Naloxone in palliative care 🧵

Naloxone can save lives in people with opioid induced respiratory failure or apnoea.

It’s use only indicated when there is a fall in respiratory rate with evidence of significant ventilatory failure There are various parameters quoted for using naloxone which include:
Resp rate <8/min with
O2 sats <85% or
Cyanosis

In palliative care patients taking regular opioid for pain great care is needed before using naloxone

Cancer cachexia in palliative care

A Thread 🧵

The term Cachexia originates from the Greek words Kakos and Hexis and translates to “bad physical state”

It is estimated to be the direct cause of death in up to 20% of cancer patients. What is it?

Definitions

5% or more loss of body weight in last 12 months or BMI < 20 with 2% or more weight loss or sarcopenia with 2% or more weight loss.

A spectrum of cachexia severity exists and early identification of the pre-cachexia stage often missed

ESPEN 2017

Case 1 discussion 🧵

https://twitter.com/existential_doc/status/1776384679332970931

Opioid induced nausea and vomiting (OINV) is very common and by no means unique to palliative care.

It is important to have an understanding of the natural history of OINV to help establish pain control in palliative care when opioids are really needed

Cheyne Stokes respiration at end of life- Thread

Can be scary to witness for family, loved ones and health care professionals looking on.

Understanding a little about what is happening may help alleviate some of that distress 🧵 Having witnessed this both at a personal and professional level I felt I needed to understand more.

Please Note ⭐️This may be a difficult topic for some to explore and not one that is commonly talked about in any detail even in my daily job.

I hope this may help a little

Cancer cachexia in palliative care

An improvised thread 🧵

Presented in screenshots due to Twitter having a wobble
Will post proper thread one day 😊

We are good at a trial of medication to see if symptoms improve.

Why about a trial without medication?

If symptoms improve this points to side-effects

If no change/worse likely related to disease progression/new illness

The follow up is where the answer becomes clear- vital There’s a temptation to attribute new symptoms to drug side-effects, stop the drug and think “job done”

What if the symptom persists and there is no follow up to check for resolution? What’s plan B

Unmet needs/symptom burden
Delayed diagnosis
Inaccurate intolerance lists

Palliative care case study 📚
25/3/23

A 46 year old gentleman with pancreatic cancer complains of abdominal pain and loose stools after eating. He has been prescribed CREON 25,000 units and is using this in the morning and at bedtime with a cup of tea How would you explain these symptoms to this gentleman?

What changes would you recommend in his management?

Would you add in anything else to his medications?

Biochemistry in palliative care 🧵

Can you really tell that much from a set of blood results?

Are they useful in palliative care? High Urea:

“Probably dehydrated right?”

Not always- Think about
-Upper GI blood loss
-Current steroid therapy (common)
-Heart failure

Low Urea:
-Cachexia/malnutrition
-Liver failure

Palliative care case part 2
See thread below for first section.

Thank you to everyone who has interacted so far. Please feel free to get involved and give any insights

https://twitter.com/Existential_Doc/status/1620169136600129539

You explain to Mr P that although he feels pain in his back, this is not because the cancer has moved to the bones here- he is reassured to hear this. You also talk through the role of the pancreas in absorbing food especially fats which is causing his yellow stools.

Palliative care case studies 🧵

Let’s try something a bit different

Running through a few case studies might help consolidate learning and stimulate discussion… I will need your interaction “Front to Back” - Case 1

You are meeting with Mr P, a 54 year old gentleman who has recently been diagnosed with pancreatic cancer. He is waiting to undergo palliative chemotherapy but has several distressing symptoms.

Opioid side effects: A thread 🧵

Often very useful drugs
Often misunderstood

This group of drugs have diverse short term and long term side-effects to know about Constipation

The bowel is the only organ that does not develop a tolerance to opioids. This means constipation occurs from the first dose until the last one.

Bowel transit time and sphincter tone are increased. Stool becomes dehydrated and harder to pass

Common causes of agitation towards end of life 🧵

A few simple things to bear in mind way before contemplating medication to address agitation Bowels and Bladder

It is the habit of a lifetime to try and avoid being incontinent- that’s a powerful drive to move or get out of bed even when very unwell.

