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Palliative Care Emergencies

Palliative Care Emergencies. Wesam S. Aziz, MD 11/5/13. Overview. Pain Crisis Respiratory Crisis Massive Hemorrhage Uncontrolled Hiccups Hypercalcemia Drug Toxicity. Seizures Tumor Lysis Syndrome SVC Obstruction SC Compression Fecal Obstruction Others. Goals. Definition

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Palliative Care Emergencies

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  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 50-100% 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, 0.5-1.0 mg/hr • Thiopental (IV): 5-7 mg/kg/hr bolus, then 20-80 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): 20-50 mg bolus (may repeat), 5-10 mg/hr • Ketamine (IV) 1-4 mg/kg bolus, 0.1-0.5 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, • 11-12 mg/dL Mild • 12-14 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 1st Line: BZD & Phenytoin 2nd Line: replace phenytoin with valproic acid or barbiturate 3rd 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 Ldaily to achieve a urine output of at least 80 to 100 mL/m2 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 • http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts • Up To Date • UNIPAC 4th edition

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