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Palliative Care Flashcards

1
Q

how many patients with any type of cancer get nausea and/or vomiting

A

70%

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2
Q

what is nausea

A

unpleasant feeling of the need to be sick, often with autonomic features (hot, skin stands on ends, sweaty, salivation)

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3
Q

what extra questions should you ask in a history of nausea and vomiting

A

triggers, volume, pattern
exacerbating and relieving factors, including individual and combinations of drugs tried and routes used
bowel habit
medication – consider drugs that may:
contribute to the nausea and vomiting
cause harm
not take effect due to the nausea and vomiting
exclude regurgitation as this will require a different approach. If suspected consider seeking advice
check for other concurrent symptoms.

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4
Q

what should you look for on exam in a patient with nausea and vomiting

A

general review for signs of dehydration, sepsis and drug toxicity
central nervous system
abdomen (for example organomegaly, bowel sounds, succussion splash)
check temperature, pulse and respiration

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5
Q

what causes of N&V affect the cerebral cortex

A

emotions, sight, smell, raised ICP, anxiety

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6
Q

what part of brain controls vomiting

A

vomiting center

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7
Q

what receptors for N&V are in the cerebral cortex and what anti emetic drugs target them

A

GABA, NK1, 5HT

Dexamethasone, Aprepitant, Benzodiazepines

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8
Q

what receptors for N&V are in the vestibular centre and what anti emetic drugs target them

A

H1, ACh

Cyclizine, Levomepromazine, Hyoscine

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9
Q

what stimulus affects the vestibular centre causing N&V

A

motion

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10
Q

what receptors for N&V are in the chemoreceptor trigger zone and what anti emetic drugs target them

A

D2, 5HT, Ach

Haloperidol, Levomepromazine, Ondansetron

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11
Q

what things can trigger the chemoreceptor trigger zone causing N&V

A

metabolic (uraemia, Ca), drugs

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12
Q

what receptors for N&V are in the GI tract and what anti emetic drugs target them

A

5HT, D2, Ach

Metoclopramide, Levomepromazine, Ondansetron, Dexamethasone
(Caution in obstruction- prokinetic drugs can cause perforation)

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13
Q

what can trigger the receptors in the GI tract causing N&V

A

GI distension, stasis, tumour mass, constipation, XRT

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14
Q

how does cerebral disease cause N&V and how does it present

A

Compression / irritation by tumour, raised ICP, anxiety

Clinical picture:
Worse in morning
Associated headache

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15
Q

how does N&V caused by oncological (chemo/radio) treatments present

A

Predictable from history

Often nausea is the main complaint

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16
Q

what can cause impaired gastric emptying

A

Locally advanced cancer, drugs, radiotherapy damage to gut, autonomic neuropathy

17
Q

what is the clinical picture of N&V caused by impaired gastric emptying

A

Not usually nauseated
very nauseated after eating
Large volume vomits
Feels better after being sick

18
Q

what can cause chemical/ metabolic N&V

A

Medication, advanced cancer, sepsis, kidney or liver impairment, biochemical

Think: Calcium, Sodium, Magnesium, Urea

19
Q

what is the chemical picture of N&V caused by chemical/ metabolic

A

persistent nausea

little relief from vomiting

20
Q

what is the non pharmacological management of N&V

A

Regular mouth care
Keep bowels moving to avoid constipation contributing
Encouraging small meals, rather than large meals
Avoid cooking or preparing food
A calm and reassuring environment
Acupressure bands (for example Seaband®)
Acupuncture
Psychological approaches

21
Q

what is anticipatory nausea

A

when being anxious about being sick makes you feel/ be sick

22
Q

what is seen on X ray in small bowel obstruction

A

vulvulae coniventes

23
Q

what is malignant bowel obstruction

A

bowel obstruction in the context of intra-abdominal cancer/ non intra-abdo cancer with clear intraperitoneal disease

Obstruction may still be due to benign causes in advanced cancer
Eg; Adhesions, post-radiotherapy (up to 50% in colorectal ca)
Also constipation may contributory factor

24
Q

what are the causes of malignant bowel obstruction

A

mechanical:
-intraluminal
-intramural
-extra mural extrinsic compression
(Omental deposits, peritoneal deposits, nodal deposits)

adynamic ileus:
-tumour infiltration of mesentery, muscle or nerves

25
Q

what is the difference between complete and partial (subacute) bowel obstruction

A

Complete- nothing can get past, completely occluded

Partial- some passage through bowel but bowel not working properly so have majority of symptoms of complete

26
Q

what cycle occurs in bowel obstruction

A

secretion- distention- secretion:

Proximal accumulation of secretions
Distension of gut
Further secretions
Reduced absorption of water and sodium
Inflammatory response - gut wall oedema
Increased motor activity
Increased intra-luminal pressure – hypoxia, gangrene and perforation
27
Q

what causes colic pain in obstruction

A

increased peristalsis of bowel

28
Q

what is the clinical presentation of bowel obstruction

A 
Nausea
Vomiting
Pain
Continuous or Colicy		
Anorexia/thirst
Systemic symptoms from underlying cancer
Reduced then absent bowel motions/flatus
Paradoxical diarrhoea 		
Gradual onset over weeks
29
Q

what is the surgical management for bowel obstruction

A

‘Drip and suck’ before surgery (NG tube brings up all of fluid and given IV fluids)
Bowel rest
NBM (nil by mouth)
Not comfortable, tube is very large

Surgical treatment
Resection
Palliative colostomy or ileostomy
Self expanding metallic stent

when palliative consider QOL

30
Q

what is the medical management for bowel obstruction

A

If partial obstruction promote resolution: antiemetic and prokinetic agents= metoclopramide
Laxatives - Docusate or movicol to soften stool in partial obstruction

Relieve pain and colic:
Opioids (will cause constipation)
Hyoscine butylbromide for colicky pain (will slow down the bowel)

Reduce vomiting to acceptable level for patient without use of NG tube:
Metoclopramide 30mg / 24 hours if not contra-indicated and partial/subacute obstruction

Relieve nausea

Relieve thirst
Fluids (will loose lots of GI fluids, not drinking as much)

Steroids (to reduce inflammation, especially If you have nodal disease)
Dexamethasone – 8-16mg / 24hours

Anti-secretory agents
Buscopan (Hyoscine butylbromide) – slows bowel down
Octreotide - 300-900 mcg/24 hours in CSCI (somatostatin analogue, potent secretion reducer)

31
Q

is metoclopromide an antiemetic or an prokinetic

A

both

32
Q

should you give metoclopramide if a patient already has colic pain

A

no- risk perforation

33
Q

should patient who are vomiting be given oral medications

A

no

will not be absorbed

34
Q

what is a common reversible cause of bowel obstruction

A

constipation

35
Q

how do you pick which antiemetic to use

A

use history and exam to find cause of nausea and vomiting- pick drug that will target to right receptor

Reproduction (51 decks)

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