Transcript Puritus, Sweating, Haemorrhage,SVC 0bst

Whitireia Palliative Care
Course
September 2016
Alison Rowe NP
CCDHB
Pruritus/itch
• Severe itch can be similar to pain in intensity
• 1% cancer patients suffer severe itch
• Itch increases with age
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“Itch: scratching more than the surface” Twycross R, Greaves M.W et al. Q.J.M 2003;96:
7-26.
Different kinds of itch
• Histamine release under skin can cause itch, usually
responsive to antihistamines
• In cancer itch is neurogenic ( imbalance of
neurotransmitters)ca itch doesn’t respond to anti-histamines
• Itch can occur in liver and kidney disease
• Paraneoplastic itch has immunological mechanisms
• Psychogenic itch can accompany depression and distress (
may be helped with antidepressants or psychotropic drugs)
Correct the correctable
• Dry skin (very common old age and
advanced disease)
– Avoid soap
– Apply emollient
• Stenting of CBD
• Review medication
• If medication likely cause swap eg antibiotics,
opioids
Treatment of itch
Non drug treatments of itch:
• Emollient creams
• Avoid soaps
• Discourage scratching: short fingernails, gentle
rubbing
• Avoid hot baths or overheating generally
• Dry skin by patting or hair dryer (cool setting!)
• UVB phototherapy (uraemia)
• Curative RT or chemo (hodgkin’s lymphoma)
Topical treatments:
• Menthol and/or phenol ( in aqueous
cream)
• Capsaicin cream
Treatment of itch
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Drugs:
• H1 receptor antagonists- antihistamines, often
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sedative
H2 receptor antagonists- ranitidine
Doxepin ( TCA and potent H1 and H2 receptor
antagonist)
Ondansetron ( most useful in itch induced by
sysemic opioids)
Sertraline (SSRI) (Uraemia, cholestsis,
paraneoplastic/idiopathic)
Mirtazepine (can be helpful in cholestais, lymphoma,
paraneoplastic and uremia)
Sweating
• Excessive seating about 16% patients with advanced cancer
• More common at night, can require change of clothes or
bedding
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Multiple causes:
Infection (check patient not at risk of neutropenic sepsis)
Lymphoma
Disseminated ca (often with liver mets)
Medication (SSRI’s, hormone Rx tamoxifen, aromatases
inhibitors)
Endocrine-oestrogen deficiency, Androgen
deficiency,hypoglycemia,hyperthyroidism
Alcohol withdrawal
Autonomic neuropathy
Management of sweating
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Treat underlying cause (including infection if appropriate)
Reduce room temperature, remove excess bedding, increase ventilation, use a fan
Maintain fluid intake
Review medication and Rx alternative if possible
Medication –
Sweating with pyrexia: Paracetamol
NSAIDs
Sweating without pyrexia: NSAIDs or dexamethasone
anti-muscarinic (amitriptyline, levomepromazine,
benztropine)
cimetidine (NB drug interactions) ? Thalidomide
Sweating with hormone insufficiency: seek advice from oncologist
? hormone replacement therapy ? Gabapentin
Kathula SK et al. Cox II inhibitors in the treatment of neoplastic fever. Support
Care Cancer 2003;11(4):258-259.
Pandya K et al. Gabapentin for hot flashes in 420 women with breast cancer: a
randomised double-blind placebo-controlled trial. Lancet 2005;366:818-824.
Calder K, Bruera E. Thalidomide for night sweats in patients with advanced
cancer. Palliative Medicine 2000, Vol 14(1): 77-78.
Haemorrhage
• In advanced cancer bleeding contributes
significantly to a patient’s death in 5% of
patients
• BUT
• External catastrophic bleeding is less
common than occult internal bleeding
Haemorrhage
• Non catastrophic bleeding - correct
correctable
• RT
• Stop anticoagulants
• Vit K
• Treat concurrent infection
• RT
Tranexamic acid (wounds or systemic)
Adrenaline (wounds)
Haemostatic dressings (alginate)
Severe Haemorrhage
End of life haemorrhage
• Severe haemoptysis
• Severe local bleed from ulcerated tumour
• Massive GI haemorrhage (haematemesis/malena)
Treatment:
• Sedation/analgesia if time
• use of dark coloured towels, local pressure if possible
• Stay with the patient and family for reassurance
• Death can occur in minutes
Harris DG, Noble SI. Management of terminal haemorrhage in patients with advanced
cancer: a systematic literature review. Journal of Pain and Symptom Management
2009;38(6):913-927.
