Transcript Symptomatic treatment

PALLIATIVE CARE
Common symptoms
By Dr Vanessa Kerai
Pain
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“An unpleasant sensory and emotional experience associated
with actual or potential tissue damage.”
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Important to identify the cause and type of pain in order to
decide on management. Different types of pain respond to
different analgesics.
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Psycho-social factors like anxiety and depression, which may
reduce tolerance to pain or exacerbated by pain, must also
be assessed and treated.
What causes pain?
MUSCLE SPASM
LYMPHOEDEMA
VISCERAL
BONE
NERVE
COMPRESSION/
INFILTRATION
SOFT TISSUE
INFILTRATION
Cancer
related
pain
RAISED
INTRACRANIAL
PRESSURE
Surgery – post
operative
scars,
adhesions
Radiotherapy –
fibrosis
Chemotherapy
- neuropathy
Pain classification
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Nociceptive pain
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Results from chemical or physical stimulation of peripheral
nerve endings with the involvement of nociceptors.
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Somatic pain - arises from bone, joint, muscle, skin, or
connective tissue. It is usually aching or throbbing in quality
and is well localized.
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Visceral pain - arises from visceral organs, such as the GI
tract and pancreas e.g tumour involvement of the organ
capsule, obstruction of hollow viscus
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Neuropathic pain
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Up to 40% of cancer-related pain may have a neuropathic
mechanism involved.
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Refers to pain arising from a primary lesion or dysfunction in
the peripheral or CNS.
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Central pain – usually an area of altered sensation
incorporating the painful area but commonly extending
beyond it with no local disease to account for the pain.
Sympathetic maintained pain: associated with dysregulation
of the autonomic nervous system.
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Peripherally Generated Pain
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Painful polyneuropathies: Pain is felt along the distribution of
many peripheral nerves. Examples: diabetic neuropathy, alcohol-nutritional
neuropathy, and those associated with Guillain-Barré syndrome.
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Painful mononeuropathies: Usually associated with a known
peripheral nerve injury, and pain is felt at least partly along
the distribution of the damaged nerve. Examples: nerve root
compression, nerve entrapment, trigeminal neuralgia.
Analgesic ladder
Dyspnoea
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It is common in patients with advanced disease, being
present in up to 70% of patients with cancer.
The causes are often multiple and are associated with both
physiological and psychological factors.
May be attributable to the presence of a primary tumour in
the respiratory system, metastatic spread to the lungs, a
pleural effusion, or advanced respiratory disease.
The causes of breathlessness can be described as:
Mechanical - airway obstruction or lung compression
Haematological – anaemia
Psychological - anxiety.
Breathlessness can cause distress, fear, and disability.
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When managing a patient with breathlessness you should
ask yourself the following questions:
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Is it appropriate to treat the underlying illness?
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Are there any potentially reversible causes of breathlessness,
e.g heart failure, infection, anaemia, pleural or pericardial
effusion, pulmonary embolus, or pneumothorax?
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How best can I treat any reversible causes, for example by
draining an effusion?
Symptomatic treatment
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Keep the patient propped up
Keep the patient cool - consider using a fan
Try nebulised saline or mecysteine for tenacious respiratory
secretions (mecysteine is a mucolytic)
Try bronchodilators if you suspect bronchospasm, such as
nebulised salbutamol 2.5-5.0 mg four times a day.
Consider oral or subcutaneous morphine or benzodiazepines,
or both, (SL lorazepam or SC midazolam)
Consider prescribing oxygen, remembering that short term
oxygen therapy is not proved to confer significant benefit,
unlike long term therapy in chronic respiratory conditions.
Supportive care
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Explore the patient's fears
Encourage simple breathing exercises and relaxation
techniques
Discuss drug management with the patient, for example with
benzodiazepines. Lorazepam 0.5-1.0 mg as required may
help patients with acute attacks of anxiety and diazepam 5.0
mg may help more chronic anxiety.
Discuss the patient's limitations and listen to the patient's and
family's concerns.
Consider the need for equipment or aids and a package of
community care
If the patient has severe or persistent problems consider
referring them to a specialist service.
Cough
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In up to 50% of terminally ill patients and up to 80% in lung
cancer patients.
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Occurs as a result of mechanical and chemical irritation of
receptors in the respiratory tract.
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Management depends on the cause which may or may not
be reversible and the clinical condition of the patient.
