Management of Non-Pain Symptoms

436 views
356 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
436
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
15
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • 34
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
  • 32
  • 33
  • Management of Non-Pain Symptoms

    1. 1. Management of Non-Pain Symptoms Junior Student Rotation in Palliative Medicine Douglas D. Ross, MD, PhD
    2. 2. General Principles <ul><li>Listen to the Patient. </li></ul><ul><li>Make a diagnosis before you treat: </li></ul><ul><ul><li>History, exam, [lab], working diagnosis </li></ul></ul><ul><li>Know the drugs you prescribe... </li></ul><ul><li>Keep it simple! </li></ul><ul><li>Not everything that hurts responds to analgesics </li></ul><ul><li>There is always something that can be done. </li></ul>
    3. 3. Prevalence of Symptoms in Patients with Cancer
    4. 4. Urgent Symptoms <ul><li>Pathologic Fracture </li></ul><ul><li>Seizure </li></ul><ul><li>Spinal Cord Compression </li></ul><ul><li>Increased Intracranial Pressure </li></ul><ul><li>Superior Vena Cava Syndrome </li></ul><ul><li>Hypercalcemia </li></ul>
    5. 5. Major Symptom Areas <ul><li>Anorexia </li></ul><ul><li>Gastrointestinal: </li></ul><ul><ul><li>Oral / Dysphagia / Nausea-vomiting / constipation / bowel obstruction </li></ul></ul><ul><li>Dyspnea </li></ul><ul><li>Delirium and terminal restlessness </li></ul>
    6. 6. Reversible causes of Anorexia <ul><li>A Aches and Pains </li></ul><ul><li>N Nausea and GI dysfunction </li></ul><ul><li>O Oral Candidiasis </li></ul><ul><li>R Reactive/organic Depression </li></ul><ul><li>E Evacuation problems </li></ul><ul><li>X Xerostomia (dry mouth) </li></ul><ul><li>I Iatrogenic--chemo, radiation </li></ul><ul><li>A Acid related: GERD, PUD </li></ul>
    7. 7. Before you place that IV or G-tube in a terminally ill patient.... CONSIDER : <ul><li>Tube or forced feedings: </li></ul><ul><ul><li>Do not prolong survival </li></ul></ul><ul><ul><li>Increase the discomfort </li></ul></ul><ul><ul><li>Aspiration, secretions, edema, ascites, effusions, pulmonary congestion, nausea, diarrhea, use of restraints </li></ul></ul><ul><li>TPN is associated with decreased survival in terminal cancer patients </li></ul>
    8. 8. Terminal patient refusal of food and water: <ul><li>Frequently more traumatic to the family than the patient </li></ul><ul><li>Chronic/terminal starvation and dehydration per se are not uncomfortable </li></ul>
    9. 9. Useful Interventions : <ul><li>Sensible dietary advice: </li></ul><ul><ul><li>small portions of favorite foods </li></ul></ul><ul><ul><li>avoid foods with strong odors </li></ul></ul><ul><ul><li>do not force intake </li></ul></ul><ul><li>Family Conference </li></ul><ul><li>TRIAL of Appetite Stimulants </li></ul><ul><ul><li>Megace 80 to 200 mg tid or qid </li></ul></ul><ul><ul><li>Prednisone 1 to 2 mg qd or bid </li></ul></ul><ul><ul><li>Marinol 2.5 to 5 mg bid or tid </li></ul></ul>
    10. 10. Dysphagia: Some causes and treatments <ul><li>Dry mouth caused by radiation </li></ul><ul><ul><li>Synthetic saliva q 1 to 2 hrs </li></ul></ul><ul><ul><li>Pilocarpine 5-10 mg tid ** caution </li></ul></ul><ul><li>Dryness caused by drugs such as </li></ul><ul><ul><li>Compazine, thorazine, amitryptyline </li></ul></ul>
