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The Basics of Symptom Management: Understanding, Assessment and Principles. Dr. Leah Steinberg. Learning Objectives:. List several good on-line resources; Review the model of pain and symptom management; Describe basic management of Constipation, Delirium, Dyspnea

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learning objectives
Learning Objectives:
  • List several good on-line resources;
  • Review the model of pain and symptom management;
  • Describe basic management of
    • Constipation, Delirium, Dyspnea
  • Appreciate the principles of symptom management.
cancer care ontario guidelines
Cancer Care Ontario Guidelines
  • www.cancercare.on.ca
  • Palliative care tools
  • Symptom management tools
objective 2 review from yesterday
Objective 2: Review from yesterday
  • Assess – rectal exam
  • Treat underlying causes
  • Treat symptoms
    • pharmacological and non-pharmacological
  • Monitor
  • Educate
objective 3 constipation
Objective 3: Constipation
  • Huge burden to patients
  • Uncomfortable, AND
  • Makes them stop using opioids
constipation definition
Constipation: Definition
  • Infrequent, hard stools, difficult to pass
  • Feeling of incomplete evacuation
  • Not just infrequency
multiple causes we know these
Multiple causes: we know these!
  • Immobility
  • Disease
  • Neurologic abnormalities
  • Metabolic abnormalities (hypercalcemia)
  • Decreased intake
  • Medications (OPIOIDS, anticholinergics)
  • Weakness
  • Physical surroundings
again to manage follow the steps
Again, to manage – follow the steps
  • Assess – rectal exam
  • Treat underlying causes
  • Treat symptoms
    • pharmacological and non-pharmacological
  • Monitor
  • Educate
management many products
Management: Many products
  • Know the classes of laxatives to use
    • Stimulant (senna)
    • Lubricant (mineral oil)
    • Osmotic (lactulose)
    • Opioid antagonist (methylnaltraxone)
  • Usually don’t recommend:
    • Fibreor docusate
  • Create a protocol for your practice
slide11

Set up regular dosing of laxatives:

    • Sennosidesor bisacodyl: 2–4 tablets at bedtime to begin plus
    • Lactulose 30 mL at bedtime or
    • PEG 3350 powder 17 g once or twice daily
  • Monitor daily.
  • If no bowel movement by day 2:
    • Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG 3350 to 30 mL twice daily
  • If no bowel movement by day 3:
    • Perform rectal examination
  • If stool in rectum:
    • Use phosphate enema or bisacodyl suppository
  • If no stool in rectum and no contraindication:
    • Give oil enema followed by saline or tap water enema to clear
  • Increase regular laxatives
  • If problems continue:
    • Do flat-plate radiograph of abdomen
    • Switch stimulant laxative
    • Use regular enemas
slide12

Set up regular dosing of laxatives:

    • Sennosidesor bisacodyl: 2–4 tablets at bedtime to begin plus
    • Lactulose 30 mL at bedtime or
    • PEG 3350 powder 17 g once or twice daily
  • Monitor daily.
  • If no bowel movement by day 2:
    • Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG 3350 to 30 mL twice daily
  • If no bowel movement by day 3:
    • Perform rectal examination
  • If stool in rectum:
    • Use phosphate enema or bisacodyl suppository
  • If no stool in rectum and no contraindication:
    • Give oil enema followed by saline or tap water enema to clear
  • Increase regular laxatives
  • If problems continue:
    • Do flat-plate radiograph of abdomen – Rule out Bowel obstruction
    • Switch stimulant laxative
    • Use regular enemas
constipation pearls
Constipation Pearls!
  • Prevent!!!
  • If not, treat aggressively
  • Myth: he’s not eating…
  • Regular laxatives if regular opioids
    • Easier to decrease laxatives
dyspnea
Dyspnea:
  • Frightening symptom
  • Often linked with anxiety, fear
  • Need lots of education and support for patient with severe dyspnea
prevalence of dyspnea
Prevalence of dyspnea
  • 50% - 70% of all cancer patients
  • 60% of patients with NSCLC
  • Worsens as disease progresses
  • Prognostic indicator
    • When patients are dysnpeic at rest, prognosis is often in the range of weeks
etiology
Etiology
  • Multifactorial:
  • Dudgeon, Lertzman Dyspnea in the advanced cancer patient, JPSM 1998 Oct;16(4)
  • Reviewed 100 pts to determine etiology of dyspnea;
  • Average number of potential causes = 5
etiology many many causes
Etiology: many many causes

