The Basics of Symptom Management: Understanding, Assessment and Principles
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Transcript of The Basics of Symptom Management: Understanding, Assessment and Principles
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• Appreciate the principles of symptom
management.
Cancer Care Ontario Guidelines
• www.cancercare.on.ca
• Palliative care tools• Symptom management tools
Objective 2: Review from yesterday
• Assess – rectal exam• Treat underlying causes• Treat symptoms
– pharmacological and non-pharmacological
• Monitor • Educate
Objective 3: Constipation
• Huge burden to patients• Uncomfortable, AND• Makes them stop using opioids
Constipation: Definition
• Infrequent, hard stools, difficult to pass
• Feeling of incomplete evacuation• Not just infrequency
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
• Assess – rectal exam• Treat underlying causes• Treat symptoms
– pharmacological and non-pharmacological
• Monitor • Educate
Management: Many products
• Know the classes of laxatives to use– Stimulant (senna)– Lubricant (mineral oil)– Osmotic (lactulose)– Opioid antagonist (methylnaltraxone)
• Usually don’t recommend:– Fibre or docusate
• Create a protocol for your practice
• Set up regular dosing of laxatives:– Sennosides or 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
• Set up regular dosing of laxatives:– Sennosides or 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!
• Prevent!!! • If not, treat aggressively• Myth: he’s not eating…• Regular laxatives if regular opioids
– Easier to decrease laxatives
Dyspnea:
• Frightening symptom• Often linked with anxiety, fear• Need lots of education and support
for patient with severe 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
• 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
From the Tumour itself;
• Compression• Obstruction• Carcinomatosis
Other Card/Resp Dx• COPD• CHF
Indirectly from tumour:
• Muscle weakness• Anemia• Thromboembolic
disease• Effusions: pleural,
pericardial, peritoneal
• Infection
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:
• Antibiotics• Drain effusion: +/- Tenchkoff catheter• Radiotherapy• Stents• Transfusions
Non-pharmacological
• Education ++• Energy Conservation• Breathing techniques• Muscle strengthening• Cool air/fan• Positioning• Relaxation exercises
Pharmacological
• Opioids are mainstay• Methyltrimeprazine• Anxiolytics• Steroids• Inhalers/diuretics• Secretion management at EOL• Trial of oxygen
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-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 dosages
• Opioid tolerant patients– titrate baseline dose by 25 - 50 %
Anxiolytics: if anxiety a component
• Lorazepam 1 – 2 mg sl q 8 hrs prn • Clonazpam 0.25 - 2.0 mg q 12 hr• Midazolam 0.5 - 1.0 mg s/c or iv q 20
mins prn
Steroids
• Dexamethasone 4 – 16 mg daily• Can give in one dose in the morning,
rather than qid
Dyspnea summary:
• Tachypnea is not dyspnea• Reverse when you can• Opioids are mainstay of medical
therapy• Use non-pharmacological measures
when you can
Delirium
• Palliative care emergency!• A delirious patient cannot express
their symptoms;• Distressing for patient and family• Remember:
– Hyperactive– Hypoactive
Patient’s remember their delirium
50% of patients remember the experience –
It is frightening for them
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
• Hydration• Opioid rotation• Bisphosponates• Stop medications if possible
Non-pharmacologic measures:
• Quiet room• Decrease stimulation• Light• Visible reminders of time and date• Verbal orientation of patient
But most importantly: TREAT IT
• Don’t leave patient untreated while attempting to reverse:
• First line:– Haloperidol 0.5 mg bid plus
breakthrough– Risperidone 0.5 mg bid plus
breakthrough– Olanzipine 2.5 mg bid plus breakthrough– If severely agitated, we use
Methyltrimeprazine
Delirium summary:
• Prevent it when possible – PCUs may use daily screening tool
(CAM)• Reverse when possible• Treat always• Counsel patient after, if needed
SUMMARY
• Many symptoms• Don’t be overwhelmed• Use the model• Use the resources out there!
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