Palliative Care Emergencies

Wesam S. Aziz, MD11/5/13

OverviewPain CrisisRespiratory CrisisMassive HemorrhageUncontrolled HiccupsHypercalcemiaDrug Toxicity

SeizuresTumor Lysis

SyndromeSVC ObstructionSC CompressionFecal ObstructionOthers

GoalsDefinitionRecognitionPreventionApproach

Non-Pharm TxPharm Tx

Acute Pain CrisisDefinition: 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).

Acute Pain CrisisApproach

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 possibleConsider: 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

Palliative Sedation (Meds)Consider proportional palliative sedation

(PPS)Midazolam (SC, IV): 5 mg bolus, 1 mg/hrLorazepam (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

Respiratory CrisisDefinition:

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

PreventionRecognizing underlying co-morbidities, and

anticipating potential outcomes

Respiratory CrisisRecognition: BREATH AIR mnemonic

B: BronchospasmR: RalesE: EffusionsA: Airway Obstruction/AspirationT: Thick SecretionsH: Hemoglobin (low)

A: AnxietyI: Interpersonal IssuesR: Religious Concerns

Respiratory CrisisApproach

Non-Pharm Tx:Oxygen (especially if hypoxic), Fan

Pharm Tx:Opioids, opioids, opioidsAnxiolyticsPPS

Massive HemorrhageDefinition:

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.

Massive Hemorrhage Approach

EOL patient’s: utilize dark sheets and towels, reposition patient, recovery position Palliative Patient’s: give back lost bloodReverse 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

HemorrhageBleeding gums:

Transenic Acid (anti-fibrinogen) SprayThrombin SprayAminocaproic acid

Uncontrolled HiccupsDefinition: (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

Uncontrolled HiccupsApproach

Non-Pharm Txgargling 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

Uncontrolled HiccupsPharm TxAnti-Psychotics

Chlorpromazine – the only FDA approved drug for hiccups.

Haloperidol – useful alternative to chlorpromazine; Anti-Convulsants

OtherGabapentin, Phenytoin, Carbamazapine, Valproic Acid

MiscellaneousBaclofen – the only drug studied in a double blind

randomized controlled study for treatment of hiccupsMetoclopramide Nifedipine - a relatively safe alternative if other

interventions have failed.

HypercalcemiaDefinition: 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

HypercalcemiaRecognition:

Mnemonic: Groans (constipation), Moans (fatigue, lethargy, nausea), Bones (bone pain), stones (kidney), and Psychiatric overtones (confusion, depression)

Caution: Can be falsely lowhypoalbuminemia can mask hypercalcemia,

measured calcium is the calcium bound to albumin,

HypercalcemiaApproach

Non-Pharm Tx: Volume expansion to increase calcium excretionEliminate extra sources of calcium

Pharm TxLoop diuretic: inhibits resorption of calcium at

loop of henleBiphosphonates: 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

Drug ToxicityMorphine Myoclonus - uncontrollable muscle

spasms, dose-related effect of opioids, associated with somnolence and AMSTX - 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)

SeizuresDefinition:

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

SeizuresApproach

Non-PharmPlace in recovery positionRemove objects that may cause injury

Pharm TxStatus Epilepticus

1st Line: BZD & Phenytoin2nd 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)

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

Tumor Lysis Syndrome (TLS)Approach is prevention

Aggressive IV fluids – 2 to 3 L daily 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.

SVC (Superior Vena Cava) ObstructionDefinition: 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, headachePrevention: Treat underlying causes

SVC ObstructionApproach

Non-Pharm TxConsider XRT, Sx, or endovascular

techniques when tumor not chemosensitive

Pharm TxSteroidsChemotherapy: especially with lymphomas

SC CompressionDefinition: Compression of Spinal Cord (SC) putting patients

at risk for pain, paresis or paralysis, incontinenceRecognition: PB KTL (lead kettle) – cancers that metastasize

to bone P: Prostate B: Breast K: Kidney T: Thyroid L: LungSIGNS: 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.

SC CompressionApproach

Non-Pharm TxXRTSurgical decompression

Pharm TxSteroids: DexamethasoneOpioids – pain control

Severe Constipation/Fecal ObstructionDefinition: 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 softenersRectal exam reveal solid mass in rectumImaging studies may reveal constipation more proximal

Severe Constipation/Fecal ObstructionPrevention:

Water, water, waterFiber & foods high in fiberStool SoftenersStimulantsLaxatives

Severe Constipation/Fecal ObstructionApproach:

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.

Other ProblemsObstructive nephropathy

FoleyCardiac tamponade Febrile neutropenia Hyper viscosity Syndrome

Plasma exchange Increased intracranial pressure

Diuretics, acetazolamide, surgical decompression/shuntHypoglycemia

IV Fluids, Insulin

Referenceshttp://www.eperc.mcw.edu/EPERC/FastFactsandCo

nceptsUp To DateUNIPAC 4th edition