In the Event of an Acute Bleed
• Stay calm and if possible summon assistance
• Ensure that someone is with the patient at all times
• If possible nurse patient on their side to keep airway clear
• Stem/disguise bleeding with dark towels/sheets
• Apply pressure to the area if bleeding from external wound
with adrenaline soaks if available
• Administer crisis medication if available which can be
repeated after 10 minutes if needed.
• (Midazolam 5- 10mgs buccal/SC/IM)
• (Usual dose of PRN analgesic – SC/IM)
REMEMBER patient support & non-drug interventions may be
more important than crisis medication
Superior vena caval
obstruction
• Obstruction of flow in the venous return of
blood from the head, upper limb and
thorax to the right atrium of the heart via
the superior vena cava.
• Lies next to upper lobe of right lung, within
mediastinum (other structures heart,
trachea, oesophagus, lymph nodes)
• Thin walled, easily compressed
• Caused by invasion or external
compression of the SVC by right lung
tumour, lymph nodes or thrombosis
• 90% caused by tumour – Lung cancer
most common, non hodgkins lymphoma
second most common – make up 94%
cases
• Metastases most commonly from breast
cancer
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Small cell lung cancer greatest risk
20% will develop SVC obstruction
Squamous cell
Adeno carcinoma
Large cell
Non hodgkins lymphoma
Any mediastinal mass may compress or
invade
Non malignant causes
• Can also be caused by paramalignant
causes eg prolonged central lines
• (increasing in frequency)
• Pacemaker leads
• Presentation depends on acuity of
obstruction
• Slow progressive allows collaterals to
develop – mild symptoms
• More acute symptoms if collaterals have
not had time to develop
Symptoms and signs
• Shortness of breath (50%)
• Facial swelling (40%)
• Headache/ head fullness – worse when bending
forward/lying
• Sensation of choking
• Arm/trunk oedema (40%)
• Cough
• Neck vein distention
• Flushing when supine or arms raised
• Difficulty swallowing
• Hoarseness
• Hallucinations, cognitive dysfunction, seizures
• If severe – stridor, coma, death
investigations
• X-ray- may show widening mediastinum
and pleural effusions
• CT
• Ultrasound – if clots suspected
• SVCO seldom life threatening - time for
investigations to be carried out
• Aim is to treat symptoms by relieving
obstruction – providing fast lasting relief
treatment
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Radiation therapy
Chemotherapy
Stent
Steroids – dexamethasone 16mgs/day
(monitor blood glucose)
Thrombolysis/anticoagulants
Anxiolytics
Opioids for SOB
Oxygen if needed
Suport to patient/family
• Very frightening for patients/family
• Nurse in upright position.
• Usual treatment for shortness of breath –
may need oxygen therapy, opoids,fan,
reassurance, assistance to mobilise, keep
bowels soft & regular
• Attention to skin
survival
• Studies reveal that there is little difference
in survival with patients with SCLC with
SVCO compared to those without –
median survival 42 weeks vs 40 weeks
• Survival more related to underlying
pathology – breast cancer and lymphoma
survival longer
Hypercalcaemia
• Generally Paraneoplastic disorder
• - symptoms that are a consequence of
cancer in the body but not due to the local
presence of cancer cells
• Can be secondary to osteolysis releasing
calcium
• Commonest life threatening metabolic
disorder associated with cancer – occurs
20 – 40% patients
• Usually occurs in patients with advanced
malignancy – produces distressing
symptoms.
• Plasma calcium maintained by complex interplay
between parathyroid hormone, calcitriol and
calcitonin. These primarily act at bone, kidney
and small intestine sites to maintain appropriate
calcium levels.
• Calcium enters the body through intestine and is
excreted via kidney. Bone can act as a storage
depot.
• Feedback loop allows individual hormones to
increase level of serum calcium
Hypercalcaemia of malgnancy
• In solid tumours process is caused by
parathyroid hormone related protein which
is produced by the tumour. Acts on
osteoclasts in bone to increase bone
resorption and promote calcium release
from the bone.
