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OLIVER A. CERQUEIRA, D.O. ASSISTANT PROFESSOR OF INTERNAL MEDICINE CLERKSHIP DIRECTOR, INTERNAL MEDICINE OU-TULSA SCHOOL OF COMMUNITY MEDICINE Non-pain.

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Presentation on theme: "OLIVER A. CERQUEIRA, D.O. ASSISTANT PROFESSOR OF INTERNAL MEDICINE CLERKSHIP DIRECTOR, INTERNAL MEDICINE OU-TULSA SCHOOL OF COMMUNITY MEDICINE Non-pain."— Presentation transcript:

1 OLIVER A. CERQUEIRA, D.O. ASSISTANT PROFESSOR OF INTERNAL MEDICINE CLERKSHIP DIRECTOR, INTERNAL MEDICINE OU-TULSA SCHOOL OF COMMUNITY MEDICINE Non-pain Symptomatic Management in Palliative Care

2 Objectives Apply generalized principles of symptom management to "real world" clinical scenarios Choose appropriate management for a variety of non-pain symptoms that are addressed by palliative care

3 Palliative Care

4 So, what S/Sx are out there to be addressed? Nausea & Vomiting** Dyspnea** Constipation Diarrhea Ascites/Pleural Effusions Bowel Obstruction Fatigue Singultus Depression Lymphedema/Edema Anuria Insomnia Hot Flashes Anxiety Delirium/Confusion** Secretions Pruritus Fever Cough Anorexia/Cachexia Xerostomia Mucositis/Stomatitis Pressure Ulcers/Wound Care/Wound Odor Bladder Spasms Candidiasis

5 Generally, what are two ways to manage S/Sx? Non-pharmacologic/Mechanical Pharmacologic  Routes of Administration  PO  IV  IM  Sub-Q  Buccal & SL  TD  PR  Intranasal/Inhalation

6 Principles of Symptom Control Four domains of the human suffering experience:  Physical  Emotional  Social  Spiritual

7 Principles of Symptom Control Do NOT overlook symptomatic management while focusing on disease-oriented care  e.g. Pleuritic CP & PNA When possible, identify the underlying pathophysiology &/or mechanism Symptoms are the patient’s experience of the illness The clinician is obligated to relieve those symptoms Unrelieved suffering is demoralizing & demeaning  Suffering patients may lose the will to live, become depressed & withdrawn, & decline more rapidly

8 Principles of Symptom Control Treatment considerations:  Anticipate predictable complications of disease states  e.g. colorectal cancer patients & bowel obstruction; head & neck cancer patients & sudden exsanguination  Anticipate associated complications of palliative treatments  e.g. opioids & N/V, constipation, sedation, delirium  Evaluate for psychosocial difficulties  e.g. poor home support & complex treatment regimens; low income & medication affordability  Ultimately, patient’s goals of care drive symptomatic management decisions  e.g. clarity of mind vs. suffering pain  Frequent re-evaluation

9 Nausea & Vomiting Occurs 60-70% of patients with advanced cancer Prevention is key: Regular dosing of antiemetics can often prevent recurrent nausea Associated with autonomic s/sx, including pallor, cold sweats, decreased respiratory rate, & sometimes diarrhea Hypersalivation Cardiac rhythm disturbances may occur Gastric emptying is reduced in the presence of nausea – don’t assume PO medications will work, even if there is no vomiting!

