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Flashcards in Palliative Deck (89):
1

What is Cheynes Stoke breathing?

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

2

Non-opioid analgesics 

Amitryptiline nocte

Baclofen

Dexamethasone od

Diazepam nocte

Diclofenac tds

Gabapentin mg

Ibuprofen tds

Naproxen bd

Pregabalin bd

3

Anti-emetic drugs 

Cyclizine 

Domperidone  

Haloperidol nocte

Buscopan (hyoscine butylbromide)  

Hyoscine hydrobromide 

Levomepromazine 

Metoclopramide  (pre-meal)

Ondansetron

4

Laxative drugs + preparation 

Co-danthrusate (capsules/ suspension) nocte

Docusate sodium (capsules) 

Lactulose (solution)

Movicol (oral powder) 1 sachet bd

Senna (tablets/ syrup) nocte

5

SE of Levomepromazine in palliative care

Can be sedating + cause hypotension

6

SE of hyoscine hydrobromide in palliative care

Can be sedating

7

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

Can cause EPSEs

Caution in under 20 y/o

D2 antagonist 5HT4 agonist

8

What time to give steroids?

Best before 2pm

9

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

domperidone = D2 antagonist

cyclizine = H1 + Ach antagonist

hyoscine = Ach antagonist

haloperidol = d2 antagonist

levomepromazine = D2, H1, Ach + 5HT2 antagonist

10

Action + indications for dexamethasone

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

11

Contraindications + SE of dexamethasone

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

12

Interactions + consequences of dexamethasone

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

Bleeding risk with NSAIDs

Increased digoxin activity

13

What are syringe drivers + how long do they last?

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

14

What are the anticipatory medicines + used for what?

Respiratory secretions = hyoscine butylbromide

Pain = opiates

Terminal agitation = midazolam

N+V = haloperidol, levomepromazine

Bowel colic = hyoscine butylbromide

15

What is terminal agitation?

Delirium with cognitive impairment

Common at end stage of cancer

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

16

Action + indications of hycoscine butylbromide

Antimuscarinic antagonist - prevents action of Ach

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

17

Contraindications of hycoscine butylbromide

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

18

SE of hycoscine butylbromide

Anticholinergic 

 

19

What is BiPAP used for?

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

20

What is CPAP used for?

Sleep apnoea

21

Bone pain - S+S + treatment

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

Treat with NSAIDs, RT + bisphosphonates

22

Visceral pain S+S + treatment

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

23

Headache due to raised ICP - S+S + treatment

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

Treatment = corticosteroids to reduce oedema, NSAIDs + paracetamol

24

Neuropathic pain - S+S + treatment

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

Treatment = TCAs + anticonvulsants (gabapentin)

Nerve compression is helped by corticosteroids

25

What is the analgesic ladder?

Step 1 = paracetamol

Step 2 = weak opioid (Codeine) + paracetamol

Step 3 = strong opioid

NSAIDs at any stage

Other adjuvant drugs: antiepileptics, antidepressants, corticosteroids

26

Strengths of co-codamol

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

27

Side effects of strong opioids + how to manage

Constipation = give laxative eg co-danthramer

N+V = settles, provide antiemetic eg haloperidol

Drowsiness = settles in 48 hrs

Confusion/ hallucination = rare

Resp depression = rare

28

S+S of opioid toxicity

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

29

Forms of oral morphine

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

Slow release = lasts 12 hours (morphine sulphate tablets)

30

Starting doses + titration of morphine

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

Titrate up by 30-50%

31

Management of breakthrough pain

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

32

Diamorphine injection + dosing

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

33

What are transdermal analgesics?

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

34

What is oxycodone used for + what are the preparations?

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

Immediate release = oxynorm

Slow release = oxycontin

35

What are non-pharmacological treatments for pain?

