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Oncology + Palliative > Palliative > Flashcards

Palliative Flashcards

1
Q

What is Cheynes Stoke breathing?

A

Progressively deeper breathing followed by gradual decrease = results in temporary apnoea Each cycle is 30s- 2 mins Oscillation of ventilation between apnoea + hyperpnoea with crescendo-diminuendo pattern

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2
Q

Non-opioid analgesics

A

Amitryptiline nocte

Baclofen

Dexamethasone od

Diazepam nocte

Diclofenac tds

Gabapentin mg

Ibuprofen tds

Naproxen bd

Pregabalin bd

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3
Q

Anti-emetic drugs

A

Cyclizine

Domperidone

Haloperidol nocte

Buscopan (hyoscine butylbromide)

Hyoscine hydrobromide

Levomepromazine

Metoclopramide (pre-meal)

Ondansetron

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4
Q

Laxative drugs + preparation

A

Co-danthrusate (capsules/ suspension) nocte

Docusate sodium (capsules)

Lactulose (solution)

Movicol (oral powder) 1 sachet bd

Senna (tablets/ syrup) nocte

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5
Q

SE of Levomepromazine in palliative care

A

Can be sedating + cause hypotension

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6
Q

SE of hyoscine hydrobromide in palliative care

A

Can be sedating

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7
Q

SE metoclopramide, method of action + caution in what age group?

A

Can cause EPSEs

Caution in under 20 y/o

D2 antagonist 5HT4 agonist

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8
Q

What time to give steroids?

A

Best before 2pm

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9
Q

Main receptor sites for domperidone, cyclizine, hyoscine, haloperidol + levomepromazine

A

domperidone = D2 antagonist

cyclizine = H1 + Ach antagonist

hyoscine = Ach antagonist

haloperidol = d2 antagonist

levomepromazine = D2, H1, Ach + 5HT2 antagonist

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10
Q

Action + indications for dexamethasone

A

Corticosteroid - agonist to glucocorticoid receptor

Indications: symptom control of anorexia, obstruction due to tumours, bronchospasm, partial obstruction, N+V adjunct, headaches due to raised ICP, pain due to nerve compression, cerebral oedema associated with malignancy

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11
Q

Contraindications + SE of dexamethasone

A

CI: systemic infection, caution in DM due to raise in blood sugar.

SE: acne, blurred vision, bruising, HTN, weight gain, body hair, muscle weakness, swollen face, water retention

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12
Q

Interactions + consequences of dexamethasone

A

Amiodarone, 1st gen AP, levopromazine, citalopram, clarithromycin, TCA, venlafaxine = torsades de point

Bleeding risk with NSAIDs

Increased digoxin activity

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13
Q

What are syringe drivers + how long do they last?

A

Sub cutaneous, usually over 24 hours, give a gradual infusion of meds CSCI - continuous

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14
Q

What are the anticipatory medicines + used for what?

A

Respiratory secretions = hyoscine butylbromide

Pain = opiates

Terminal agitation = midazolam

N+V = haloperidol, levomepromazine

Bowel colic = hyoscine butylbromide

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15
Q

What is terminal agitation?

A

Delirium with cognitive impairment

Common at end stage of cancer

S+S: agitation, myoclonic jerks, irritability, hallucinations, confusion

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16
Q

Action + indications of hycoscine butylbromide

A

Antimuscarinic antagonist - prevents action of Ach

Indications: relief of GI spasm, IBS, excessive resp secretions, bowel colic

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17
Q

Contraindications of hycoscine butylbromide

A

Tachycardia GI obstruction/ ileus Glaucoma Prostatic enlargement

Myasthenia gravis Pyloric stenosis

Severe ulcerative colitis Significant bladder outflow obstruction toxic megacolon

Urinary retention Acute MI/ arrhythmias

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18
Q

SE of hycoscine butylbromide

A

Anticholinergic

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19
Q

What is BiPAP used for?

A

2 pressure settings - prescribed pressure for inhalation + lower pressure for exhalation Used in sleep apnoea 2nd line to CPAP

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20
Q

What is CPAP used for?

A

Sleep apnoea

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21
Q

Bone pain - S+S + treatment

A

Features: dull ache over large area or well localised tenderness over bone. Worse on weight bearing

Treat with NSAIDs, RT + bisphosphonates

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22
Q

Visceral pain S+S + treatment

A

Features = dull, deep seated, poorly localised pain. Can be spasmodic

Treatment = follow analgesic ladder.

Colic pain = give anticholinergic drugs eg hyoscine butylbromide for bowel colic, or oxybutynin for bladder spasm

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23
Q

Headache due to raised ICP - S+S + treatment

A

Features = dull, oppressive pain, worse on waking, coughing + sneezing

Treatment = corticosteroids to reduce oedema, NSAIDs + paracetamol

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24
Q

Neuropathic pain - S+S + treatment

A

Features = pain in area of abnormal sensation (numbness, sweating, burning)

Treatment = TCAs + anticonvulsants (gabapentin)

Nerve compression is helped by corticosteroids

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25
Q

What is the analgesic ladder?

