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Palliative Care Emergencies Wesam S. Aziz, MD 11/5/13.

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Presentation on theme: "Palliative Care Emergencies Wesam S. Aziz, MD 11/5/13."— Presentation transcript:

1 Palliative Care Emergencies Wesam S. Aziz, MD 11/5/13

2 Overview Pain Crisis Respiratory Crisis Massive Hemorrhage Uncontrolled Hiccups Hypercalcemia Drug Toxicity Seizures Tumor Lysis Syndrome SVC Obstruction SC Compression Fecal Obstruction Others

3 Goals Definition Recognition Prevention Approach Non-Pharm Tx Pharm Tx

4 Acute Pain Crisis Definition: Episodes of acute pain either new or flare of underlying chronic pain. Recognition: Pain not controlled; patient’s vocalization, vital signs (VS), grimacing, body posturing, pain scales Prevention: Educating caregivers, nursing, and staff to recognize pain. Treat sooner than later. Anticipate pain and types of pain as disease progresses and patient nears end-of-life (EOL).

5 Acute Pain Crisis Approach First and Foremost: rapidly titrate opioids to effect; increase dose by % Q2H, best achieved by short acting IV such as morphine, PCA if possible Consider: Corticosteroids (i.e. Dexamethasone) Other: NSAIDs or acetaminophen, Severe Neuropathic Pain: IV lidocaine 0.5mg/kg over 30 min, dose can be doubled every few hours. Interventional Pain: intrathecal or epidural catheters

6 Palliative Sedation (Meds) Consider proportional palliative sedation (PPS) Midazolam (SC, IV): 5 mg bolus, 1 mg/hr Lorazepam (SC, IV): 2-5 mg bolus, mg/hr Thiopental (IV): 5-7 mg/kg/hr bolus, then mg/hr Pentobarbital (IV): 1-3 mg/kg bolus, 1 mg/kg/hr Phenobarbital (IV, SC): 200 mg bolus (can repeat q10-15 min), then 25 mg/hr Propofol (IV): mg bolus (may repeat), 5-10 mg/hr Ketamine (IV) 1-4 mg/kg bolus, mg/min

7 Respiratory Crisis Definition: Dyspnea: A complex, uncomfortable sensation that includes air hunger, increased work/effort of breathing, and chest tightness Like pain; a subjective sensation, can be very disturbing for patient and caregivers Prevention Recognizing underlying co-morbidities, and anticipating potential outcomes

8 Respiratory Crisis Recognition: BREATH AIR mnemonic B: Bronchospasm R: Rales E: Effusions A: Airway Obstruction/Aspiration T: Thick Secretions H: Hemoglobin (low) A: Anxiety I: Interpersonal Issues R: Religious Concerns

9 Respiratory Crisis Approach Non-Pharm Tx: Oxygen (especially if hypoxic), Fan Pharm Tx: Opioids, opioids, opioids Anxiolytics PPS

10 Massive Hemorrhage Definition: Catastrophic exsanguination. Can occurs when tumors erode into adjacent vessels. Underlying medical conditions or medications thrombocytopenia, coagulopathy, ASA or warfarin tx. Recognition: Gross Bleeding, acute changes in VS ie.) tachycardia, tachypnea Prevention: reversal of underlying condition or stopping potential medications that can cause bleeding. Educate family and caregivers.

11 Massive Hemorrhage Approach EOL patient’s: utilize dark sheets and towels, reposition patient, recovery position Palliative Patient’s: give back lost blood Reverse cause of bleeding: FFP, vit K, plts First line  compression, can use cold (such as ice water) Hemoptysis: Aerosolized Vasopressin, embolization, bronchoscopy Uremic Bleeding: DDAVP (desmopression) SC/IV/Nasal Thrombocytopenia: Aminocaproic acid (plasmin inhibitor) IV/PO GI bleed: Endoscopy, sclerotherapy, embolization

12 Hemorrhage Bleeding gums: Transenic Acid (anti-fibrinogen) Spray Thrombin Spray Aminocaproic acid

13 Uncontrolled Hiccups Definition: (singultus) Involuntary reflex involving the respiratory muscles of the chest and diaphragm, mediated by the phrenic (C3-C5) and vagus (CN X) nerves basically diaphragm contracts and pushes air up through closed larynx. Recognition: “I know it when I see it” – Supreme Court Justice Potter Stewart. Once hiccups have lasted to annoyance, intervention may be appropriate Prevention: treatment of underlying cause ie.) medications, infection

14 Uncontrolled Hiccups Approach Non-Pharm Tx gargling with water, biting a lemon, swallowing sugar, vagal stimulation such as carotid massage or valsalva maneuver Rubbing over the 5th cervical vertebrae (interrupting phrenic n.) interrupting the respiratory cycle through sneezing, coughing, breath holding, hyperventilation, or breathing into a paper bag

15 Uncontrolled Hiccups Pharm Tx Anti-Psychotics Chlorpromazine – the only FDA approved drug for hiccups. Haloperidol – useful alternative to chlorpromazine; Anti- Convulsants Other Gabapentin, Phenytoin, Carbamazapine, Valproic Acid Miscellaneous Baclofen – the only drug studied in a double blind randomized controlled study for treatment of hiccups Metoclopramide Nifedipine - a relatively safe alternative if other interventions have failed.

