Management of Non-Pain Symptoms

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Transcript

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