From the Tumour itself;

  • Compression
  • Obstruction
  • Carcinomatosis

Other Card/RespDx

  • COPD
  • CHF

Indirectly from tumour:

  • Muscle weakness
  • Anemia
  • Thromboembolic disease
  • Effusions: pleural, pericardial, peritoneal
  • Infection
again to manage follow the steps1
Again, to manage – follow the steps
  • Assess: to diagnose
    • Tachypnea is not dyspnea
  • Reverse when you can
  • Treat the symptoms
  • Monitor
  • Educate
treat underlying cause if possible
Treat underlying cause if possible:
  • Antibiotics
  • Drain effusion: +/- Tenchkoff catheter
  • Radiotherapy
  • Stents
  • Transfusions
non pharmacological
Non-pharmacological
  • Education ++
  • Energy Conservation
  • Breathing techniques
  • Muscle strengthening
  • Cool air/fan
  • Positioning
  • Relaxation exercises
pharmacological
Pharmacological
  • Opioids are mainstay
  • Methyltrimeprazine
  • Anxiolytics
  • Steroids
  • Inhalers/diuretics
  • Secretion management at EOL
  • Trial of oxygen
what about respiration compromise
What about respiration compromise?
  • 11 studies looked for evidence of respiratory compromise – no clinically relevant compromise found
  • Again, related to opioid naive
opioid dosages
Opioid dosages
  • Opioid-naïve patients, mild dyspnea
    • codeine 30 mg q 4 hr
    • morphine 2.5 mg q 4 hr
  • Opioid-naïve patients, moderate - severe
    • morphine 2.5 - 5.0 mg q 4 hr (or equivalent)
    • titrate 25 - 50% every 24 hrs
    • in COPD, start low and go slower
opioid dosages1
Opioid dosages
  • Opioid tolerant patients
    • titrate baseline dose by 25 - 50 %
anxiolytics if anxiety a component
Anxiolytics: if anxiety a component
  • Lorazepam 1 – 2 mg sl q 8 hrsprn
  • Clonazpam0.25 - 2.0 mg q 12 hr
  • Midazolam 0.5 - 1.0 mg s/c or iv q 20 minsprn
steroids
Steroids
  • Dexamethasone 4 – 16 mg daily
  • Can give in one dose in the morning, rather than qid
dyspnea summary
Dyspnea summary:
  • Tachypnea is not dyspnea
  • Reverse when you can
  • Opioids are mainstay of medical therapy
  • Use non-pharmacological measures when you can
delirium
Delirium
  • Palliative care emergency!
  • A delirious patient cannot express their symptoms;
  • Distressing for patient and family
  • Remember:
    • Hyperactive
    • Hypoactive
patient s remember their delirium
Patient’s remember their delirium

50% of patients remember the experience –

It is frightening for them

to manage follow the steps
To manage – follow the steps
  • Assess: to diagnose
    • Don’t forget to do physical exam
  • Reverse when you can
  • Treat the symptoms
  • Monitor
  • Educate
reverse when that is the goal
Reverse when that is the goal
  • Hydration
  • Opioid rotation
  • Bisphosponates
  • Stop medications if possible
non pharmacologic measures
Non-pharmacologic measures:
  • Quiet room
  • Decrease stimulation
  • Light
  • Visible reminders of time and date
  • Verbal orientation of patient
but most importantly treat it
But most importantly: TREAT IT
  • Don’t leave patient untreated while attempting to reverse:
  • First line:
    • Haloperidol 0.5 mg bid plus breakthrough
    • Risperidone0.5 mg bid plus breakthrough
    • Olanzipine 2.5 mg bid plus breakthrough
    • If severely agitated, we use Methyltrimeprazine
delirium summary
Delirium summary:
  • Prevent it when possible
    • PCUs may use daily screening tool (CAM)
  • Reverse when possible
  • Treat always
  • Counsel patient after, if needed
summary
SUMMARY
  • Many symptoms
  • Don’t be overwhelmed
  • Use the model
  • Use the resources out there!
opioids treat symptom of dyspnea
Opioids treat symptom of dyspnea
  • Cochrane review
  • Mechanism unclear
  • Systemic naloxone increases dyspnea
  • Opioid receptors in tracheobronchial tree and alveolar walls
  • But, no clear role for nebulized though