16 Hypercalcemia Definition: Elevated calcium, mg/dL Mild mg/dl moderate >14 mg/dl severe 10-20% of cancer patients most common in NSCLC, Beast Ca, H&N Ca, RCC, MM, T-Cell Lymphoma; 80% caused by PTH-Like Peptide released by cancer or Bone destruction caused by metastatic disease Prevention: Treating underlying causes

17 Hypercalcemia Recognition: Mnemonic: Groans (constipation), Moans (fatigue, lethargy, nausea), Bones (bone pain), stones (kidney), and Psychiatric overtones (confusion, depression) Caution: Can be falsely low hypoalbuminemia can mask hypercalcemia, measured calcium is the calcium bound to albumin,

18 Hypercalcemia Approach Non-Pharm Tx: Volume expansion to increase calcium excretion Eliminate extra sources of calcium Pharm Tx Loop diuretic: inhibits resorption of calcium at loop of henle Biphosphonates: Mainstay therapy, takes 2-4 days to work, risk of BONJ – high incidence with IV formulation vs. low incidence with PO Calcitonin: given acutely because, short lasting

19 Drug Toxicity Morphine Myoclonus - uncontrollable muscle spasms, dose-related effect of opioids, associated with somnolence and AMS TX - change to another analgesic, can use intermediate/short-acting BZD such as clonazapam or lorazapam Opioid-Induced Hyperanalgesia – patient’s receiving opioids may actually become more sensitive to certain painful stimuli and may experience pain from ordinarily non-painful stimuli (allodynia)

20 Seizures Definition: Most often occur in patients with cerebral or leptomeningeal malignancies, cerebrovascular diseases, and electrolyte abnormalities (ie. hyponatremia, hypercalcemia) Recognition: Acute mental status changes, partial or generalized tonic/clonic movements, maybe incontinence (urinary/fecal). Most challenging to recognize is NCSE (Non-Convulsive Status Epilepticus) Prevention In patients with advanced brain tumors AAN (American Association of Neurology) does not recommend prophylactic use of anti-epileptic drugs

21 Seizures Approach Non-Pharm Place in recovery position Remove objects that may cause injury Pharm Tx Status Epilepticus 1 st Line: BZD & Phenytoin 2 nd Line: replace phenytoin with valproic acid or barbiturate 3 rd Line: Levetiracetem (levels more consistent, don’t need to monitor levels, and less drug/drug interactions)

22 Tumor Lysis Syndrome (TLS) Definition - an oncologic emergency caused by massive tumor cell lysis with the release of large amounts of potassium, phosphate, and nucleic acids into blood steam Recognition – Patient’s recently started on chemotherapy: nausea, vomiting, diarrhea, anorexia, lethargy, heart failure, cardiac dysrhythmias, seizures, muscle cramps, tetany, and possible sudden death Prevention – Anticipate in patients with Rapidly growing tumors Chemosensitivity of the malignancy Large tumor burden

23 Tumor Lysis Syndrome (TLS) Approach is prevention Aggressive IV fluids – 2 to 3 L daily to achieve a urine output of at least 80 to 100 mL/m 2 per hour. Allopurinol – decreases the formation of new uric acid Rasburicase – alternative to allopurinol, useful in patients who are currently hyperuricemic.

24 SVC (Superior Vena Cava) Obstruction Definition: Obstruction of SVC (upper right mediastinum) caused by primary or metastatic dz Recognition: Facial plethora, facial and/or upper extremity edema, dilated vessels of the chest/neck/arms, patient can experience cough, hoarseness, headache Prevention: Treat underlying causes

25 SVC Obstruction Approach Non-Pharm Tx Consider XRT, Sx, or endovascular techniques when tumor not chemosensitive Pharm Tx Steroids Chemotherapy: especially with lymphomas

26 SC Compression Definition: Compression of Spinal Cord (SC) putting patients at risk for pain, paresis or paralysis, incontinence Recognition: PB KTL (lead kettle) – cancers that metastasize to bone P: Prostate B: Breast K: Kidney T: Thyroid L: Lung SIGNS: Red-Flags New, progressively severe back pain (particularly thoracic) presenting as (burning, shooting, numbness), saddle paresthesia Bowel or bladder disturbance - loss of sphincter control is a late sign with a poor prognosis.

27 SC Compression Approach Non-Pharm Tx XRT Surgical decompression Pharm Tx Steroids: Dexamethasone Opioids – pain control

28 Severe Constipation/Fecal Obstruction Definition: A fecal impaction is a solid, immobile bulk of feces that can develop in rectum or colon as a result of chronic constipation. Opioid induced constipation: side-effect that one does not grow tolerance to, opioids decrease gastic and intestinal motility, via mu-receptors. Recognition: “need to ask” “when was your last BM?” No BM after conventional methods of stimulants and softeners Rectal exam reveal solid mass in rectum Imaging studies may reveal constipation more proximal

29 Severe Constipation/Fecal Obstruction Prevention: Water, water, water Fiber & foods high in fiber Stool Softeners Stimulants Laxatives

30 Severe Constipation/Fecal Obstruction Approach: Non-Pharm Water Fiber Pharm Titrate up softeners and stimulants Add Laxative Retention enemas Methlynaltrexone, selectively antagonized peripheral mu- opioid receptors, inhibiting opioid-induced hypomotility. Weight based, given SQ, pt must not be obstructed, risk of perforation.

31 Other Problems Obstructive nephropathy Foley Cardiac tamponade Febrile neutropenia Hyper viscosity Syndrome Plasma exchange Increased intracranial pressure Diuretics, acetazolamide, surgical decompression/shunt Hypoglycemia IV Fluids, Insulin

32 References pts pts Up To Date UNIPAC 4 th edition


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