• inhibits calcium excretion from kidney
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Occurs in 10-20% of all adults with cancer
Breast
Lung
Renal
Ovarian/cervical
Haematoloigcal malignancies – especially
multiple myeloma (up to 50% of patients)
• 20% occur in absence of bone mets
• Occasionally presenting symptoms of
malgnancy
• Mild to moderate ( serum calcium 2.6 3.00 mmol/l)
• Moderate to severe (serum calcium 3.0 to
3.5mmol/l)
• Normal calcium (2.2 – 2.6mmol/L)
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Thirst and dehydration
Increased urinary output
Pain – usually back and abdominal
Muscle/joint aches
• Severity does not always relate to level of
hypercalcaemia
Symptoms
General:
Dehydration
Polydipsia
Polyuria
pruritis
• Gastrointestinal:
Anorexia
Weight loss
Nausea
Vomiting
Constipation
ileus
• Neurological:
Fatigue
Lethargy
Confusion
Seizures
myopathy
coma
• Cardiological:
Bradycardia
Atrial arrhythmias
Ventricular arrhythmias
Prolonged P-R interval
Prolonged Q-T interval
Wide T waves
management
• Make diagnosis
• Decide whether to treat or not
• Provide symptom relief and reduce serum
calcium levels
• Rehydrate
• Bisphosphonate – inhibit osteoclast
function
• pamidronate 30 -90mg iv infusion in
500mls over 4 hours
• zoledronic acid 4mgs iv - over 15 mins
• Maximal effect 5-7 days lasting 3-4 weeks
• NB Treating underlying cancer can reduce hypercalcaemia
• One year survival 10-30%
• Median survival is 3-4 months
• Resistent hypercalcaemia = very poor
prognosis
Lymphoedema
• Lymphoedema results from reduced lymphatic drainage due
to obstruction, tumour, infection or scarring
• Damage to lymphatic system allows fluid to build up- the
protein in the oedema fluid draws more fluid out of the bloodthe protein in the fluid encourages inflammation-infection may
occur
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Key Questions:
Is infection present?
Is skin drier or wetter than usual?
Is ischemia present?
Is venous obstruction present?
Is massage possible?
Is support indicated?
Will the patient’s prognosis allow reduction of lymphoedema?
Nursing considerations
• Daily skin care – apply emollient daily
• Avoid trauma – shaving, cutting nails,
footwear
• Important to maintain skin integrity
• Positioning – support heavy limb
• Avoid excessive heat (including sun)
• Dry well between digits to prevent fungal
infections
• Careful attention to cuts etc
Management of lymphoedema
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Treat underlying cause ie cancer with chemo
Provide analgesia if painful
Treat infection/cellulitis
Early referral to trained lymphoedema therapist
Exercise
Massage if indicated
Compression garments if appropriate
Trial of steroids
Diuretics not usually helpful (except in heart failure)
Fluid can be drained with a sc needle
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Jacobsen J, Blinderman CD. Subcutaneous lymphatic drainage (lymphcentesis) for palliation of severe
refractory lymphoedema in cancer patients. J Pain Symptom Manage 2011;41(6):1094-1097.
Management of lymphorrhoea
• Oil based emollient around leak
• Elevation of limb to reduce pressure
• Absorbent pads to reduce moisture
contact with skin
Anorexia
• Anorexia common in advanced disease
– Cytokines inhibit response to fasting signals
– Inhibit appetite stimulating hormones
– Stimulate appetite suppressing hormones
Early satiety
• Delayed gastic emptying
• Hepatomegaly
• Gross ascites
Other causes of poor appetite
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Unappetizing food
Too much food
Altered smell/taste
Nausea and/or vomiting
Constipation
Sore mouth
ill fitting dentures
Pain
Anxiety
etc
Anorexia/Cachexia
Anorexia
1. “loss of desire to eat” Loss of appetite
• Cachexia
• Loss of weight (involuntary) in someone who is not trying to
lose weight – loss of skeletal muscle and fat +/- body fat that
cannt be totally reversed by usual nutrition
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Anorexia/cachexia syndrome
Complex metabolic syndrome associated withLoss of weight, muscle atrophy, fatigue, weakness, and
significant loss of appetite
Loss of weight of > 2% in 2 months or >5% in 6 months,
reduced nutritional intake > 75% of normal
Symptoms in patient of: weight loss, loss of appetite, nausea,
early satiety, bloating, fatigue, weakness
ACS- present in 80% of advanced cancer patients
Cherny NI.Taking care of the terminally ill cancer patient: management of
gastrointestinal symptoms in patients with advanced cancer. Ann Oncol
2004;15 (suppl 4): 205-213.