A

Step 1 = paracetamol

Step 2 = weak opioid (Codeine) + paracetamol

Step 3 = strong opioid

NSAIDs at any stage

Other adjuvant drugs: antiepileptics, antidepressants, corticosteroids

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26
Q

Strengths of co-codamol

A

8mg codeine 15mg codeine 30mg codeine All with 500mg paracetamol

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27
Q

Side effects of strong opioids + how to manage

A

Constipation = give laxative eg co-danthramer

N+V = settles, provide antiemetic eg haloperidol

Drowsiness = settles in 48 hrs

Confusion/ hallucination = rare

Resp depression = rare

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28
Q

S+S of opioid toxicity

A

N+V, drowsiness, confusion, visual hallucinations, myoclonic jerks, respiratory depression

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29
Q

Forms of oral morphine

A

Immediate release = 20-30 mins for effectiveness, lasts 4 hours (oramorph)

Slow release = lasts 12 hours (morphine sulphate tablets)

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30
Q

Starting doses + titration of morphine

A

MST 20mg bd if been on max strength co-codamol

Titrate up by 30-50%

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31
Q

Management of breakthrough pain

A

Should have 1/6th of total 24hr morphine dose as PRN = eg oramorph 10mg PRN

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32
Q

Diamorphine injection + dosing

A

SC as required or in syringe driver 3 times more potent than oral morphine Should be 1/3 of total oral morphine dose

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33
Q

What are transdermal analgesics?

A

Fentanyl or buprenorphine patches - duration of 72 hours. Suitable for pts with severe chronic pain already stabilised

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34
Q

What is oxycodone used for + what are the preparations?

A

Similar to morphine, 2nd line - good for renal impairment or if morphine not tolerated

Immediate release = oxynorm

Slow release = oxycontin

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35
Q

What are non-pharmacological treatments for pain?

A

RT (bone pain), chemo, surgery, anaesthetic interventions eg nerve block, CBT, TENS, aromatherapy etc

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36
Q

Mouth problems in palliative care + how to manage

A

Dry mouth (xerostomia) = due to reduced oral intake + SE of drugs (antiemetics, antidepressants, RT to head and neck)

Oral thrush = treat with fluconazole or nystatin

37
Q

Anorexia in palliative care - how to manage

A

Dexamethasone - wears off after 2-3 weeks

Megestrol acetate - may cause fluid retention

Present food nicely + offer small portions

38
Q

What causes N+V in palliative care?

A

Stimulation of vomiting centre by 4 pathways:

Gastric stasis/ irritation

Toxic causes

Cerebral causes

Vestibular causes

39
Q

Describe gastric stasis/ irritation - S+S, causes + treatment

A

Features: early satiety, fullness, heartburn.

Due to tumour, hepatomegaly, ascites, dysmotility

Treatment: metoclopramide before meals or SC over 24hrs. Consider PPI

40
Q

Describe the S+S + toxic causes of N+V + how to manage

A

Features: nausea, small vomits, possets, retching

Due to drugs (opioids, digoxin, antiepileptics), hypercalcaemia, uraemia, infections

Treatment: haloperidol

41
Q

Describe the cerebral causes of N+V - S+S + treatment

A

Raised ICP Features: early morning headache, vomiting, neurological signs

Treatment: dexamethasone + cyclizine

Anxiety: precipitated by certain situations

Treatment: benzos, CBT Indeterminate - consider levomepromazine

42
Q

Describe the vestibular causes of N+V - S+S + treatment

A

Features - associated with movement, hearing loss, vertigo or tinnitus

Treatment: cyclizine, hyoscine, cinnarizine

43
Q

Stool softener laxative use, SE

A

Lactulose + sodium docusate

Causes bloating + flatulence

44
Q

Stimulant laxative use, cautions

A

Senna, dantron

Avoid in colic

45
Q

Main laxative use in palliative care

A

Mixed softener + stimulant eg co-danthrusate (dantron + docusate) or Senna

Good for opioid induced constipation

46
Q

What are the features of intestinal obstruction in advanced cancer?

A

Frequently incomplete, intermittent + at multiple sites

High incidence with bowel + ovarian cancer

S+S: N+V, colicky pain, abdo distension, dull pain, diarrhoea/ constipation

47
Q

Management of intestinal obstruction

A

Medication given by SC

Antiemetics, analgesics, antispasmodics

If colic is a feature, give stimulant laxatives

Prokinetic drugs (metoclopramide) should be stopped

Prescribe antispasmodics (hyoscine butylbromide)

48
Q

Non pharmacological management of SOB

A

Breath training + relaxation

O2 for acute episodes

Fan on face

49
Q

Pharmacological management of SOB

A

Opioids - low dose oral morphine

Benzos - lorazepam or midazolam

50
Q

Causes of cough in palliative care

A

Excessive production of fluid in lung (due to tumour), IFB, abnormal stimulation of airway receptors

51
Q

Management of cough

A

Saline nebs if difficulty expectorating

Linctus for dry + irritating cough

Opioids as cough suppressants

52
Q

What meds can be stopped when pt unable to swallow?