10 Nausea & Vomiting – 4 Inputs

11 Nausea & Vomiting

12 Nausea & Vomiting – Pharmacologic Treatment V.O.M.I.T. acronym  Vestibular  Cholinergic, Histaminic  Scopolamine, Promethazine  Obstruction of bowel by constipation ( NOT mechanical obstruction )  Cholinergic, histaminic, likely 5HT3  Stimulate myenteric plexus – Senna  DysMotility of the upper gut  Cholinergic, histaminic, 5HT3, 5HT4  Metoclopramide  Infection, Inflammation  Cholinergic, histaminic, 5HT3, NK1  Toxins stimulating CTZ  Dopamine 2, 5HT3  Haloperidol, Odansetron, Prochlorperazine

13 Nausea & Vomiting – Pharmacologic Treatment

14 Nausea & Vomiting – Non-pharmacologic Ginger Root  5HT3 antagonism in animal models Measures to enhance gastric emptying and decrease gastric distention  Liquid diet  Frequent small meals  Foods low in fats & fiber, high in protein Measures to minimize other noxious or associated stimuli  Cool foods  Foods with a pleasant appearance & w/o odors Acupuncture  At the P6 or pericardium 6 point  Produces vagal modulation & enhances 5HT3RA efficacy Cognitive—Behavioral Therapy  Induces muscle relaxation & reverses autonomic arousal that accompanies ALL nausea

15 Delirium - Definition

16 Delirium – Subtype Manifestations Three subtypes based on arousal levels & psychomotor behavior  Hyperactive delirium  Hallucinations, agitation, delusions, & disorientation  Hypoactive delirium  Decreased consciousness, somnolence  In PC, is more common – up to 80%  Mixed-form with alternating features

17 Delirium - Pathophysiology

18 Delirium – Risk Factors & Causes

19 Medications are the most common identifiable causes of delirium in the hospital setting!  Anti-cholinergics  Sedative-hypnotics  Opioids Other common causes:  Metabolic derangements  Infections  CNS pathology  Drug/alcohol withdrawal

20 Delirium – Risk Factors & Causes

21 Delirium – Pharmacologic Treatment Benzodiazepines may cause paradoxical worsening of symptoms (possibly by a serotonergic mechanism) & should not be used first line Use lowest doses possible, especially with haloperidol as EPS side effects are dose- dependant! IV haloperidol may cause less EPS than PO When reaching maximum dosages of haloperidol, one option is to add or switch to a more sedative neuroleptic

22 Delirium – Non-pharmacologic

23 Dyspnea Experienced by up to 70% of terminally ill cancer patients at some point during the course of their disease Diminishes functional status, social activities, QOL, & the will to live In one multi-center study from 2000, terminal sedation was prompted by dyspnea 3X more commonly than by pain The typical pattern is one of chronic dyspnea, punctuated by unpredictable, but expected, acute episodes SUBJECTIVE!!  e.g. patients may be hypoxic & “look dyspneic,” but when well-palliated, they report no sense of dyspnea  Patient self-report is the only accurate measure of dyspnea

24 Dyspnea – Multidimensional

25 Dyspnea – Physiology & Pathophysiology The sensory cortex receives copies of respiratory motor commands arising from the medulla or motor cortex & sensory information from peripheral chemoreceptors & mechanoreceptors Dyspnea occurs if the degree of motor output required is perceived to be unsustainable or disproportionate to the sensory information received

26 Dyspnea – Generalized Treatment Measures Address the underlying etiology or etiologies, if at all possible Reduce the need for exertion Repositioning, usually to a more upright position Keep the compromised lung down in unilateral pulmonary disease Improve air circulation – open doors & windows, use a fan Avoid strong odors, fumes, & smoke Identify & avoid any triggers that precipitate or worsen dyspnea

27 Dyspnea – Opioids First-line therapy Can be used alone or aside reversible etiologies Most beneficial for dyspnea at rest Evidence has repeatedly shown that opioids can be safe & effective at controlling dyspnea in several clinical populations, including COPD, CHF, pulmonary fibrosis, & cancer Respiratory depression is uncommon when titration is appropriate & is almost always preceded by drowsiness/sedation  Hold Parameters

28 Dyspnea – Opioids Reversal agents (i.e., naloxone) should only be used in the setting of life-threatening opioid toxicity Most published trials studied morphine, but trials of other opioids such as fentanyl, M6G, & hydromorphone suggest a class effect Most common adverse effects experienced in this population: Constipation, nausea, sedation

