07 Presentation Ferris Common Symptoms

8/3/2019 07 Presentation Ferris Common Symptoms

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To prevent and relievesuffering, and promote quality

of lifeat every stage of life


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Common Symptoms

Frank D. Ferris, MDMedical Director, Palliative Care StandardsCENTER FOR P ALLIATIVE S TUDIESSan Diego Hospice and Palliative Care

Education and Research in the Art and Science of Palliative Care

Department of Family and Preventative Medicine,UCSD School of Medicine

Department of Family and Community Medicine, andJoint Center for Bioethics, University of Toronto


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Objectives

Know general guidelines formanaging non-pain symptoms

Know how to assess and managecommon symptoms

www.CPSOnline.info

Publications / presentations


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. . . General guidelines

Provide education, support

Involve entire interdisciplinary teamReassess frequently


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HIV Wasting


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HIV Wasting

Loss of weight > 10% of baseline withfever, weakness, diarrhea > 30 days

inadequate nutrient intake

excessive nutrient loss

metabolic dysregulation


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Management

of anorexia / cachexia . . .Assess, manage comorbidconditions

Educate, support

Favorite foods / nutritional

supplements


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. . . Management

of anorexia / cachexiaAlcohol

Megestrol acetateDexamethasone

Dronabinol

Androgens, eg, testosterone


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Fatigue /Weakness


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Management

of fatigue / weakness . . .Promote energy conservationEvaluate medicationsOptimize fluid, electrolyte intakePermission to rest

Clarify role of underlying illnessEducate, support patient, familyInclude other disciplines


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. . . Management

of fatigue / weaknessDexamethasone

feeling of well-being, increased energyeffect may wane after 4-6 weeks

continue until death

Methylphenidate


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Fever /Sweats


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Management of fever /

sweatsParacetamol (acetaminophen)

NSAIDs, eg, ibuprofenCorticosteroids, eg, dexamethasone

Anticholinergics, eg, scopolamine

Rehydration

Bathing, drying


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Nausea /Vomiting


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Nausea / vomiting

Nausea

subjective sensationstimulation

gastrointestinal lining, CTZ, vestibularapparatus, cerebral cortex

Vomitingneuromuscular reflex


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Causes

of nausea / vomitingMetastases

Meningealirritation

Movement

Mental anxietyMedications

Mucosal irritation

Mechanicalobstruction

Motility

Metabolic

MicrobesMyocardial


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Pathophysiology

of nausea / vomitingCortex

Vestibularapparatus

GI tract

ChemoreceptorTrigger Zone (CTZ)

Neurotransmitters AcetylcholineDopamineHistamine

Serotonin

Vomiting center


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Management

of nausea / vomitingDopamineantagonists

Antihistamines

Anticholinergics

Serotoninantagonists

Prokinetic agents

Antacids

Cytoprotectiveagents

Other medications


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Acetylcholine antagonists

(anticholinergics)Scopolamine

Atropine


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Dopamine antagonistsHaloperidol

Prochlorperazine

Metoclopramide (also prokinetic)


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Histamine antagonists(antihistamines)

Diphenhydramine

MeclizineHydroxyzine


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Serotonin antagonists

Ondansetron

Granisetron


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AntacidsAntacids

H2 receptor antagonists

cimetidineranitidine

Proton pump inhibitors

omeprazole


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Cytoprotective agents

Misoprostol

Proton pump inhibitorsomeprazole


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Other medications

Dexamethasone

Tetrahydrocannabinol

Lorazepam

Octreotide


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Constipation


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ConstipationMedications

opioidscalcium-channel

blockersanticholinergic

Decreased motility

IleusMechanicalobstruction

Metabolicabnormalities

Spinal cordcompression

Dehydration

Autonomicdysfunction

Malignancy


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Management

of constipationGeneral measures

establishnormal bowelpattern

regular toileting

gastrocolic reflex

Specific measuresstimulants

osmotics

detergents

lubricants

large volumeenemas


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Stimulant laxatives

Prune juice

SennaCasanthranol

Bisacodyl


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Osmotic laxatives

Milk of magnesia (other Mg salts)

LactulosePolyethylene glycol

Sorbitol

Magnesium citrate


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Surfactant laxatives(stool softeners)

Sodium docusate

Calcium docusatePhosphosoda enema prn


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Prokinetic agents

Metoclopramide


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Lubricant stimulants

Glycerin suppositories

Oilsmineral

peanut


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Large-volume enemas

Warm water

Soap suds


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Constipation

from opioids . . .Occurs with all opioids

Pharmacologic tolerance developedslowly, or not at all

Dietary interventions alone usually

not sufficientAvoid bulk-forming agents indebilitated patients


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. . . Constipation

from opioidsCombination stimulant / softenersare useful first-line medications

casanthranol + docusate sodium

senna + docusate sodium

Prokinetic agents


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Diarrhea


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Causes of diarrheaInfectionsGI bleeding

Malabsorption, eg, lactose intoleranceMedications, eg, HAARTObstruction, eg, cancer

Overflow incontinenceStress


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Management of diarrhea

Establish normal bowel pattern

Treat underlying causeAvoid gas-forming foods

Increase bulk, i.e., fiber

Transient, mild diarrheabismuth salts


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Management

of persistent diarrheaRehydration

Oral salt containing fluidsParenteral

Loperamide

Diphenoxylate / atropineTincture of opiumOctreotide


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Shortness

of Breath(Dyspnea)


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Breathlessness

(dyspnea) . . .Described as

shortness of breatha smothering feeling

inability to get enough air

suffocation


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. . . Breathlessness

(dyspnea)Only reliable measure is patient self-

reportRespiratory rate, pO 2, blood gasdeterminations DO NOT correlate

with the feeling of breathlessnessPrevalence 12 74%


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Causes of breathlessness

Anemia

Anxiety

Airway obstruction

Bronchospasm

HypoxemiaInfections

Metabolic

Pleural effusion

Pulmonary edema

Pulmonaryembolism

Thick secretions

Family / financial /legal / spiritual /practical issues


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Management

of breathlessness . . .Treat the underlying cause

antibiotics

avoid fluid overload

dry secretions

Mechanical ventilation


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. . . Management

of breathlessnessSymptomatic management

oxygen

opioids

anxiolytics

nonpharmacologic interventions


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Oxygen

Pulse oximetry not helpful

Potent symbol of medical careExpensive

Fan may do just as well


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Opioids

Small doses

Central and peripheral actionRelief not related to respiratory rate

No ethical or professional barriers

Do not shorten life


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Anxiolytics

Safe in combination with opioidslorazepam

0.5-2 mg po q 1 h prn until settled then dose routinely q 4 6 h to keep settled


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Nonpharmacologic

interventions . . .Reassure, work to manage anxiety

Behavioral approaches, eg,relaxation, distraction, hypnosis

Limit the number of people in the

roomOpen window


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Nonpharmacologic

interventions . . .Eliminate environmental irritants

Keep line of sight clear to outsideReduce the room temperature

Avoid chilling the patient


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. . . Nonpharmacologic

interventionsIntroduce humidity

Repositionelevate the head of the bedmove patient to one side or other

Educate, support the family


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CommonSymptoms

Summary


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07 Presentation Ferris Common Symptoms

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