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Flashcards in Palliative Care Medicines Deck (43):
0

What are the causes of N+V in patients under palliative care?

Gastric stasis/irritation
Toxic causes - drugs
Raised ICP
Anxiety and anticipatory N+V
Indeterminate cause

1

What are the features, causes and management of N+V due to gastric stasis?

Features: early satiety, hiccups, heartburn, epigastric fullness

Causes: tumour, hepatomegaly, ascites, dysmotility

Treatment: metoclopramide 30mins before meals

2

What are the features, causes and treatment if N+V due to toxic causes?b

Features: Persistent or intermittent nausea, small vomits, possess and retching

Causes: opioids, digoxin, anti epileptics, hypercalcaemia, uraemia, infections

Treatment: haloperidol 1.5-5mg

3

What are the features and management of nausea due to raised ICP?

Features - early morning headache, vomiting with little nausea, neurological signs

Treatment - dexamethasone 8-16mg PO OD plus cyclizine 50mg TDS PO/sc

4

What are the features and treatment of anxiety related N+V?

Features - precipitated by certain situations, anxiety and depression

Treatment - BDZ, CBT, complementary therapies

5

Which Antiemetics are dopamine antagonists?

Haloperidol
Metoclopramide
Levomepromazine
Pro chlorpromazine
Olanzapine

6

What are dopamine antagonist Antiemetics good for?

Toxin related nausea from medications

7

What are the side effects of dopamine antagonist Antiemetics?

Extrapyramidal side effects (avoid in little old ladies)

Neuroleptic malignant syndrome

Sedation

8

Which Antiemetics are anticholinergics /antihistamines?

Cyclizine
Hyoscine

9

What are anticholinergics/antihistamines Antiemetics good for?

Movement related nausea (act on vestibular apparatus)

Cerebral metastases

10

What are the side effects of anticholinergics/antihistaminergics?

Dry mouth
Drowsiness
Urinalysis retention
Constipation

Antagonise the actions of pro kinetics

11

What are the prokinetic Antiemetics?

Metoclopramide
Domperidone
Erythromycin

12

When are prokinetic Antiemetics indicated?

Delayed gastric emptying
Partial bowel obstruction
Motility disorders

13

What are the side effects of prokinetic Antiemetics?

Colic
Extrapyramidal symptoms
Prolonged QTc

Do not giving complete bowel obstruction - colic!

14

What are 5HT3 antagonists?

Block action of serotonin in gut and brainstem

Include ondansetron

15

What are the side effects of ondansetron?

Constipation
Headache
Expensive

16

What type of antiemetic is aprepitant?

Neurokinin antagonist

17

What are some non pharmacological treatments for breathlessness?

Relaxation and breathing techniques
Electric fan
Encourage exertion to increase tolerance
Reduce feelings if isolation - daycare - support group

18

When can bronchodilators be used to relieve dyspnoea in palliative care?

Good for airflow obstruction - lung malignancy, COPD etc

B2 agonist with or without antimuscarinic

19

When is morphine used to treat breathlessness?

Best in breathlessness at rest

Helps reduce ventilators response to hypercapnoea

Start on 2.5-5mg morphine PO PRN

20

When are anxiolytics use to treat breathlessness?

Used if breathlessness is related to anxiety

Diazepam 2-5mg PRN

21

What are are some general measures that can be taken to reduce constipation?

Stop/reduce dose of constipating drugs
Mobilise the patient if possible
Use commode rather than the bedpan
Diet - add fibre
Increase fluids
Encourage fruit juices

22

What are the contact/stimulant laxatives?

Codanthramer (dantron and poloxamer
Codanthrusate (dantron and docusate)
Senna

23

When are stimulant laxatives best used?

Opioid induced constipation

Avoid in colic

24

What are the stool softeners?

Sodium docusate 100-200mg BD tablets

25

What are the osmotic laxatives?

Lactulose - 15mls BD
Movicol - 1 sachet twice daily

26

What are the bulk forming drugs?

Fybogel - 1 sachet twice daily

These are rarely appropriate in palliative care

NOT for opioid induced!

27

What are the side effects of strong opioids?

Constipation:
co-prescribe Codanthramer

Nausea and vomiting:
In one third of patients
Usually settles in a few days
Co prescribe haloperidol
Consider regular antiemetic

Drowsiness:
Usually improves within 48 hours

Confusion and visual hallucinations
Respiratory depression
Psychological dependence

28

What are signs of opioid toxicity?

Nausea and vomiting
Persistent drowsiness
Confusion and visual hallucinations
Myoclonic jerks
Respiratory depression
Pinpoint pupils

29

How long do normal release morphine last?

4 hours

Oromorph
Sevredol

30

How long does modified/slow release morphine last for?

Up to 12 hours

MST 20mg every four hours if stepping up from max cocodamol

Zomorph

31

How many times more powerful is parenteral Diamorphine than oral morphine?

Three times

Divide total 24 hour dose by 3 to convert

32

How many times more powerful is parenteral morphine than oral morphine?

Two times

Divide 24 hour dose by 2 to convert

33

How long do fentanyl transdermal patches last?

72 hours

For severe chronic pain already stabilised on opioids

34

What are other strong opioids?

Oxycodone - if morphine not suitable
Alfentanil
Methadone

35

How should prn doses be calculated?

All patients on MST should have normal release morphine prescribed PRN for breakthrough pain

This should be 1/6th of the total 24 hour morphine dose

This can be taken up to hourly if needed

36

How should doses of oral morphine be titrated upwards?

Titrate dose upwards by adding on 30-50% of the total daily dose - remember this gives you the new total daily dose!


Or

Can add on the total prn dosage taken

37

What is a reasonable maximum dose in 24 hours for a PRN normal release oral morphine?

6-10 times the PRN dose

38

What are some signs that someone is reaching the end of their life?

Profound weakness
Confined to bed for most of the day
Drowsiness for extended periods
Disorientated
Reduced attention
Loss of interest in food and drink
Too weak to swallow

39

Should patients on terminal care have artificial hydration?

Usually not necessary

Reduced food and fluid intake is part of the process

Artificial hydration does not increase comfort, may cause oedema, and cannulation may be uncomfortable

40

What medications should be stopped in terminal care?

May be stopped:
Vitamins
Hormones
Anticoagulants
Corticosteroids
Antibiotics
Antidepressants
Anticonvulsants

Only keep drugs used for symptom management!

41

What is death rattle?

Movement of secretions in airways when patient can't expectorate

Doesn't bother the patient!

Repositioning may help

42

When is a syringe driver indicated?

Inability to swallow - reduced consciousness, last days of life
Persistent nausea and vomiting
Intestinal obstruction
Malabsorption of drugs
Dysphagia