Infection
Antibiotics
Lung tumour
Radiotherapy
LVF/Pulmonary oedema
Diuretics
Asthma/Bronchospasm
Bronchodilators
Corticosteroids
Oesophageal reflux
PPI
Metoclopramide
Post-nasal drip
Antibioitic if sinusitis
Nasal corticosteroid spray
Nasal decongestant
Aspiration
Speech therapist may be able to
advise
Tracheo-oesophageal fistula
Covered metallic stent
Dyspepsia
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Gastro-oesophageal reflux/Oesophagitis
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Assessment
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Exclude or treat oesophageal candida
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Consider oesophageal spasm
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Review drugs which cause esophagitis – potassium, NSAIDs,
antimuscarinics
Consider cardiac cause of pain
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Treatment
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Raise head of bed to reduce reflux
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Consider paracentesis for tense ascites
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Metoclopramide if signs of gastric stasis or distension
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Antacid – gaviscon (for mild symptoms)
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PPI
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NSAID and steroid related dyspepsia
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Treatment
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Consider stopping or reducing dose of NSAID/steroids
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PPI for severe symptoms or proven pathology
Nausea and vomiting
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Affects 40-70% cancer patients
Common causes
GI problems
Pharyngeal irritation – e.g Candida, difficulty in expectorating
sputum
Drugs – opioids, antibiotics, NSAIDs
Metabolic – hypercalcaemia, renal failure
Radiotherapy and chemotherapy
Infection
Pain
Anxiety or fear
Brain mets
Anti-emetics
INDICATION
DRUG
DOSE
Gastric Stasis
Metoclopramide
PO: 10mg tds
SC infusion: 30-40 mg in
24hrs
Domperidone
Drugs/biochemical upset
Haloperidol
SC infusion: 1.5mg – 5mg
in 24 hrs
Raised ICP
Distension of abdo or
pelvic organs
Cyclizine
Dexamethasone 4-16mg
PO: 50mg tds
SC infusion: 50-150 mg in
24 hrs
Bowel obstruction
Cyclizine
Octreotide
Hyoscine
Radiotherapy
Chemotherapy
Haloperidol
Dexamethasone
Metoclopramide
1.5 mg noct/bd
4-8mg od
20mg qds
Constipation
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Constipation is often multifactorial in origin. Causes include:
A tumour within or pressing on the bowel wall
A tumour damaging the lumbosacral spinal cord, cauda
equina, or pelvic plexus
Hypercalcaemia
Dehydration
Diminished food intake, low fibre diet, and immobility
Drugs, such as opioids and anticholinergics
Concurrent disease, such as hypothyroidism, hypokalaemia,
or an anal fissure.
Often patients with cancer have more than one cause of their
constipation.
Determine and treat the cause
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First diagnose the cause of the constipation.
When managing a patient with constipation you should ask
yourself the following questions:
Is it appropriate to treat the underlying illness? Check with a
specialist if in doubt
Are there any potentially reversible causes of constipation, for
example dehydration or use of opioids?
How best can I treat any reversible causes, for example by
encouraging a dehydrated patient to take more fluids?
If you cannot find a reversible cause or if your initial treatment
does not work you may have to attempt symptomatic
treatment.
Symptomatic treatment
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Good fluid intake
High fibre diet
Identify and treat any hypercalcaemia
You should titrate up the dose of laxatives until constipation is
controlled.
Co-danthramer is licensed only for use in terminally ill
patients. It may colour the urine red and can cause a
characteristic red rash over the buttocks and perineum. The
risk is increased if the patient is incontinent of urine or faeces.
Generally avoid bulk forming laxatives, such as Fybogel, in
patients with terminal cancer because these are not suitable
for patients with a poor fluid intake, or when opioids have
reduced bowel motility.
Recommendations for
prescribing laxatives
Type of constipation
Acute constipation or hard impaction
Mode of action
Osmotic
Osmotic
Osmotic
Preparation/dose
Microenema - one at night
Phosphate enema - one mane
Movicol
Soft impaction
Stimulant
Senna - two tablets at night
High impaction
Stimulant
Sodium picosulphate
Chronic constipation
Stimulant
Osmotic
Senna - two tablets at night
Movicol - one to two sachets daily
Opioid induced constipation
Softener and
stimulant
Co-danthramer
Stimulant
Senna - two tablets at night
Diarrhoea
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Occurs in up to 10% of cancer patients on admission to
hospice.
