

Mechanism of action of Haloperidol, and uses?

Dopamine antagonist - acts at the CTZ

Best used for chemical causes, e.g. drugs, renal failure, hypercalcaemia

10

Mechanism of action of Cyclizine, and uses?

Antihistamine and anticholinergic with acts at the vomiting centre

Used in complete bowel obstruction, raised ICP, motion sickness

11

Mechanism of action of Metaclopramide, and uses?

Peripheral DA antagonist and 5HT4 agonist, and a central 5HT3 antagonist

Helps to control acid reflux (prokinetic)

12

Mechanism of Levopromazine, and uses

Acts at multiple receptors

- many S/Es, broad spectrum

13

Causes of bowel obstruction in palliative care patient?

Extrinsic compression e.g primary tumour, omental masses, malignant adhesions, fibrosis

Intraluminal occlusion from tumour

Motility disorders (tumour infiltrating muscle)

14

Management of complete bowel obstruction in the palliative care patient?

- Pain control
- Improve motility (laxatives, maybe steroids or prokinetics)
- Anti-emetics
- Reduce colic if present
- Reduce gastric secretions (anticholinergic/somatostatin analogue)
- NG tube (often last resort in palliation)

15

Antispasmodic antisecretory agents?

Hyoscine butylbromide (Buscopan) – Ach antagonist

Octreotide = somatostatin analogue

16

Palliative surgical procedures for bowel obstruction?

- Venting gastrostomy (tube from stomach to outside of abdomen)
- Duodenal/rectal stent
- Surgical palliative bypass

17

When might you use continuous subcutaneous infusions in palliative care?

• Intractable vomiting (treatment resistant)
• Severe dysphagia
• Poor GI absorption
• Too weak to swallow oral medications

18

Metastases that can compress the spinal cord?

- Lung
- Breast
- Prostate
- Kidney
- Melanoma
- Multiple myeloma
- Lymphoma

19

Regions of the spinal cord that can be compressed?

- Cervical (breast)
- Thoracic (lung, breast, prostate)
- Lumbosacral (GI, prostate)
- Below L1/L2 = cauda equina syndrome

20

Signs and Symptoms of spinal cord compression?

Symptoms:

• Back pain (often band-like)
• Tingling and numbness – often starts in feet and goes
• Myelopathy – rapid onset
• Bladder/bowel symptoms are typically late and so indicate poor prognosis


Signs:

- Sensory change (possibly with a level)
- Hypo/hyperreflexia
- Weakness
- Perianal sensory changes/loss of sphincter tone

21

Management of spinal cord compression?

• High dose dexamethasone (2 separate 16mg doses)
• Radiotherapy and/or surgery
• MDR approach to rehab

22

Management of neuropathic pain?

- TCAs e.g. amitriptyline
- Anticonvulsants e.g. gabapentin
- Steroids e.g. dexamethasone

23

What is total pain, what aspects make up total pain?

All the pain a patient may be experiencing, including:

Physical pain
Social pain
Pyschological pain
Spiritual pain

24

Common causes of vomiting?

Mouth and pharynx - Taste, secretions, candida

GI - stasis, obstruction, gastritis, constipation

Drugs

Metabolic e.g. hypercalcaemia

Toxic, infection

Raised ICP

Balance

Anxiety/fear

25

Compression below the level of L1/2 is called what?

Cauda equina syndrome

26

Most common level of spinal cord compression?

Thoracic