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
Buscopan (hyoscine butylbromide)
Laxative drugs + preparation
Co-danthrusate (capsules/ suspension) nocte
Docusate sodium (capsules)
Movicol (oral powder) 1 sachet bd
Senna (tablets/ syrup) nocte
SE of Levomepromazine in palliative care
Can be sedating + cause hypotension
SE of hyoscine hydrobromide in palliative care
Can be sedating
SE metoclopramide, method of action + caution in what age group?
Can cause EPSEs
Caution in under 20 y/o
D2 antagonist 5HT4 agonist
What time to give steroids?
Best before 2pm
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
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
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
Interactions + consequences of dexamethasone
Amiodarone, 1st gen AP, levopromazine, citalopram, clarithromycin, TCA, venlafaxine = torsades de point
Bleeding risk with NSAIDs
Increased digoxin activity
What are syringe drivers + how long do they last?
Sub cutaneous, usually over 24 hours, give a gradual infusion of meds CSCI - continuous
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
What is terminal agitation?
Delirium with cognitive impairment
Common at end stage of cancer
S+S: agitation, myoclonic jerks, irritability, hallucinations, confusion
Action + indications of hycoscine butylbromide
Antimuscarinic antagonist - prevents action of Ach
Indications: relief of GI spasm, IBS, excessive resp secretions, bowel colic
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
SE of hycoscine butylbromide
What is BiPAP used for?
2 pressure settings - prescribed pressure for inhalation + lower pressure for exhalation Used in sleep apnoea 2nd line to CPAP
What is CPAP used for?
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
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
Headache due to raised ICP - S+S + treatment
Features = dull, oppressive pain, worse on waking, coughing + sneezing
Treatment = corticosteroids to reduce oedema, NSAIDs + paracetamol
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
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
Strengths of co-codamol
8mg codeine 15mg codeine 30mg codeine All with 500mg paracetamol
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
S+S of opioid toxicity
N+V, drowsiness, confusion, visual hallucinations, myoclonic jerks, respiratory depression
Forms of oral morphine
Immediate release = 20-30 mins for effectiveness, lasts 4 hours (oramorph)
Slow release = lasts 12 hours (morphine sulphate tablets)
Starting doses + titration of morphine
MST 20mg bd if been on max strength co-codamol
Titrate up by 30-50%
Management of breakthrough pain
Should have 1/6th of total 24hr morphine dose as PRN = eg oramorph 10mg PRN
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
What are transdermal analgesics?
Fentanyl or buprenorphine patches - duration of 72 hours. Suitable for pts with severe chronic pain already stabilised
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
What are non-pharmacological treatments for pain?
RT (bone pain), chemo, surgery, anaesthetic interventions eg nerve block, CBT, TENS, aromatherapy etc
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
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
What causes N+V in palliative care?
Stimulation of vomiting centre by 4 pathways:
Gastric stasis/ irritation
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
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
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
Describe the vestibular causes of N+V - S+S + treatment
Features - associated with movement, hearing loss, vertigo or tinnitus
Treatment: cyclizine, hyoscine, cinnarizine
Stool softener laxative use, SE
Lactulose + sodium docusate
Causes bloating + flatulence
Stimulant laxative use, cautions
Avoid in colic
Main laxative use in palliative care
Mixed softener + stimulant eg co-danthrusate (dantron + docusate) or Senna
Good for opioid induced constipation
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
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)
Non pharmacological management of SOB
Breath training + relaxation
O2 for acute episodes
Fan on face
Pharmacological management of SOB
Opioids - low dose oral morphine
Benzos - lorazepam or midazolam
Causes of cough in palliative care
Excessive production of fluid in lung (due to tumour), IFB, abnormal stimulation of airway receptors
Management of cough
Saline nebs if difficulty expectorating
Linctus for dry + irritating cough
Opioids as cough suppressants
What meds can be stopped when pt unable to swallow?
Vitamins/ iron Hormones Anticoagulants Corticosteroids Abx Antidepressants CV drugs Anticonvulsants used for pain
Management of terminal restlessness
Midazolam +- levomepromazine
How can the death rattle be managed?
Antisecretory drugs eg hyoscine butylbromide/ hydrombromide
Indications for syringe drivers
Inability to swallow Persistent N+V Intestinal obstruction Malabsorption
What can be used for hiccups?
What can be used to treat headaches caused by raised ICP?
What are the preferred opioids for patients with CKD?
Buprenorphine, alfentanil + fentanyl
How to convert codeine dose to morphine?
Divide by 10
Which laxatives are bulk forming?
Which laxatives are used to soften stools?
What are the stimulant laxatives?
Which laxatives are softeners + stimulants?
Movicol Macrogol Condanthrosate
Which anti-emetics cause constipation?
What advice should be given with condranthramer?
Turns urine red/ orange
What are the NICE guidelines re laxatives?
Start with a stimulant eg Senna
What type of N+V should metoclopramide be used for?
Gastric causes eg stasis
How should N+V associated with raised ICP be treated?
Cyclizine + dexamethasone
How should anticipatory N+V be treated?
How should N+V associated with renal failure be treated?
What anti-emetic should be used for opioid associated nausea?
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
Opiate toxicity S+S
Constricted pupils Respiratory depression
What is GSF?
Gold Standard Framework 1) Identifies patients in last year of life 2) Assess needs 3) Plan for care
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
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%
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%
How to work out diamorphine needs?
Divide total daily dose of morphine by 3 for 24 hour dose
How often does a syringe driver need changing?
What medicines aren't allowed in syringe drivers and why?
Chlorpromazine, diazepam, prochlorperazine
Due to skin reactions
What to give for the symptom of SOB?
Oromorph or benzos
What can palliative RT be helpful in achieving?
Helps to control bleeding
When should chemo not be attempted?
In patients with low performance status or HF
What 2 drugs are likely to cause serotonin syndrome?
Tramadol + SSRIs
What does a burning feeling around ribs/ skin during chemo signify? How is it treated?
Shingles - treat with amitryptiline
Which anti-emetics work centrally + peripherally on dopamine receptors?
Metaclopramide = central D2
Domperidone = peripheral
When is metoclopramide CI?
Parkinsons + bowel obstruction
Palliative pt with renal failure - what meds should you change/ stop?
DAMN - diuretics, ACEi, metformin, NSAIDs - STOP
Switch morphine to oxycodone
What commonly causes gastric stasis?