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

36

Mouth problems in palliative care + how to manage

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

Anorexia in palliative care - how to manage

Dexamethasone - wears off after 2-3 weeks

Megestrol acetate - may cause fluid retention

Present food nicely + offer small portions

38

What causes N+V in palliative care?

Stimulation of vomiting centre by 4 pathways:

Gastric stasis/ irritation

Toxic causes

Cerebral causes

Vestibular causes

39

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

Features: early satiety, fullness, heartburn.

Due to tumour, hepatomegaly, ascites, dysmotility

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

40

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

Features: nausea, small vomits, possets, retching

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

Treatment: haloperidol

41

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

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

Treatment: dexamethasone + cyclizine

Anxiety: precipitated by certain situations

Treatment: benzos, CBT Indeterminate - consider levomepromazine

42

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

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

Treatment: cyclizine, hyoscine, cinnarizine

43

Stool softener laxative use, SE

Lactulose + sodium docusate

Causes bloating + flatulence

44

Stimulant laxative use, cautions

Senna, dantron

Avoid in colic

45

Main laxative use in palliative care

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

Good for opioid induced constipation

46

What are the features of intestinal obstruction in advanced cancer?

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

Management of intestinal obstruction

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

Non pharmacological management of SOB

Breath training + relaxation

O2 for acute episodes

Fan on face

49

Pharmacological management of SOB

Opioids - low dose oral morphine

Benzos - lorazepam or midazolam

50

Causes of cough in palliative care

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

51

Management of cough

Saline nebs if difficulty expectorating

Linctus for dry + irritating cough

Opioids as cough suppressants

52

What meds can be stopped when pt unable to swallow?

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

53

Management of terminal restlessness

Midazolam +- levomepromazine

54

How can the death rattle be managed?

Repositioning

Antisecretory drugs eg hyoscine butylbromide/ hydrombromide

55

Indications for syringe drivers

Inability to swallow Persistent N+V Intestinal obstruction Malabsorption

56

What can be used for hiccups?

Chlorpromazine

57

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

Dexamethasone

58

What are the preferred opioids for patients with CKD?

Buprenorphine, alfentanil + fentanyl

59

How to convert codeine dose to morphine?

Divide by 10

60

Which laxatives are bulk forming?

Fybogel

61

Which laxatives are used to soften stools?

Lactulose Docusate

62

What are the stimulant laxatives?

Seena Bisodyl

63

Which laxatives are softeners + stimulants?

Movicol Macrogol Condanthrosate

64

Which anti-emetics cause constipation?

Ondansetron

65

What advice should be given with condranthramer?

Turns urine red/ orange

66

What are the NICE guidelines re laxatives?

Start with a stimulant eg Senna

67

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

Gastric causes eg stasis

68

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

Cyclizine + dexamethasone

69

How should anticipatory N+V be treated?

Lorazepam

70

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

Haloperidol

71

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

Haloperidol

72

How to manage pain (calculations of dose)?

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

73

Opiate toxicity S+S

Constricted pupils Respiratory depression

74

What is GSF?

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

75

What drugs should be considered stopping, and stopped?

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

76

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

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

77

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

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

78

How to work out diamorphine needs?

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

79

How often does a syringe driver need changing?

Every 24hrs 

80

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

Chlorpromazine, diazepam, prochlorperazine

Due to skin reactions 

81

What to give for the symptom of SOB?

Oromorph or benzos

82

What can palliative RT be helpful in achieving?

Helps to control bleeding

83

When should chemo not be attempted?

In patients with low performance status or HF

84

What 2 drugs are likely to cause serotonin syndrome?

Tramadol + SSRIs

85

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

Shingles - treat with amitryptiline 

86

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

Metaclopramide = central D2 

Domperidone = peripheral 

87

When is metoclopramide CI?

Parkinsons + bowel obstruction 

88

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

DAMN - diuretics, ACEi, metformin, NSAIDs - STOP 

Switch morphine to oxycodone 

89

What commonly causes gastric stasis?

Liver mets