Palliative medicine Flashcards by John Darlington

What is meant by titration in pain medicine?

When a patient uses more frequent “as required” doses on top of their daily dose, the following day the “as required” is added onto their daily dose.

this keeps occurring until the symptoms settle and a balance is met

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What are some signs of opioid toxicity?

Confusion 
Drowsiness 
myoclonus 
nightmares 
hallucination

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What drugs can be used for N&V in patients?

Start with things such as metoclopramide *avoid in bowel obstruction due to the promotility effects

Ondansetron - 5HT3 antagonist can be used for severe

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What is the conversion from oral codeine to oral morphine?

divide by 10

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What is the conversion from oral morphine to subcut morphine?

Divide by 2

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What is a useful mechanism to aid shortness of breath in a terminally ill patient?

Hand fan over the patient

- due to temperature change of air stimulates reflexes to slow breathing

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What is an effective tool that can be used to aid the treatment received in hospice into a hospital setting?

Liverpool care pathway

- 4 step approach

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What are some common symptoms of palliative care?

Dry mouth

Excessive Respirations

Restlessness

Nausea and vomiting

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What drugs can be used for excessive respiratory secretions?

Hyoscine butylbromide

Glycopyrronium bromide

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What drugs are used for nausea in palliative medicine??

Metoclopramide

Haloperidol

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What drugs can be used for intractable hiccups?

Chlorpromazine
or
Haloperidol

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What medication can be used for bowel obstruction pain?

Hyoscine Butylbromide

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What can be used for respiratory secretions?

Hyoscine hydrobromide

**remember secretions with “hydro”

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What dose should be given when changing from oral morphine to SC diamorphine?

divide by 3

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Which drugs are ideal to use in severe kidney disease for pain relief?

Fentanyl

Alfentanil

Buprenorphine

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If you are switching someone from oral codeine to oral morphine, what dose should you give?

Divide by 10

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What does metastatic bone pain respond too?

Analgesia
Bisphosphonates
Radiotherapy

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Confusion in a palliative patient, what is the management?

Look for reversible causes:

hypercalcaemia
infection
urinary retention

1st line: Haloperidol
2nd line: Chlorpromazine

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Which drug is good for increased ICP pain?

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Dexamethasone

Between morphine and oxycodone, which is safer to prescribe in renal failure?

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Oxycodone

preferred over morphine in CKD

What is the treatment for constipation?

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Hydration
Ensure privacy access to toilet

Senna - stimulant

Macrogol - osmotic

Phosphate enemas
glycerol suppositories

How is breathlessness managed?

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Remove causes

infection
effusion
arrhythmias etc

Low dose opioids for distress
+/-
Benzodiazepine for stress

What are some approaches to dealing with a patients spiritual pain?

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Remember the whole person when treating them

Provide companionship

palliative teams
Macmillan nurses
Chaplains

Remember spiritual pain can be exacerbated by physical pain
- look to sort these first

What are some core features of the final days towards death?

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Bed bound

Semi - comatose

Unable to take tablets

Only able to take small sips of water

When a patient is entering the dying days, how should your general management change?

Focus treatment on symptom control Stop carrying out daily investigations Only treat reversible problems as appropriate towards symptoms - urinary retention Rationalise medications

What specific things are done as a person enters their last days of life?

Prescribe PRN end of life drugs Start a syringe driver Manage Agitation - diazepams Manage secretions - reposition - suction - hyoscine hydrobromide Hydration Plan for death - DNACPR - Die at home? - arrange with district nurses Respond to changes in clinical situation Communicate

Which types of drugs can be put through a syringe driver?

Pain - Morphine Anxiety/ Agitation/ Delirium - Midazolam - Haloperidol N&V - Cyclizine - Haloperidol - Levomepromazine Respiratory secretions - Hyoscine Hydrobromide - Glycopyrronium Seizures - Midazolam

What are the red flags for back pain?

``` <20 years old, >55 years old Weight loss / Fever Taking steroids History of malignancy Disturbance of continence Saddle anaesthesia Thoracic spine tenderness Night pain ```

Name some oncological emergencies:

Neutropenic sepsis Spinal cord compression Tumour lysis syndrome Malignancy associated hypercalcemia Superior Vena cava syndrome Raised ICP

What are some side effects of opioids:

``` N&V Constipation Drowsiness/ sedation Dry Mouth Hypotension - vasodilatory properties Respiratory depression ```

In renal failure, what is the danger of using morphine?

Build up of toxic metabolites, especially: - M6G - M3G M6G is the active form and will lead to the overdose. usually first seen with myoclonus.

Symptoms of hypercalcemia?

``` Tiredness Confusion Depression Anorexia Polydipsia Polyuria Constipation +/- Bone pain +/- Renal pain ```

What is the calculation of oral morphine to subcut?

divide by 2

What is the calculation of oral morphine to diamorphine | subcut?

Divide by 3

What is the calculation of oral codeine to oral morphine?

Divide by 10

In a cancer patient, list several causes of symptoms of nausea:

Drugs: - morphine, chemotherapy ICP - metastasis to brain Pain - induces feeling of nausea Metabolic changes - hypercalcemia Gastric: - stasis - obstruction

What is the calculation for working out the daily dose of modified release opioid?

Calculate the total daily dose + PRN. the Following day the PRN should be added to the previous dose. Divide into two 12 hour Modified release MST

What should the dose of PRN be?

1/6 of the total daily dose

What should be prescribed along with opioids?

Laxative Antiemetic

What are some of the complications with a PICC line/ Hickmann Line?

Infection Thrombosis Electrolyte imbalances Osmotic changes Vitamin deficiencies Refeeding syndrome

What are the types of pain experienced by people?

Biological Social Psychological Spiritual

What drugs can be given for itch?

Hepatic: Cholestyramine Uraemia: Gabapentin Unknown: Chlorpheniramine

What drugs should be avoided in end stage liver disease:

NSAIDs Codeine Dihydrocodeine

What things should be thought about when planning for death:

Speaking to family Welfare and power of attorney DNACPR Prescribing anticipatory medicines - Just incase medicines Contact with palliative care

What are some reversible causes of deterioration in the dying patient?

Dehydration Opioid toxicity Hypercalemia Delirium Infection Glucose levels - hypo/ hyper

When are syringe pumps indicated and how are the medications delivered?

Persistent N&V NIl by mouth Gastric obstruction Excessive medication load - too much to continually inject or give orally End of life days **given Subcut

What are some just incase medications that are commonly prescribed?

Opioids for pain Antiemetics Anti - Anxiolytics Anti- secretory

Palliative medicine Flashcards

(47 cards)