Non pharmacological
• Small regular meals
• Fortified foods – full milk, butter, sugar
• Stronger flavours – fats/salt
• Support patient and family to understand
anorexia/cachexia
• Think about clothing, equipment,
maintaining skin integrity etc
Treatment of anorexia/cachexia
• Multidimensional: pharmacological, nutritional
support, psychological.
Pharmacological:
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Steroids
Androgenic steroids (AIDS)
NSAIDs
Progestins
Anti-cytokines (thalidomide)
Omega 3 fatty acids
Cannabinoids
Prokinetics
Ghrelin
Terminal dehydration/Hydration
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Most patients with cancer will decrease their oral intake before death as a result of
severe anorexia, nausea, dysphagia and/or delirium
Dehydration ? Normal part of the dying process
There is no correlation between dry mouth, thirst, diminished conscious state and
hydration/dehydration
Dry mouth/thirst is usually relieved by topical therapy and mouth care
Parenteral hydration not better than placebo in improving symptoms associated
with dehydration, or improving fatigue, nausea, dysphagia, delirium (study of
patients with advanced cancer)
Artificial hydration can cause hypoalbuminemia without normalising blood
urea,Cr,K, Na
Even when on artificial hydration given, blood Na,K were within normal range in
patients
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? Pathophysiology of dehydration in terminally ill- water depletion caused by fluid
shift from intravascular to interstitial spaces (not total body dehydration)
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Morita T et al. Artificial hydration therapy, laboratory findings and fluid balance in
terminally ill patients with abdominal malignancies. J Pain Symptom Mange 2006;31(2):
130-138
Bruera E et al. Parenteral hydration in patients with advanced cancer: a multicentre,
double-blind, placebo-controlled randomised trial. J Clin Oncol 2013;31(1):111-117.
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Artificial nutrition
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“ordinary care” is to provide oral nutrition to the patient who wants to eat
Nutrition administered by a different route is indicated if the patient is hungry an cannot eat
( when there is a neurologic abnormality affecting swallow or an obstruction e.g head and
neck ca)
There is no evidence that artificial nutrition alone improves functional ability or energy,
improves survival or symptom control if it is the cancer which is responsible for the
anorexia/weight loss.
PEG tubes increase the risk of aspiration rather than reduce it, and reduce QOL
Complications of PEG tubes: infection, obstruction, oedema, ascites, aspiration pneumonia
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Parenteral nutrition does not improve survival or symptoms inpatients with cancer.
Patients with cancer who receive parenteral nutrition die faster than patients who do
not
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American College of Physicians (position paper). Parenteral nutrition inpatients
receiving cancer chemotherapy. 1989;110(9):734-736.
McCann RM et al. Comfort care for terminally ill patients: the appropriate use of
nutrition and hydration. JAMA 1994;272: 1263-1266.
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Conclusions eating/drinking
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It is often the “meaning “ of not eating that distresses patients and families
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Finding “meaning” is emotional and spiritual not a biological issue
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There is no evidence that parenteral nutrition improves survival or quality of life
in terminal cancer patients.
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There is no evidence that iv fluids relieve thirst in in a patient with advanced
cancer
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Stopping medication with anti-cholinergic side effects and administering good lip
and mouth care has been shown to relieve thirst
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Persson CR et al. A randomised study of nutritional support in patients with colorectal and
gastric cancer. Nutr Cancer 2002;42:48-58.
Huang ZB et al. Nutrition and hydration in terminally ill patients: an update. Clin Geriatr
Med 2000;16: 313-325.
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• Introducing palliative care – 5th ed
palliativedrugs.com, Tycross & Wilcock
eds
• Information from slides from Dr Annabel
Dunn, MPH