Management of CA SE and Pain Flashcards Preview

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Flashcards in Management of CA SE and Pain Deck (34):
1

Anti-neoplastic Agents
-aka
-cause of SE?

aka: chemo

Cause: these agents are unable to discriminate between neoplastic and normal cells.

2

Alopecia:
-tx

Anorexia
-tx

Alopecia: wigs, will grow back once finished with chemo.

Anorexia: antiemetics, megesterol* (Megace), dronabinol* (Marinol)

* = appetite stimulants

3

Cardiotoxicity
-acute or chronic?
-main drug causing this
-tx

usually chronic from cumulative dosing of cardiotoxic drugs, irreversible

Doxorubicin

Tx:
-MUGA scan*, exercise and diet modification, dose reduction, EKG
-Dexrazoxone (Zinecard) = cardioprotective, prevents free radicals

4

Constipation:
-pathophys
-cause
-tx

Pathphys: neurotoxic effects resulting in decreased peristalsis

Cause: vinca alkaloid, hypercalcemia, opiod pain management, dehydration

Management: bowel program, exercise and diet modifications, laxative and stool softener, increase fluids.

5

Skin or cutaneous responses:
-MC manifestations
-tx
-example; what is this? MC associated with which drug? prevention?

MC reactions include rash, photosensitivity, hypersensitivity

Tx: skin care

Example: acral erythema (aka hand-foot syndrome)
-MC associated with 5FU, capecitabine, doxirubicin
-prevention: holding ice packs during infusion and/or taking pyridoxine.

6

Diarrhea:
-tx

Fatigue:
-pathophys
-tx

Tx: hydration
-IV fluids
-loperamide/diphenoxylate

Fatigue:
-pathophys: anemia, changes in sleep patterns, pain, psychosocial factors

Tx: energy management, referral ?

7

Hemorrhagic cystitis:
-pathophys
-cause
-sx
-tx

Pathophys: bladder mucosal irritation from metabolic by-product of drugs

Cause: cyclophosphamide**, high dose methotrexate

Sx: dysuria, urinary frequency, burning, hematuria, previous hx of pelvic radiation

Tx:
PO/IV hydration with diuretics (to keep the bladder flushed)

8

Hepatotoxicity
-pathophysiology
-cause
-signs and sx
-tx

pathophys: direct toxic effect to liver when drugs are being metabolized

cause: ETOH use, liver dz, medication use,

signs and sx: jaundice, ascites, hepatomegaly, pain

Tx:
-limit acetaminophen to less than 4g/day
-avoid alcohol
**if they get this you must stop the medication.

9

Hypersensitivity Rxn
-pathophys
-tx

pathophys: antigen/aby rxn

Tx: premedication prior to chemo, steroids, H1 and H2 blockers, epi
*treated just like any other allergic rxn*

10

Mucositis/Stomatitis/Esophagitis
-pathophys
-cause
-sx
-tx

Pathophys: direct effect of drug or radiation on oral mucosa

Cause: leukemia, lymphoma, just about all head and neck CA patients

Sx:
-xerostomia: dysphagia, plaque formation, pale dry oral mucosa (non-painful)

-mucositis: erythemia, desquamation, ulceration (painful)

-yeast infections: thrush, oral or esophageal candidiasis

Tx:
-dental referral
-magic mouthwash (viscous lidocaine, benadryl, nystatin susp.)
-chlorhexidine(Peridex) rinse
-cryotherapy (suck on ice)
-frequent oral hygiene, baking soda rinse QID.

11

Nausea and vomiting:
-pathophys
-associated with which drug class most commonly?
-tx

Pathophys:
1. stimulation of the vagus nerve be the release of serotonin
2. stimulation of the chemoreceptor trigger zone in the medulla
3. stimulation of the true vomiting center

MC associated with alkylating agents.

Tx:
-MOST effective therapy is 5-HT3 agent PLUS dexamethasone.
--Palonestron (aloxi) is now the preferred agent though it used to be zofran.

Other agents:
-lorazepam
-prochlorperazine (phenothiazine, compro)

12

Nephrotoxicity
-MC caused by which 2 drugs?
-tx

MC caused by cisplatin and high dose methotrexate

Tx:
-adequate IV hydration & fluid intake.

13

Neurotoxicity
-pathophysiology
-sx
-tx

pathophys: metabolic encephalopathy, intracranial hemorrhage d/t coagulopathy or myelosuppression

Sx:
-tinnitus, peripheral neuropathies, fine motor loss, numbness, tingling, gait disturbance, changes in mentation, urinary retention, constipation

Tx:
-avoid extremes in temperature

14

Pulmonary Toxicity:
-pathophys
-caused by which drug most commonly?
-tx

Pathophys: toxic damage to alveoli resulting in pneumonitis and pulmonary fibrosis

MC caused by bleomycin*

Tx: PFT prior to therapy & corticosteroids
-d/c chemo*

15

Sexual and reproductive dysfunction:
-signs
-tx

signs:
-early menopause, sterility

Tx: sperm banking, counseling

16

Myelosuppression:
-pathophys
-cause

pathophys: anemia, neutropenia, thrombocytopenia, pancytopenia

cause;
-leukemia
-taxanes
-alkylating agents
-antimetabolites
-etoposide
-nitrosureas

17

Anemia:
-sx
-tx

sx: dyspnea, fatigue, poor nutritional status

tx; RBC transfusions prn, iron supplememnts, O2, EPO only if absolutely necessary as increased risk of death associated with CA pts*

18

Neutropenia:
-pathophys
-sx
-tx

pathophys: absolute neutrophil count equal to or less than 1500. (Normal range is 1500-8000)

sx:
-signs of infection, malnutrition, prior chemotherapy or radiation

tx:
-filgrastim or pegfilgrastim (bone marrow stimulant)
*any fever gets admitted to the hospital*

19

How do you calculate the absolute neutrophil count?