Whatever way you can help preserve someone’s dignity it is so important.

Palliative care: Opioids 🧵

Alfentanil and Fentanyl belong to the Phenylpiperidine family and have a much higher affinity for Mu opioid receptors than Morphine and Oxycodone which belong to the Phenanthrene class.

They are more potent but this difference has other implications You decide to rotate a person taking 150mg of oral morphine/day to an equivalent transdermal Fentanyl patch. Their pain is stable and they are fed up taking so many pills. You do the maths and decide on a 50microgram/hour patch.

@TheSPICT tool is a really useful guide as a prompt to earlier referral to palliative care. I am convinced that earlier referral not only improves patient care but reduces 11th hour work pressures for all community teams especially district nurses A larger community palliative care caseload with earlier referrals will ultimately be more manageable and rewarding for all involved than a smaller crisis focused caseload. Crisis aversion is one of the biggest impacts community palliative care can make. #notjustendoflife

Malignant Spinal Cord Compression (MSCC)- A Thread 🧵

Old fashioned medical tools of history and clinical examination are the key

Trust your instincts with this diagnosis Can be the presenting symptom of previously unknown cancer.

Most commonly occurs in patients with a known malignancy (5-10% of all patients)

More common in the following cancers:

-breast
-lung
-melanoma
-prostate
-myeloma
-lymphoma

Can occur with ANY malignancy

Ketamine in palliative care
A Thread 🧵

An interesting drug that divides opinion in palliative care.
Let’s have a look at how it works and when it might have a role Ketamine was first synthesised as an alternative anaesthetic agent to PCP in the 1960’s

It was FDA approved in 1970 and used in the Vietnam war as a battlefield anaesthetic agent.

It is a dissociative anaesthetic drug that changes perception of time, consciousness and pain

Allodynia - Thread 1 of 2 🧵

Allo=different
Dynia=pain

Allodynia refers to the sensation of pain produced by stimuli that do not normally cause pain.

e.g. light touch, mild temperature changes, gentle friction/rubbing, movement of joints/muscles.

It is a form of neuropathy Mechanisms?

Reorganisation and sprouting of connections between C- fibre nociceptors (pain) and A - mechanoreceptors (normal sensation) in the dorsal spinal cord.

This may occur in response to peripheral nerve or spinal injury

District nursing levels have fallen by over 40% since 2009
Complexity and number of people receiving palliative and end of life care has risen
ACP injectable med/CSCI logistics remain challenging

Time to be looking seriously at alternative routes of drug administration The time spent obtaining prescriptions, sourcing injectables and documenting is impacting on face to face end of life care. Reduced job satisfaction is not going to help retention of staff.

The wastage of medication is horrendous. Sustainability and environmental impact

Managing bleeding in palliative care
A Thread 🧵

One of the most difficult topics to discuss. Bleeding reminds us all of our own fragility and elicits an immediate response from all who witness this.

Lets’s start with bleeding from local areas Surface bleeding

Often from primary skin tumours, fungating (tumours that break through the skin) or metastatic deposits.

Dressings with haemostatic additives such as Kaltostat which contain calcium alginates from seaweed may help. The calcium activates platelets ➡️ clotting

Methadone: A palliative care thread History

Developed in Germany during WWII to address opioid shortages
Polamidon patented 1941
1947 Eli Lilly & Co release Dolophine= Dolor (Pain) Fin
Used for pain and cough
1960’s: used in treatment of heroin addicts
1965 UK allow treatment of opioid addiction with methadone

Lithium: end of life considerations
A short thread

Lithium carbonate is used as a mood stabilising agent in uni and bipolar affective disorder.

It can be life changing for patients and is generally well tolerated. It needs blood level monitoring to maintain a therapeutic range Cessation of lithium and other mood stabilisers can lead to rebound changes in mood and anxiety. There is no direct replacement for lithium’s therapeutic effect that can be given parenterally when oral intake is lost.