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
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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