Palliative care + Pain + LA😖 Flashcards
(18 cards)
Definition of Palliative care
Definition:
Palliative care is active total care of patients and their family whose disease is not responsive to curative treatment.
It encompasses all treatment modalities with the aims:
- improve quality of life
- Controlling cancer related symptoms can ameliorate the pt’s limited remaining time with family and friends
Modalities of palliative care
MDT: involves palliative physician, surgeon, oncologist, nutritionist, psychologist, anaesthetist, nurses.
Consists of:
1) Education and psychological support
2) Spiritual support
3) Pain control
4) Palliative Surgical Procedure
5) Nutrition
6) Hygiene
7) other symptoms control
Education and Psychological support
- To patient and family members about the disease, course of disease and its prognosis
- Explain on mode of treatment available towards palliation
- Patient’s status requiring emotional support from family members. Avoid depression.
- Group support with regular home visits
Pain control
Various methods according to aetiology
- Analgesia according to WHO ladder
- Choice: Opiates, NSAID, Steroid, tricyclic antidepressant for neuropathic pain, local anaesthesia
Pelvic radiation for sacral pain in advanced rectal disease – lumbosacral nerve plexus tumour infiltration
Palliative surgical procedure
- in the context of non-curable illness to relieve symptoms and thus to improve quality of life may or may not prolonged life
- Common indications for palliative procedures – surgery/interventional procedure:
- Drainage of effusion
- Relief of obstruction
- Palliative tumour resection
- Fixation for bony metastases
- Control of bleeding
- Relieve spinal stenosis
- Relieve airway obstruction
Drainage of effusion:
Ascites, pleura, pericardium
Tapping of the fluid, placement of in-dwelling catheters or open surgery
Surgery: paracentesis, peritoneo-venous shunt
Relief of obstruction:
Colorectal, Urology, Vascular, Bronchus, Hepatobiliary
Palliative stenting in:
- Colonic stenting endoscopically in advanced colon cancer cancer
- Ureteric stent endoscopically in advanced bladder tumour
- Vascular stenting under interventional radiology for arterial stenotic in unfit patient for bypass
- Biliary stenting via ERCP for advanced periampullary carcinoma
Stoma creation in obstructing colorectal carcinoma
Palliative tumour resection:
Goal is primary tumour control for symptoms even in the presence of metastases
Eg: palliative mastectomy, gastrectomy in obstructed/bleeding/perforation gastric carcinoma
Control bleeding:
Control bleeding via various method.
- Endoscopic – APC, heater probe, clip, injection
- Radiological – angioembolization
- Systemic – vitamin K, vasopressin, somatostatin analogue, anti-fibrinolytic agent (Tranexamic acid)
- Surgery – palliative gastrectomy, colectomy, etc.
Palliative chemoradiation
- Pelvic radiation for bleeding advanced bladder tumour/rectal bleeding in rectal tumour or radiation proctitis
Nutrition
- Well balanced diet. Need high protein calorie to prevent protein energy malnutrition in catabolic state like in advanced tumour
- Oral nutrition supplement can be given
Hygiene
- Dry mouth (xerostomia) and oral candida infections are common. Candida causes loss of taste, dysphagia and soreness.
- If candida white spots are visible on the oral mucosae, treat with topical nystatin or a course of fluconazole; dentures (which harbour candida) need meticulous cleaning.
- supportive measures can help, for example: sucking ice chips, chewing gum, artificial saliva spray, frequent sips of fluid, mouth swabs.
- Other personal hygiene
Other symptoms Control
- Constipation: require stool softener
- Diarrhea: maintain hydration, treat accordingly if it is a/w clostridium difficile
- Nausea, vomiting: require antiemetic
- Anaemia: supplemented with haematinics or transfusion if severe anaemia
Differences between Palliative care and Hospice
Hospice care: Hospice care is a form of palliative care provided to patients in the final stages of a terminal illness, focusing on comfort and quality of life rather than curative treatments.
📌 Summary:
* Palliative Care: Broader, offered by hospitals (govt + private), early in illness
* Hospice Care: Focus on last 6 months, mainly home-based, run by NGOs, free/donation-supported
Definition of pain
PAIN
Definition: unpleasant sensory and/or emotional experience associated with actual/potential tissue damage
Principle of post opt pain management
Principles of post-op pain management:
* Pre-op:
pre-emptive analgesia; NSAIDs or nerve block
* Intra-op
use of opioids analgesia
* regional nerve block wound infiltration with LA
* Post-op
* pharmacological therapy regional anaesthetic blocks alternative methods
How can post-op pain be assessed?
- subjectively
- objectively (verbal numerical scale or visual analogue scale)
What is the pain-relief ladder?
- a stepwise approach to control pain (WHO) where additional drugs are introduced until pain is fully controlled
- the first step of analgesic ladder → non-opioid drugs; PCM / NSAIDs
- if not sufficient → weak opioid; codeine & tramadol
- final step of the ladder involves the use of strong opioid drugs; ramorph or morphine
- at each steps, the use of adjuvants (eg anxiolysis) should be considered
- if complete analgesia not achieved with regular administration of drug at one level, then the pt should move up one level
What other drugs are used in conjunction with the analgesic ladder?
- anxiolytics (diazepam)
- anti-emetics (cyclizine & ondansetron) to ease nausea & vomiting, esply with opioid drugs
- gabapentin & amitriptyline - for neuropathic pain
- steroids (dexamethasone & prednisolone) to improve efficacy of analgesia, esply for the terminally ill pt
What are the systemic effects of post-operative pain?
CVS
* enhanced myocardial 02 demand
* myocardial ischaemia
* increase symp stimulation → increase CO → decreased in renal & splanchnic perfusion
Respiratory
* decrease cough reflex → sputum retention - chest infection
* ° atelectasts →hypoxia
GIT
* decreased Gl motility → constipation
* ileus
Genitourinary: urinary retention
metabolic; hyperglycaemia / hypernatraemia
psychological; stress / depression
general; longerhospital in-stay
What is PCA & how does it work?
- allows the pt to administer IV analgesia when needed & avoids waiting for the nurses to give medication
- Patient is given an initial loading dose → minimum dose needed for analgesia consistently without producing SEs (usually 1mg for morphine)
- there is lockout interval when the pump will not administer a further dose, to prevent overdosing (usually 5 mins)
Advantages:
- frees the nurses for other ward work
- empowers pts to have control over their pain & helps to alleviate anxiety, which in turn decrease pain experience
- immediate & effective
- no injection required; so no pain from the actual injection itself
Disadvantages:
* button can be accidentally pressed, delivering an unneeded dose of the medication
* incorrect setup of loading dose & lock-out can lead to inadequate pain-relief or overdose
What are alternative methods of pain relief?
- good pt education
- relaxation technique
- acupuncture
- trans-cutaneous electrical nerve stimulation (TENS)
Overview of Local analgesia (LA)
Therapeutic index : Toxic Dose at 50% of population divide by Effective Dose at 50% population ( the higher the TI, the safer the drug)