Add neutrophils and bands and then convert to a %. multiply the total WBC by the total neutrophil percentage.

Ex. WBC = 1600, neutrophils = 48, bands =5

48+5 = 53
53/100 = 0.53
1600x0.53= 848
ANC = 848.

20

Thrombocytopenia
-what is this?
-signs and sx
-tx

what: decreased platelet production
*platelets less than 50,000 risk of bleeding, less than 20,000 high risk for bleeding, less than 10,000 critical risk

Normal: 150x10^9- 440x10^9)

signs and sx:
-petechiae, bruising, hemorrhage

Tx:
-platelet transfusion
-thrombocytopenic precautions: electric raxor, no suppositories, no dental flossing, no injections)

21

Radiation SE

Long term:
-nausea, vomiting, trouble swallowing, fatigue**, decreased platelets and lymphocytes

-skin: erythema, hair loss at site

-mucous membranes: fibrin plaquing, urinary bladder changes

-reproductive organs: sterility

bone: suppress osteoblast activity, decreased osteocytes

22

Signs and sx of pain

Pain measurement tools

hypertension, tachycardia, diaphoresis

agitation or confusion

apathy, inactivity, or irritability

refusal to eat

guarding

Tools:
-pain scale
-McGill pain questionnaire
-Memorial Pain assessment card

23

Somatic pain
-what is this?
-everyday example
-MC cause of somatic pain in CA pts

what: potential or real injury to tissues and is typical pain that is tender and localised to the site of injury. Constant and sometimes throbbing or aching.

ex. pain associated with cutaneous burn or an arthritic joint

MC cause is bone mets in CA pts.

24

Visceral Pain
-what is this?
-MOA
-common causes in CA pts?

what: poorly localized and often referred to a distant site which may be tender. it may be less constant than somatic pain, occurring in dull, colicky waves. often associated with nausea and diaphoresis

MOA: activation of pain receptors resulting from infiltration, compression, extension, or stretching of the thoracic abdominal or pelvic viscera.

MC causes include pancreatic CA and mets in the abd.

25

Neuropathic pain
-what is this?
-sx
-resistant to what type of drugs?
-cause

what: prolonged, severe, burning or stabbing pain, constant but may be interrupted by paroxysms of dramatically increased pain

sx: autonomic instability (tachycardia and diaphoresis)

Resistant to opiods, making it the most challenging types of pain to treat

Caused by injury to the nervous system, tumor compressing nerves or spinal cord. Cancer infiltrating the nerves or spinal cord.

26

Pain management

radiation, chemo, and palliative surgery should be applied to debulk or shrink the tumor

pharmacological agents including both non-opioid and opioid agents, as well as analgesic adjuvants

neurosurgical and anesthetic interventional procedures which physically or pharmacologically abrogate the nerve conduction pathways for pain.

27

Step one of three pain management

Step 2 & 3

Non-steroidals (NSAIDS) and acetaminophen

Step 2:
-opiods (tramadol); short half life, PRN

Step 3:
-opiods (morphine, fentanyl, oxycodone); sustained-release preparation.

*Have baseline long acting aceteminophen around the clock, soemtimes yo give them morphine for quick relief

Most pts end up on long acting opiod with short acting formulation for rescue. Once they start using more rescue you go up on the dose of long acting opiod.

28

Which two drugs do you not use in CA pts?

Remember don’t use codiene or meperidine in CA!!You don’t use meperidine/demerol b/c it has unique metabolism and metabolites that are toxic and if you keep redosing it the toxic effects build up.

29

Tramodol
-MOA

MOA: inhibits neuronal reuptake of serotonin and NE, like TCA.

30

Why might we use antidepressants, anticonvulsants, and local anesthetics when treating CA pain?

use to provide opioid sparing effect therby lessening opioid SE and possibly slowing the development of opioid tolerance.

*treating neuropathic pain which is often difficult to treat with opioids alone.

31

What is the MD Anderson protocol of pain?
-mild to moderate pain
-moderate to severe pain
-tingling and burning pain
-pain caused by swelling

mild-mod: Non-opioids such as acetaminophen and NSAIDS such as aspirin and ibuprofen

Mod-severe: opioids such as morphine, hydromorphone (dilaudid), oxycodone, hydrocodone, codeine, fentanyl, and methadone

Tingle/burn: antidepressants such as amitriptyline, imipramine, doxepin

antiepileptics such as gabapentin (neurontin)

Swelling: steroids such as prednisone, and dexamethasone

32

Rating scale of pain:
-mild
-moderate
-severe

mild: 1-3
mod: 4-6
severe: 7-10

33

What are some anesthesic interventional approaches to the management of CA pain?

nerve blocks
-celiac plexus block
-superior hypogastric plexus block
-myofascial injection
-neuroma injections
-spinal cord stimulation
-intrathecal and epidural injections

34

Alternative pain management

-biofeedback: gaining conscious voluntary control and can influence their level of pain

Breathing and relaxation exercises

distraction

heat or cold

hypnosis

imagery

massage, pressure, and vibration

TENS: transcutaneous electrical nerve stimulation