Palliative Care and Oncology - PowerPoint Presentation

1. Palliative Care and OncologyWe will cover:Palliative care – pre-emptive prescribing, morphine conversions and analgesia typesOncology – mainly oncological emergencies

2. Palliative Care Q+A for FinalsDon’t forget links to Geris – advance directives etc.

3. Pre-emptive prescribingYou are the F1 on a geriatric ward. One of your patients is a 89 year old woman. She was admitted for worsening symptoms of heart failure and it has been decided by your seniors that she is for end of life care. You are asked to prescribe the pre-emptive medications.What are the 5 symptoms you need to prescribe for?What do you prescribe for each?

4. Pre-emptive prescribingPain – morphine, ideally in a syringe driver, dose dependent on current medicationBreathlessness – morphine PRN 1-2 hourlyAgitation – midazolam PRN hourlySecretions – hyoscine butylbromide PRN hourlyNausea – haloperidol PRN 4 hourlyMouth care, comfort cares

5. Syringe driversThe patient is on 50mg modified release morphine (Zomorph) a day with 15mg PRN. What is the correct prescription of morphine for the syringe driver?

6. Syringe driversPumps that gradually administer small amounts of medication continuouslyPainkillers, sedatives, anti-emeticsInjectable opioids are twice as strong as oralIf on modified release morphine 50mg BD and PRN 15mg use half the total 24hr dose:50mg/2 is 25mg, and 15mg/2 is 7.5mg x 6 = 45mg25 BD = 50 + 45 = 95mg

7. Morphine conversionWhat is the equivalent 24hr dose of morphine of 60mg codeine QDS?What is the equivalent 24hr dose of morphine with 100mg tramadol QDS?

8. Morphine conversionCodeine and tramadol are 1/10th as potent as morphineCodeine 60mg QDS = 240mg = 24mg morphine10mg BD modified release morphine i.e. ZomorphTramadol 100mg QDS = 400mg = 40mg morphine20mg BD modified release morphineTry to control background and breakthrough (with PRN)

9. Morphine conversionPatient on 30mg Zomorph BD. What is her PRN dose, and how often can this be taken?What are 3 side effects of opioid analgesia?

10. Morphine conversionPRN doses are 1/6th of the 24hr doseModified release morphine 30mg BD = 60mg 24hrs give 10mg PRN oramorph 4hrlyMain side effects are nausea, constipation, drowsiness, dry mouthRarely can cause respiratory depression

11. More opioidsCan you name any more opioids used in palliative care?What would be a good choice of opioid to prescribe in patients with renal impairment?

12. More opioidsDiamorphine, oxycodone both roughly 2x as potent as morphineBuprenorphine, fentanyl patches - BNFFentanyl patch is for stable opioid responsive pain, takes 12 hours so not for acute pain – lasts 72 hours (60mg morphine = 25mcg patch)Renal friendly!

13. Adjuvant analgesicsFor neuropathic pain – amitriptyline, pregabalin, gabapentinMuscle spasms – baclofen, clonazepam, diazepamCompression symptoms – dexamethasoneBone pain – zolendronic acid

14. Oncology Q+A for Finals Don’t forget specific cancersCancer screening

15. Back painYou see a patient in a GP surgery who has a history of breast cancer treated by wide local excision and radiotherapy 2 years ago. She is complaining of back pain.What are some red flag symptoms of back pain?

16. Back painRed flags: thoracic pain, non mechanical, Hx of malignancy, saddle anaesthesia, incontinence, leg weakness, systemic features <20 or >55 yearsShe does not have any red flags except Hx of malignancy. What are you worried might be the cause of the back pain?

17. Spinal metastasesOn further investigation, she is found to have spinal metastases. What are some options for management of this?

18. Spinal metastasesAnalgesia (pain ladder, specialist pain teams)Palliative radiotherapyVertebroplasty/spinal stabilisation surgeryBisphosphonates – only if involvement from breast or prostate cancer or myeloma

19. Spinal metastasesThe same patient presents to A+E 3 months later. She is complaining of back pain, leg weakness and has been incontinent of urine.What are you worried about?What do you do – 2 main things?

