Palliative Care Emergencies

Wesam S. Aziz, MD11/5/13

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

Recognition

Prevention

ApproachNon-Pharm TxPharm Tx

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).

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 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

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 Crisis

ApproachNon-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 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

HemorrhageBleeding gums:

Transenic Acid (anti-fibrinogen) SprayThrombin SprayAminocaproic acid

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

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.

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

Hypercalcemia

Recognition: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 Toxicity

Morphine 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 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)

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 preventionAggressive 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) 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

SVC Obstruction

ApproachNon-Pharm Tx

Consider 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, 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.

SC Compression

ApproachNon-Pharm Tx

XRTSurgical decompression

Pharm TxSteroids: DexamethasoneOpioids – pain control

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

Severe Constipation/Fecal Obstruction

Prevention:Water, water, waterFiber & foods high in fiberStool SoftenersStimulantsLaxatives

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.

Other ProblemsObstructive nephropathy

Foley

Cardiac tamponade

Febrile neutropenia

Hyper viscosity SyndromePlasma exchange

Increased intracranial pressure Diuretics, acetazolamide, surgical decompression/shunt

Hypoglycemia IV Fluids, Insulin

References

http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts

Up To Date

UNIPAC 4th edition