    11. 11. Dysphagia, continued : Infectious causes and treatments <ul><li>Oral Candidiasis </li></ul><ul><ul><li>Nystatin; Clotrimazole troches </li></ul></ul><ul><ul><li>Ketoconazole 200 mg qd x 14 d </li></ul></ul><ul><ul><li>Fluconazole 100 mg qd x 14 d </li></ul></ul><ul><li>Bacterial: periodontal disease </li></ul><ul><li>Viral-- Herpes simplex </li></ul><ul><ul><li>Acyclovir 400 mg 5 times/day x 10 d </li></ul></ul>
    12. 12. Dysphagia, continued : More causes and treatments <ul><li>Reflux esophagitis </li></ul><ul><li>Mucosal damage--soothing agents </li></ul><ul><ul><li>Benadryl and kayopectate mouthwash </li></ul></ul><ul><ul><li>Viscous lidocaine </li></ul></ul><ul><ul><li>May require parenteral opioids </li></ul></ul><ul><li>Systemic dehydration </li></ul><ul><ul><li>ice chips, sips of fluid, moist sponge stick </li></ul></ul>
    13. 13. Dyspnea <ul><li>“ An uncomfortable awareness of breathing” ( UNIPAC #4 ) </li></ul><ul><li>DISTINGUISH dyspnea from hyperpnea and tachypnea </li></ul><ul><li>DIAGNOSE and treat underlying cause when possible and reasonable </li></ul>
    14. 14. Dyspnea, treatable causes <ul><li>B Bronchospasm </li></ul><ul><li>R Rales--CHF, volume overload </li></ul><ul><li>E Effusions </li></ul><ul><li>A Airway obstruction </li></ul><ul><li>T Thick Secretions </li></ul><ul><li>H Hemoglobin low--caution </li></ul><ul><li>A Anxiety </li></ul><ul><li>I Interpersonal issues </li></ul><ul><li>R Religious concerns </li></ul>
    15. 15. When to treat dyspnea symptomatically <ul><li>No treatable etiology identified </li></ul><ul><li> OR </li></ul><ul><li>The treatments do not completely relieve the distressing symptom (dyspnea) </li></ul>
    16. 16. Opioid Therapy for Dyspnea: Considerations <ul><li>safe and effective when titrated </li></ul><ul><ul><li>start with usual anti pain doses, increase dose 30 to 50% q 4 to 12 hrs until patient is comfortable </li></ul></ul><ul><li>In COPD patients, opioids increase exercise tolerance with decreased breathlessness, reduce O 2 need </li></ul>
    17. 17. Opioid Therapy for Dyspnea Continued... <ul><li>Mild Dyspnea </li></ul><ul><ul><li>Hydrocodone 5 mg q4h and q2h prn </li></ul></ul><ul><ul><li>Codeine (30 mg)- 1 tab q4h and q2h prn </li></ul></ul><ul><li>Severe Dyspnea </li></ul><ul><ul><li>for patients on no or weak opioids </li></ul></ul><ul><ul><ul><li>Oxycodone 3-10 mg q4h and q2h prn </li></ul></ul></ul><ul><ul><ul><li>Oral morphine-3-10 mg q4h and q2h prn </li></ul></ul></ul><ul><ul><ul><li>Hydromorphone 0.5-2 mg q4h and q2h prn </li></ul></ul></ul><ul><ul><ul><li>Nebulized morphine... </li></ul></ul></ul>
    18. 18. Therapy of Severe Dyspnea Continued... <ul><li>Patients already taking strong opioids... </li></ul><ul><li>Consider the anxiety component of dyspnea: </li></ul><ul><ul><li>ADD Benzodiazipines (short acting) </li></ul></ul><ul><ul><ul><li>mild: PO lorazapam 0.2 to 2 mg q8h </li></ul></ul></ul><ul><ul><ul><li>severe: may need midazolam titration-start with 0.25 mg SQ q hr--TITRATE </li></ul></ul></ul>
    19. 19. Dyspnea: other considerations <ul><li>Use of Oxygen </li></ul><ul><ul><li>Reserve for hypoxic patients?? </li></ul></ul><ul><ul><li>Opioids are first choice for dyspnea, the symptom </li></ul></ul><ul><ul><li>Use least invasive delivery--nasal prongs </li></ul></ul><ul><li>The terminal state </li></ul><ul><ul><li>benzodiazepines </li></ul></ul>