A

Vitamins/ iron Hormones Anticoagulants Corticosteroids Abx Antidepressants CV drugs Anticonvulsants used for pain

53
Q

Management of terminal restlessness

A

Midazolam +- levomepromazine

54
Q

How can the death rattle be managed?

A

Repositioning

Antisecretory drugs eg hyoscine butylbromide/ hydrombromide

55
Q

Indications for syringe drivers

A

Inability to swallow Persistent N+V Intestinal obstruction Malabsorption

56
Q

What can be used for hiccups?

A

Chlorpromazine

57
Q

What can be used to treat headaches caused by raised ICP?

A

Dexamethasone

58
Q

What are the preferred opioids for patients with CKD?

A

Buprenorphine, alfentanil + fentanyl

59
Q

How to convert codeine dose to morphine?

A

Divide by 10

60
Q

Which laxatives are bulk forming?

A

Fybogel

61
Q

Which laxatives are used to soften stools?

A

Lactulose Docusate

62
Q

What are the stimulant laxatives?

A

Seena Bisodyl

63
Q

Which laxatives are softeners + stimulants?

A

Movicol Macrogol Condanthrosate

64
Q

Which anti-emetics cause constipation?

A

Ondansetron

65
Q

What advice should be given with condranthramer?

A

Turns urine red/ orange

66
Q

What are the NICE guidelines re laxatives?

A

Start with a stimulant eg Senna

67
Q

What type of N+V should metoclopramide be used for?

A

Gastric causes eg stasis

68
Q

How should N+V associated with raised ICP be treated?

A

Cyclizine + dexamethasone

69
Q

How should anticipatory N+V be treated?

A

Lorazepam

70
Q

How should N+V associated with renal failure be treated?

A

Haloperidol

71
Q

What anti-emetic should be used for opioid associated nausea?

A

Haloperidol

72
Q

How to manage pain (calculations of dose)?

A

Add up 24hr use of MST + oropmorph Convert to MST x2 (12hrly BD) Divide this dose by 6 = PRN dose

73
Q

Opiate toxicity S+S

A

Constricted pupils Respiratory depression

74
Q

What is GSF?

A

Gold Standard Framework 1) Identifies patients in last year of life 2) Assess needs 3) Plan for care

75
Q

What drugs should be considered stopping, and stopped?

A

Consider: corticosteroids, hypoglycaemics, anticonvulsants Non essential: Antihypertensives, Antidepressants Laxatives, Anti ulcer drugs, Anticoagulants Long term antibiotics, Iron, Vitamins, Diuretics, Arrhythmics

76
Q

What percentage of people get the following symptoms in their last day - death rattle, urinary dysfunction, pain, agitation?

A

Death rattle 56% Urinary dysfunction 53% Pain 51% Restlessness agitation 42%

77
Q

What percentage of people get the following symptoms in their last day - SOB, N+V, sweating, jerking, confusion?

A

Breathlessness 22% Nausea and vomiting 14% Sweating 14% Jerking/plucking/twitching 12% Confusion 9%

78
Q

How to work out diamorphine needs?

A

Divide total daily dose of morphine by 3 for 24 hour dose

79
Q

How often does a syringe driver need changing?

A

Every 24hrs

80
Q

What medicines aren’t allowed in syringe drivers and why?

A

Chlorpromazine, diazepam, prochlorperazine

Due to skin reactions

81
Q

What to give for the symptom of SOB?

A

Oromorph or benzos

82
Q

What can palliative RT be helpful in achieving?

A

Helps to control bleeding

83
Q

When should chemo not be attempted?

A

In patients with low performance status or HF

84
Q

What 2 drugs are likely to cause serotonin syndrome?

A

Tramadol + SSRIs

85
Q

What does a burning feeling around ribs/ skin during chemo signify? How is it treated?

A

Shingles - treat with amitryptiline

86
Q

Which anti-emetics work centrally + peripherally on dopamine receptors?

A

Metaclopramide = central D2

Domperidone = peripheral

87
Q

When is metoclopramide CI?

A

Parkinsons + bowel obstruction

88
Q

Palliative pt with renal failure - what meds should you change/ stop?

A

DAMN - diuretics, ACEi, metformin, NSAIDs - STOP

Switch morphine to oxycodone

89
Q

What commonly causes gastric stasis?

A

Liver mets

Oncology + Palliative (23 decks)

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