Makindo Medical Notes

Related Subjects: |Analgesia and Pain management |Sedation and Analgesia on ITU |Neuropathic Pain Management |Codeine |Dihydrocodeine |Diamorphine |Morphine |Paracetamol (Acetaminophen)

📖 About

• Always 📘 check the BNF for exact dosing before prescribing.
• 💡 Remember: titrate to symptoms, use the lowest effective dose, and anticipate common side effects.
• ⚠️ Always consider renal/hepatic function, frailty, and co-morbidities when prescribing.

🤢 Nausea and Vomiting

• Very common in advanced disease (uraemia, opioids, constipation, raised ICP, drugs).
• Opioid-induced nausea usually improves after 4–5 days.
• Non-drug measures: meticulous mouth care, removal of triggers (smells, fatty foods), relaxation, distraction, massage.
• Evidence supports acupuncture and ginger in chemotherapy-induced nausea.

🧠 Raised Intracranial Pressure (ICP)

• 🎯 Dexamethasone 8 mg OD (BD if severe), taper after 5 days according to response.
• 💬 Discuss radiotherapy with oncology if appropriate.
• ⚠️ Co-prescribe gastroprotection if on NSAIDs (steroids + NSAIDs ↑ GI bleed risk 4-fold).
• ⚡ First seizure → start anticonvulsant (Levetiracetam 250 mg OD recommended); seek neurology input.

😮‍💨 Breathlessness

• At advanced stages, diagnosis (PE, pneumonia) often not pursued → focus on symptom control.
• Always discuss with patient and family.
• Causes: pulmonary oedema, effusion, anxiety, acidosis, tumour obstruction, lung disease.
• Therapies:
  • ⛅ Fan blowing air across face; O₂ if hypoxic.
  • 💉 Thoracentesis for large pleural effusion (short-lived benefit, weigh risks).
  • 💊 Opiates are mainstay when other options not feasible.
  • 😟 Treat anxiety with Diazepam or Midazolam.
  • 🫁 Bronchodilators for wheeze; Prednisolone 60 mg OD for SVC/tumour obstruction.
  • 🩸 Consider anticoagulation if PE suspected and in patient’s best interest.

⚰️ Terminal Breathlessness (Opioid Naïve)

Doses tend to be lower than for pain; titrate to effect.

💊 Analgesia: Mild–Moderate Pain

💉 Moderate–Severe Pain (Opioid Naïve)

🫀 Hepatic Distension Syndrome (Capsular Pain)

• Follow WHO analgesic ladder; usually responds well to opioids.
• If uncontrolled → consider Dexamethasone (specialist advice).

💦 Palliation: Respiratory Secretions (“Death Rattle”)

• At this stage, focus on comfort rather than diagnosis (PE/pneumonia not pursued).
• Have an open conversation with patient/family about expectations.

📚 References

• Scottish Palliative Care Guidance
• BNF – Palliative Care Prescribing