    20. 20. Nausea and Vomiting <ul><li>Frequency in terminal cancer: </li></ul><ul><ul><li>Nausea--50% to 60% of patients </li></ul></ul><ul><ul><li>Vomiting--30% of patients </li></ul></ul><ul><li>Can be controlled in 90% of cases </li></ul><ul><li>Pathophysiology: </li></ul><ul><ul><li>Cerebral cortex </li></ul></ul><ul><ul><li>Vestibular apparatus </li></ul></ul><ul><ul><li>Chemoreceptor trigger zone </li></ul></ul><ul><ul><li>Gastrointestinal tract </li></ul></ul>
    21. 21. Nausea and Vomiting: Some treatable causes <ul><li>Cortical: </li></ul><ul><ul><li>CNS tumor </li></ul></ul><ul><ul><li>Intracranial pressure </li></ul></ul><ul><ul><li>Anxiety, uncontrolled pain </li></ul></ul><ul><li>Vestibular / Middle ear </li></ul><ul><ul><li>Vestibular disease </li></ul></ul><ul><ul><li>Middle ear infections </li></ul></ul>
    22. 22. Nausea and Vomiting: More treatable causes <ul><li>Chemoreceptor Trigger Zone </li></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Metabolic--e.g., renal, liver </li></ul></ul><ul><ul><li>Hyponatremia, Hypercalcemia </li></ul></ul><ul><li>Gastrointestinal Tract </li></ul><ul><ul><li>Gastritis/esophagitis </li></ul></ul><ul><ul><li>Constipation, impaction </li></ul></ul><ul><ul><li>Obstruction </li></ul></ul><ul><ul><li>Tube feedings </li></ul></ul>
    23. 23. Persistent nausea... in a terminally ill patient <ul><li>Rule out bowel obstruction </li></ul><ul><li>Start with </li></ul><ul><ul><li>Haloperidol 1 mg PO or SC bid or tid, increase to 10 to 15 mg/day, as needed </li></ul></ul><ul><li>If needed, add: </li></ul><ul><ul><li>Antihistamine (e.g., hydroxyzine) and /or </li></ul></ul><ul><ul><li>Metoclopramide (beware in bowel obstruction) </li></ul></ul><ul><ul><li>Other: Ondansetron (Zofran), Granisitron (Kytril), methotrimeprazine (Levoprome) </li></ul></ul>
    24. 24. Bowel Obstruction... in advanced cancer <ul><li>Incidence--3% overall in Hospice </li></ul><ul><ul><li>Ovarian Cancer: 5% to 42% </li></ul></ul><ul><ul><li>Colorectal Cancer: 10% to 30% </li></ul></ul><ul><li>Mechanism: mechanical, paralytic </li></ul><ul><li>Symptoms... </li></ul><ul><li>Surgery...limited usefulness in terminally ill cancer patients </li></ul>
    25. 25. Bowel Obstruction... in advanced cancer <ul><li>GOAL: no cramps, no pain, minimal nausea, no more than 1 emesis/day </li></ul><ul><li>Achieved IN MOST CASES </li></ul><ul><ul><li>WITH analgesics, anticholinergic and antiemetic drugs </li></ul></ul><ul><ul><li>WITHOUT the use of decompression tubes, surgery or IV fluids </li></ul></ul>
    26. 26. Pharmacologic treatment of malignant bowel obstruction <ul><li>Pain: strong opioids </li></ul><ul><li>Nausea: </li></ul><ul><ul><li>haloperidol, antihistamines, phenothiazines (anticholinegic effect); </li></ul></ul><ul><ul><li>metoclopramide: may make sx worse in mechanical obstruction </li></ul></ul><ul><li>Mechanical: vomiting of GI secretions, cutaneous fistulas </li></ul><ul><ul><li>Octreotide (Sandostatin) </li></ul></ul>
    27. 27. Octreotide (Sandostatin TM ) <ul><li>Synthetic analogue of Somatostatin: </li></ul><ul><ul><li>Decreases intestinal secretion, bile flow </li></ul></ul><ul><ul><li>Increases intestinal absorption </li></ul></ul><ul><li>Adverse effects: </li></ul><ul><ul><li>Dry mouth, Flatulence </li></ul></ul><ul><ul><li>Hypo- or hyperglycemia </li></ul></ul><ul><ul><li>Pain at injection site... </li></ul></ul><ul><li>Dosage and administration </li></ul><ul><ul><li>150   g SC, bid OR </li></ul></ul><ul><ul><li>300   g over 24h by SC infusion. Max. 600  g/day </li></ul></ul>