20. Spinal cord compressionE.g. from spinal metastasesSx: pain, sensory loss at level, weakness below level, loss of continenceIf below L1/L2 think cauda equinaRefer to neurosurgery for MRI whole spineGive IV dexamethasone and VTE prophylaxis

21. Oncological emergenciesOther than spinal cord compression, what are other oncological emergencies you can think of?

22. Neutropenic sepsisOverwhelming infection with low neutrophils, suspect if fever + chemo in last 6 weeksNeutrophil count <0.5x10^9/L AND pyrexia >37.5Ix:FBC, LFT, U+E, CRP, clotting, lactate, glucoseBlood cultures, venous blood gasUrine cultureSwab/culture central line

23. Neutropenic sepsisSepsis 6 within 1 hour:Blood cultures (+ septic screen e.g. urine, CXR)Urine output - catheterFluids – bolus if neededAntibiotics – what are you going to give?Lactate – ABG/VBGOxygen

24. Neutropenic sepsis IV antibiotics:Tazocin 4.5g TDS IV (piperacillin and tazobactam) Can also give granulocyte colony stimulating factor – Filgrastim – d/w OncologyFluconazole, aciclovir if suspecting fungal/viral

25. Hypercalcaemia of malignancyHumoral is caused by secretion of parathyroid hormone related peptide by tumour, activating osteoclasts suppressing osteoblasts, releasing CaCa renal, ovarian, breast, endometrial, squamous cellRelease of factors by bony mets increasing osteoclastsMyelomaBreast bony metsCalcitriol productionLymphomaEctopic hyperparathyroidismSmall cell lung cancer

26. Hypercalcaemia symptoms?Dehydration!Bones, stones, groans, thrones and psychic moansBone painIncreased risk of kidney stonesAbdominal pain, nauseaConstipation, polyuria (+polydipsia)Confusion, fatigue

27. Hypercalcaemia management?REHYDRATE, MONITOR U+ESTreat malignancy, support and monitor, avoid meds that worsen hypercalcaemiaThiazides, calcitriol/calcium supps, antacids, lithiumIf severeIV bisphosphonates/denosumabFurosemide

28. HypercalcaemiaTotal calcium elevated, corrected calcium >2.6Urgent if over 3Check ECG (may have short QT)PTH elevated if ectopic, serum PTHrP elevated if humoral, calcitriol high in lymphomaSkeletal XRs if not known metastasesCXR – lung Ca, sarcoidosis

29. Superior vena cava obstruction3 mechanisms of SVC obstruction?Malignancy either from intraluminal obstruction or extrinsic compression, or a thrombus75% lung cancer (esp. non small cell)15% lymphoma10% mets from breast, colon, oesophagusVenous return from head/thorax/arms is obstructed leading to increased venous pressure

30. Superior vena cava obstructionSymptoms?Oedema of face and upper limbs, dyspnoea, venous engorgement (facial plethora, neck and chest), cough, hoarse voiceVenous engorgement worse leaning forwardFixed non pulsatile raised JVPDo CXR for lung mass, CT thorax with contrast for collateral vessels and location, and USS upper extremities (for dilation SVC, thrombi)

31. Superior vena cava obstructionWhat do you do?If acute airway obstruction – airway adjuncts and call anaesthetics, DEXAMETHASONELocal radiotherapyTreat malignancy

32. Tumour lysis syndromeMetabolic and electrolyte abnormalities and renal impairment – due to lysis of rapidly dividing cancer cells, releasing intracellular contents into circulationUsually hours/days into chemotherapyUsually chemosensitive lymphoma/leukaemiaCancer cells have high turnover, produce lots of uric acid and phosphate, renal ability for excretion is saturated

33. Tumour lysis syndromeAt risk if dehydrated, renal impairment, prechemo high urate and lactateRenal saturation causes:Hyperuricaemia – can cause uric acid nephropathy and AKIHyperphosphataemia – can cause calcium phosphate deposition and obstructionSecondary hypocalcaemia (from high phosphate)Hyperkalaemia (from cell degradation)

34. Tumour lysis syndromePresents with Syncope/chest pain/dyspnoeaSeizuresNausea, D+VMuscle weakness and crampsInvestigations25% INCREASE in uric acid, phosphate, potassium25% DECREASE in calcium High creatinine and LDH

35. Tumour lysis syndromePrevention is keyPrechemotherapy IV fluids, avoid nephrotoxic meds, use allopurinol (blocks conversion to uric acid)Treating – hydrate, correct high potassium, give rasburicase (oxidises uric acid), give aluminium hydroxide (phosphate binder)