29 Dyspnea – Opioids Mechanisms by Which Opioids May Reduce Dyspnea:  Decreased metabolic rate and ventilatory requirements  Reduced medullary sensitivity & response to hypercarbia or hypoxia  Alteration of neurotransmission within medullary respiratory center  Cortical sedation (i.e., suppression of respiratory awareness)  Analgesia reduction of pain-induced respiratory drive  Vasodilation (i.e., improved cardiac function)  Anxiolytic effects

30 Dyspnea – Opioids Opiate-naïve older age or patients with CKD  Consider reducing starting dose by ½  Avoid morphine in renal disease if possible DOE or dyspnea with movement  Give 30 minutes prior to activity If on stable IR dosage, consider trial of LA as baseline with IR PRN in between doses

31 Dyspnea – Other Treatment Benzodiazepines  Addresses concomitant anxiety  No evidence that there is a direct benefit Oxygen  Often patients report improved dyspnea, even when not hypoxemic or when they remain hypoxemic  ? Placebo effect due to inherent medical symbolism  Some studies have demonstrated dampening of dyspnea due to stimulation of the trigeminal nerve, V2 branch  Depending on patient preference, generally avoid face masks

32 Dyspnea – Pursed Lip Breathing

33 The End!!

34 References Bruera, Eduardo et al. Textbook of Palliative Medicine. 1st ed. Houston, TX: CRC Press; Adamis, D. et al. Delirium Scales: A review of current Evidence. Aging & Mental Health. 2010; Vol 14, No.5; Walsh, Declan et al. Palliative Medicine. 1st ed. Philadelphia, PA: Saunders; Karnani, NG. Management of Selected Non-Pain Symptoms at the End of Life. Northeast Florida Medicine. 2010; Vol 61, No.4: Rousseau, Paul. Nonpain Symptom Management in the Dying Patient. Hospital Physician. 2002; Feb: Montagnini, Marcos et al. Non-Pain Symptom Management in Palliative Care. Clinics in Family Practice. 2004;Vol 6, No.2: Quill, Timothy E. et al. Primer of Palliative Care. 5th ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; Weissman, DE. Dyspnea at End-of-Life, 2nd ed. Fast Facts and Concepts. July 2005;27. Accessed Feb 10, Weissman, DE. Diagnosis and Management of Terminal Delirium, 2nd ed. Fast Facts and Concepts. July 2005;1. Accessed Feb 10, Quijada, E, Billings JA. Pharmacologic Management of Delirium; Update on Newer Agents, 2nd Ed. Fast Facts and Concepts. July 2006;60. Accessed Feb 10, Hallenbeck J. The Causes of Nause and Vomiting (V.O.M.I.T.), 2nd Ed. Fast Facts and Concepts. July 2005; 5. Accessed Feb 10, Shirk, Mary B. et al. Unlabeled Uses of Nebulized Medications. Am J Health-Syst Pharm. Sept 15, 2006; Vol 63: Kallet, Richard H. The Role of Inhaled Opiods and Furosemide for the Treatment of Dyspnea. Respiratory Care. Jul 2007; Vol 52, No.7: Casarett, DJ, and Inouye, SK. Diagnosis and Management of Delirium near the End of Life. Ann Intern Med. 3 July 2001;135(1): Manepalli, Jothika N. et al. Differential Diagnosis of the Older Patient With Psychotic Symptoms. Primary Psychiatry. 2007;14(8): Mergenhagen, KA and Arif, S. Delirium in the Elderly: Medications, Causes, and Treatment. Updated June 1, Accessed Feb 10, Walker HK, et al. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Chapter 83: Nausea and Vomiting by William F. Maule. Boston: Butterworths; Leonard R Johnson; John H Byrne; et al. Essential medical physiology, 3rd ed Amsterdam : Elsevier Academic Press, ©2003. Fallon, M. and Hanks, G. ABC of Palliative Medicine, 2nd Ed. Malden, MA: Blackwell Publishing Ltd;


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