    28. 28. Delirium and terminal agitation <ul><li>Delirium: up to 85% of terminal cancer patients </li></ul><ul><li>Features may include </li></ul><ul><ul><li>Clouding of consciousness, altered attention </li></ul></ul><ul><ul><li>Perceptual disturbances </li></ul></ul><ul><ul><li>Acute onset, fluctuating course </li></ul></ul>
    29. 29. Delirium--Causes <ul><li>D Drugs, especially psychotropics </li></ul><ul><li>E Electrolyte imbalance </li></ul><ul><li>L Liver failure </li></ul><ul><li>I Ischemia or hypoxia </li></ul><ul><li>R Renal failure </li></ul><ul><li>I Impaction of stool </li></ul><ul><li>U Urinary tract or other infection </li></ul><ul><li>M Metastases, other neurological </li></ul>
    30. 30. Drug Treatment of Delirium <ul><li>Haloperidol 1-2 mg PO or SC q1h to calm the crisis, then q6-12 hr </li></ul><ul><li>If more sedation is desired, or for the AIDS dementia complex, use </li></ul><ul><ul><li>Thioridazine (Mellaril) 25-50 mg PO q1h until calm then q6-12 hr OR </li></ul></ul><ul><ul><li>Chlorpromazine 25-50 mg PO or IV until calm then q6-12 hr </li></ul></ul>
    31. 31. Severe Agitated Delirium <ul><li>Consider ADDING </li></ul><ul><ul><li>Lorazepam (Ativan) 1-2 mg q1hr until calm (PO, SL or IV) </li></ul></ul><ul><ul><li>Midazolam (Versed) 0.4-4 mg/hr continuous SC infusion </li></ul></ul><ul><ul><li>Chlorpromazine (Thorazine) 100 mg q1h PO, PR or IV until calm </li></ul></ul><ul><ul><li>Methotrimeperazine (Levoprome) 20 mg q1h IM or IV, until calm </li></ul></ul>
    32. 32. Smelly Tumors <ul><li>Cause: Necrotic exposed tumor mass </li></ul><ul><ul><li>Breast (25%), Lung 7%, Renal (5%), Colon (3%) </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Pain Control </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Control odor: etiol. Bacteroides sp. </li></ul></ul><ul><ul><ul><li>apply METRONIDAZOLE gel (0.8%) + systemic treatment (200-400 mg PO tid) </li></ul></ul></ul><ul><ul><ul><li>Charcoal Dressings </li></ul></ul></ul><ul><ul><ul><li>MAALOX </li></ul></ul></ul><ul><ul><li>Soak dressings off </li></ul></ul>
    33. 33. Other Non-pain Symptom Areas <ul><li>Pressure Sores </li></ul><ul><li>Stomas/fistulas </li></ul><ul><li>Edema/lymphedema </li></ul><ul><li>Pruritis/skin problems </li></ul><ul><li>Other GI-diarrhea, ascites, impactions </li></ul><ul><li>Hemoptysis </li></ul><ul><li>Pleural effusions </li></ul><ul><li>Incontinence </li></ul><ul><li>Urinary retention </li></ul><ul><li>Hematuria </li></ul><ul><li>Drug reactions </li></ul><ul><li>Seizures, other neurological </li></ul><ul><li>Metabolic symptoms </li></ul><ul><li>Fever, infections </li></ul>
    34. 34. SUMMARY Non-pain symptom management <ul><li>Listen to the Patient. </li></ul><ul><li>Make a diagnosis before you treat: </li></ul><ul><ul><li>History, exam, [lab], working diagnosis </li></ul></ul><ul><li>Know the drugs you prescribe... </li></ul><ul><li>Keep it simple! </li></ul><ul><li>Not everything that hurts responds to analgesics </li></ul><ul><li>There is always something that can be done. </li></ul>

    ×