Common causes:
Imbalance of laxative therapy (should settle within 24 hrs if
laxatives stopped and reintroduced at a lower dose).
Drugs (antibiotics, NSAIDs, iron, antacids)
Malignant partial intestinal obstruction and faecal impaction
Radiotherapy
Malabsorption (associated with ca pancreas, gastrectomy,
ileal resection, colectomy).
Colonic or rectal tumour
Rare endocrine tumours (e.g carcinoid)
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Investigations
Faecal impaction needs to be excluded by abdominal and
rectal examination.
Persistent watery diarrhoea with systemic upset which might
indicate an infective cause my requite investigation.
Treatment
Look for cause before using antidiarrhoeals
General measures – increase fluids
Non specific drug treatment
Opioids – such as codeine or loperamide act via gut opioid
receptors to reduce peristalsis and increase anal sphincter
tone.
Specific measures
Causes
Treatment
Fat Malabsorption
Pancreatin
Radiation diarrhoea
Ondansetron 4mg tds
Pseudomembranous Colitis
1st line metronidazole 400mg tds
2nd line vancomycin 125mg tds
Profuse secretory diarrhoea
Somatostatin analogues (best given via
syringe driver)
Ascites
Malignant ascites accounts for 10% of all cases of ascites
and in up to 50% of all patient with ovarian cancer.
 May be the presenting feature of the malignancy or be
indicative of recurrence or metastatic spread.
 It is caused by malignant peritoneal deposits irritating the
serosa, blockage of subdiaphragmatic lymphatics and
secondary sodium retention.
Symptoms:
 Abdominal distension, discomfort and pain
 Dyspnoea
 Nausea & vomiting
 Oesophageal reflux
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Treatment options:
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Chemotherapy
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Paracentesis – poor prognosis
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Diuretics – if prognosis >4 wks, paracentesis unsuccessful or
unacceptable or leg oedema. Spironolactone is the drug of
choice.
Peritoneovenous shunt – considered if persistent recurring
ascites. Complications: shunt obstruction, sepsis.
Intestinal obstruction
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Most commonly occurs with carcinoma of the ovary or bowel.
Not uncommonly partial or subacute and often precipitated by
constipation.
Severe constipation with faecal impaction can mimic
obstruction.
Initial drug management:
The optimum treatment is surgery, but often inappropriate in
advanced cancer.
Relieve nausea and reduce vomiting as much as possible:
metoclopramide (may increase colic or vomiting in complete
obstruction, but may resolve partial upper GI tract
obstruction). Cyclizine 150mg + haloperidol 2.5mg/24 hrs. If
nausea persists replace with levomepromazine.
Ensure constant pain is adequately relieved with
diamorphine.
Stop any stimulant laxatives
Anorexia/Cachexia/Asthenia
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Anorexia – absence or loss of appetite
Cachexia – profound weight loss and catabolic loss of muscle
and adipose tissue.
Asthenia – encompasses fatigue or easy tiring and reduced
sustainability of performance. Generalised weaknesss, poor
concentration, impaired memory and emotional lability.
Occur in about 70% of patients with advanced cancer
particularly pancreatic and gastric cancer.
Reversible causes must be excluded such as dysphagia
(due to thrush, mucositis, ulceration), nausea and vomiting,
constipation, pain, anxiety and depression.
If no reversible factors consider dexamethasone (continue if
response after a few days).
Pruritus
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Generalised pruritus in the absence of a rash may be due to:
Cholestatic jaundice (commonest cause in advanced
malignancy)
Renal failure
Opioids
Anaemia
Thyroid disease
Myeloma, lymphoma
Paraneoplastic syndrome: breast, colon, lung, stomach ca
Diabetes
Treat the underlying cause
Lymphoedema
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Excess accumulation of fluid in the body tissues caused by
inadequate lymphatic drainage.
Treatment
Explanation and information about lymphoedema
Skin care to avoid dryness, cracking and infection
Avoidance of trauma, including sunburn, venepuncture, or
vaccinations on the affected limb in order to minimise the
chance of infection.
Massage
Compression bandaging
Compression garments
Exercise
References
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European Journal of Palliative Care, 1998; 5(2):39-45
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Adult palliative care guidance 2006
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Palliative care handbook 3rd edition
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BMJ learning module – palliative care in the community
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Palliative care, symptom control handbook for health professionals
Thanks for listening