36. Other stuffPalliative care – also learn advance directives/power of attorney etc and specific care of the elderly topicsOncology – learn specific cancers with each system you revise, make sure to revise screening programmes (e.g. specific ones and also general public health topics about screening)

37. Resources – questions are keyPassmedicine Pastest – good as also has SAQsSample questions on MinervaPast years papers and peer teaching presentationsThe pastest SAQ bookThe complete SAQ study guide (red book)Placement handbooks for topics

38. Palliative Care – more info

39. Palliative careDeals with supportive care, end of life care, terminal care, bereavement supportPhysical, psychosocial, spiritualEnd of life = last 12 monthsNeeded more due to ageing population and more people wanting to die at home Need symptomatic relief to improve quality of life, reduce distress, reduce admissions

40. Recognising dyingChange in symptoms, sudden deterioration:Weight loss, poor appetiteFatigue, sleeping moreDeteriorating mobilitySocial withdrawalChange in consciousnessStruggling with medications

41. Recognising dyingWorsening performance status, needing assistance for ADLsCV changesPulse strengthChange in colourMottled skinResp changesNoisy secretionsLaboured breathingApnoeic episodes, Cheyne-Stokes breathing (rapid breaths followed by apnoea)

42. Nausea and vomitingCausesBowels – constipation, obstruction, infection, gastric stasis, mucositisBrain – raised ICPBiochemical – medications inc. chemo, hypercalcaemia, uraemia, infectionVarious receptors involved – 5HT3, GABA, D2

43. Anti-emeticsBowelsDomperidone – D2 antagonistHyoscine butylbromide - antimuscarinicBrain and bowelsOndansetron – 5HT3 antagonistMetoclopramide – D2 antagonistBrainCyclizine – H2 antagonistProchlorperazineBiochemistry and brainHaloperidol – D2 antagonistLevopromazine – D2, H2, 5HT3 antagonist

44. ConstipationCommon symptomPrescribe a stool softener (such as docusate) and a stimulant laxative (senna)

45. PainAn unpleasant sensory and emotional experience associated with actual or potential tissue damageAffects sleep, rest, movementNociceptive is tissue damage, neuropathic is nerve damageCan be pathological or functional pain

46.

47. AnalgesiaSimple Paracetamol (caution: liver impairment, cachexia)NSAIDs (caution: renal impairment, low platelets, GI bleed, asthma, on blood thinners or steroids)Weak opioidsCodeineDihydrocodeineTramadolStrong opioidsMorphine, diamorphine, oxycodone, buprenorphine, fentanyl, alfentanil, methadone, ketamine

48. Oncology – more info

49. TerminologyHypertrophy – increased size of cells/organHyperplasia – increased number of cellsAtrophy – decrease in size of cell/organMetaplasia – transformation of one terminally differentiated cell into another Dysplasia – abnormal increased cell growth with atypia, decreased differentiationApoptosis – programmed cell deathNecrosis – cell/tissue death from pathological cause i.e. trauma or ischaemia

50. TerminologyCarcinogenesis – transformation of normal cells to neoplastic cells through permanent genetic alteration/mutationCarcinogen – mutagenic substance, cause cancers i.e. viral/radiationNeoplasm – a new lesion resulting from abnormal cell proliferation – persists after initiating stimulus removed

51. TerminologyBenign (OMA) – can put pressure on structures, obstruct flow, produce hormonesLocalised, non invasiveClosely resemble normal structuresCircumscribedNormal morphologyMalignant (SARCOMA) – destroy tissue, cause blood lossInvasive, metastaticRapid growth down and inVariable resemblance to normal structuresPoorly defined border, increased mitosis

52. TerminologyPapilloma – benign epithelial neoplasmAdenoma – benign epithelial neoplasm of glandular/secretoryCarcinoma – malignant tumour of epithelial cellsAdenocarcinoma – malignant tumour of glandular/secretory epithelium

53. Tumour invasion stepsNormal tissueCarcinogenesisDysplasia In situ neoplasiaInvasive malignancyMetastatic cascade (intravasation, evasion, adherence, angiogenesis)Metastatic diseaseDeath

54. Grading1 – looks like normal cells, growing slowly2 – less like normal cells, quicker growth3 – abnormal fast growing cellsT0-3 (extent of tumour) N0-3 (presence/extent of regional lymph nodes) M0-1 (presence of metastases)

