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Symptom Control in Palliative Care. Cathy Corden GP VTS ST1. Case Study 1. Mrs AB 68 year old lady Ca breast with metastatic disease Worsening pain in back, cannot get comfortable at all Nauseous, lethargic and her daughter feels she has become more confused recently. - PowerPoint PPT Presentation
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Symptom Control in Palliative Care
Cathy CordenGP VTS ST1
Case Study 1
Mrs AB 68 year old lady Ca breast with metastatic disease Worsening pain in back, cannot get
comfortable at all Nauseous, lethargic and her
daughter feels she has become more confused recently.
On paracetamol 1 gram qds, codeine 30mg qds
Case Study 1
What are the main issues in this case? What investigations might you want to
carry out? Is there anything else you would want to
know to help make decisions? If all investigations normal, what would be
the next management steps for pain control?
Spinal Cord Compression
Back pain most often thoracic Weakness of lower limbs Sensory level Urinary symptoms
Up to 5% cancer sufferersCa prostate, breast, bronchus,
myeloma
Spinal Cord Compression
http://intqhc.oxfordjournals.org/content/19/6/377.full
Spinal Cord Compression cont
GP can start dexamethasone 16mg/day whilst referring urgently to oncology/spinal centre
MRI scan Radiotherapy Spinal surgery
Hypercalcaemia
10-20% advanced cancer Myeloma, breast, renal, squamous
cell carcinomas Nausea, vomiting, confusion,
constipation, thirst, fits, coma. More commonly caused by
parathyroid hormone-related peptide secreting tumour rather than lytic metastases
Hypercalcaemia cont
Symptoms appear when calcium rises quickly and over 3.0 mmol/L
Admit for fluids and IV bisphosphonates
May require PO bisphosphonates to reduce recurrence rates.
Bony metastases
Significant pain Pathological fractures Analgesia Radiotherapy Bisphosphonates Surgical inj steroids/anaesthetics
WHO analgesic ladder
Opioid Analgesia
Immediate release e.g. oramorph. Work within 20mins and last 4 hours.
Modified release e.g. Zomorph, MST MR.
Start 10 mg immediate release 4 hourly and increase by 30-50% every 3 days until pain relief achieved/SEs. Beware elderly pts.
Opioid Analgesia
Once stable pain control transfer to modified release preparation.
Need immediate release preparation for breakthrough pain. Should be 1/6 total dose e.g. if taking 60 mg MST bd would need 20 mg oramorph 4 hourly.
Remember the laxative, antiemetic
Case Study 2
Mrs CD 56 year old ladyMetastatic ovarian carcinomaContinuous vomiting last 4 daysIntermittant bowel obstruction. Last opened
bowels 3 days ago. Abdominal painOn MST 60 mg bd, oramorph prn,
metoclopramide 10mg tds POWishes not to go back to hospital as does
not want NG tube/prolonged hospital stay
Case Study 2
You decide to set up a syringe driver at home.
What are the common reasons for using syringe driver?
What medications could you choose, what dosages?
As a GP how do you order syringe drivers? What is the important info needed on prescription?
Syringe Drivers
Persistent vomiting
Reduced level consciousness
Weak Dysphagia Forgets to take
PO medication Last days of life
Pain Control
Diamorphine s/c To convert from oral morphine to s/c
diamorphine ratio is 3:1 On MST 60 mg bd, 40 mg oramorph
in 24 hours therefore total morphine 160 mg. Diamorphine dose in 24 hours would be just over 50mg.
Vomiting
www.yorkshire-cancer-net.org.uk/
Ordering Syringe Drivers
Medication in words and numbers if controlled drugs
Made up to 15 ml with water for injection
To run over 24 hours Aseptic services – part of pharmacy D/W district nurses Need to sign pink form for DN to set
up driver.
Syringe Drivers
Diamorphine can be combined with any of the following in a driver:
Cyclizine Haloperidol Hyoscine Hydrobromide Hyoscine Butylbromide Levomepromazine Metoclopramide Midazolam
Case Study 3
79 year old gentleman Ca bronchus Struggling with dyspnoea. His wife
tells you that he has been deteriorating rapidly last two days and is now very agitated.
On home oxygen
Case Study 3
What are the common causes of dyspnoea in someone who is palliative?
How would you manage a patient such as this? Consider:
- dyspnoea - agitation
Dyspnoea
Uncomfortable awareness of breathing. Frightening.
Common in end stage COPD, cardiac failure, cancer, neurological conditions
Rule out COPD exacerbation, PE, pulmonary oedema, pneumonia, SVCO, anaemia, pleural effusion, ascites, lung mets, lymphangitis carcinomatosa
Superior Vena Caval Obstruction
SOB Swelling face,
arms Collateral veins Dizziness Visual changes Headache Urgent referral
with high dose dexamethasone
http://www.bmj.com/content/315/7121/1525.extract
Dyspnoea
O2 Optimise bronchodilators in COPD Use fan/open window to ease
sensation Position upright Physiotherapy Good oral care
Dyspnoea
Oramorph 2.5 mg 4 hourly. Titrate up. Not used enough for dyspnoea for fear of respiratory depression. However very effective.
Diamorphine s/c Midazolam 2.5 mg s/c anxiety/fear
suffocation.
Agitation
Pain Urinary retention Constipation Anxiety Uncomfortable positioning Nausea/vomiting SE medication Cerebral irritation
Agitation
Once all above reversible causes have been excluded likely terminal agitation.
Levomepromazine 12.5-25.0 mg s/c 4-6 hourly, 25-150 mg s/c 24 hours.
Midazolam 2.5-5.0 mg s/c 4 hourly, 10-60mg s/c 24 hours.
References
Oxford Handbook of Palliative Care Derby Hospitals: Syringe Driver
Combinations from CASU www.bathgped.co.uk/presentations www.yorkshire-cancer-net.org.uk/