55. Radio/chemotherapyRadiotherapy – high energy beam of X rays, curative or palliative, given in fractions Palliative if unfit for surgery, anatomically unresectableCan cause fatigue, skin irritation, D+V, infertility, lymphoedemaNeoadjuvant – before surgeryAdjuvant – after surgeryChemotherapy – not curative except in leukaemia/lymphoma, given in cyclesCan cause anaemia/infection/bleeding, alopecia, D+V, anaphylaxis (STOP, do ABCDE etc)Extravasation injury – may lead to skin necrosis

56. Thrombosis/bleedingCancers are prothrombotic so VTE prophylaxis important Can cause higher number of platelets and clotting factorsSurgery/chemo can damage vessels and cause increased clotsCancer and chemo can also lead to low plateletsCancer can directly erode blood vesselsClotting factors decrease with chemo or liver involvement

57. Paraneoplastic syndromesThese are a consequence of cancer in the body but not due to local infiltration or metastasesAppear to be due to inappropriate secretion of humoral factors - hormones/growth factors either from the cancer cells or from immune response to tumourCommon in lung, pancreatic, lymphoma, breast, prostate cancersMay be first presentation of the cancer

58. Paraneoplastic syndromes - endocrineSyndrome of inappropriate antidiuretic hormone (SIADH)Mostly small cell lung cancerCushing’s syndrome – overproduction of ACTH precursorsMostly small cell lung cancer, non SCLC, carcinoidsHypercalcaemia – most caused by bony mets, this is humoral hypercalcaemia of malignancySquamous cell – NSCLC, head/neck, renal

59. Paraneoplastic syndromes - neuroPeripheral neuropathySCLC, myeloma, Hodgkin’s, breast, GIEncephalomyelopathiesSCLCCerebellar degenerationSCLC, breast, Hodgin’sLambert-Eaton myasthenic syndrome SCLC

60. Other PNSHaematological i.e. anaemia, leukocytosis, thrombocytosis – mostly renal, lymphomas, leurkaemias, lung squamous cellDermatological i.e. pruritus, pigmentation, erythema, bullous pemphigus – mostly lymphoma/leukaemia, some GI

61. Carcinoid syndromeDue to secretion of serotonin and kinins from neuroendocrine tumours Gastric carcinoma, bronchial adenoma, pancreatic carcinoma – often liver metsFlushing, diarrhoea, wheeze, abdo painTreat with resection, octreotide (somatostatin analogue)

62. Neuroendocrine tumoursNeoplasms arising from endocrine or nervous systemCommonly in the intestine (can be called carcinoid tumours)Also in pancreas, lung (SCLC)

63. SarcomaCancer of connective tissue, some associated with specific gene mutationsPresents as soft tissue swelling and painTypes:LiposarcomaLeiomyosarcoma (uterine bleed)FibrosarcomaGIST (acute abdomen, bleed)Synovial sarcomaKaposi’s sarcoma (AIDS related)

64. SarcomaPresents as >5cm enlarging, painful, deep, solid mass that recurs after excision in same placeFamilial syndromes: neurofibromatosis 1 = peripheral nerve s heath tumour, retinoblastoma leads to osteosarcomaAggressive: angiosarcoma (long term bruising at breast) and Ewing’s sarcoma (bone sarcoma young males)

65. Sarcoma Ix RxIx: CT/MRI of the mass shows heterogeneous mass with central necrosis, patchy contrast enhancementCT chest for mets, HIV test, biopsy and histology, genetic testing Rx: wide local excision with pre and post of radiotherapyPossible chemo but not very sensitive

66. LymphoedemaChronic progressive swelling of tissue with protein rich fluid as a consequence of developmental or acquired disruption of lymphatic system Majority malignancy or cancer treatmentNormally in extremities (unilateral) or genitalsMechanismsInflammation and increased vascular permeabilityLymphatic obstruction of drainageHypoalbuminaemia decreased oncotic pressureVenous oedema from increased venous pressure

67. LymphoedemaLymphatic stasis (no return via throacic duct) = fat hypertrophy, thickening subcutaneous tissue, immune dysfunctionPossible caused by filariasis nemotode blocking outflow, Milroy’s (genetic)MRI/CT shows thickened skin, honeycombing of fluid and fibrous tissueBlood smear for filariasis

68. LymphoedemaSkin care, compression bandaging, elevation, exercise, weight loss, psych supportIf filiariasis = diethylcarbamazine or albendazole