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Welcome to Dr. Hamid Sanatinia's Virtual Headquarters
Palliative Care

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Should we treat or not???
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Hypercalcemia of malignancy
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<<<<<<<<<>>>>>>>>>
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<<<<<<<<<>>>>>>>>>
Molecular Genetics
Oncogenes, the list!
Immunoperoxidase stains
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Mechanism of Action
Dose Modifications (Renal)
Dose Modifications (hepatic)
MDR

Pain Relief
Neurological Issues
-> terminal restlessness
-> delirium
Gastrointestinal issues
-> Nausea/Vomiting
-> Bowel Obstruction
Respiatory issues
-> dyspenea

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Cancer Pain

NSAID:
Has a celing effect.
Can be synergistic with opiods.
Beware of toxicities.
May try COX-2 inhibitors (there are still many side effects including GI bleed...)

OPIODS
There is no maximum dose of opiods. the right dose is the effective dose with no or tolerabe side effects.
----Morphine
The recommended starting parenteral dose of morphine for adult with no significant comorbid medical problems is 0.1-0.15 mg/kg
----Methadone
Some of the metabolites have a very long half-life. Use if the patient is on a very high doses of morphine. Then can be changed to methadone.
----Transdermal fentanyl
Takes about a day for pain to take effect. To switch from Po opiods to duragesic patch, need to cover for almost a day so that the patch would start taking effect.
----Codeine
----Hydromorphone (Dilaudid)
----Oxycodone/Oxycontin

OPIOD CAUTIONS:
***Never use meperidine (too many potential side effects)
***Nalxone to reverse opiod effects: use 0.4 mg in 10 ml of saline and give small amounts to raise consciousness. NEVER give bolus naloxone!
***Start patients on bwel mechanical stimulants
***Opiods can cause histmaine release causing pruritis, hives, and bronchospasm. The safest drug to use in this case is methadone.

ANTIDEPRESSANTS
Tricyclics:
Start with lower doses (for pain control not depression). Increase dosage Q4-10 days to tolerated/effective dose.
Target doses:
Nortryptyline 100-150 mg po qhs
Desipramine 100-300 mg po qhs
use a very low dose for the elderly and increase by the same dose every 5-7 days if needed.

ANTICONVULSANTS
Gabapentin 300 mg po tid & titrate up
Carbamazepine 200 mg po bid-qid
valproic acid 200-400 mg po bid-tid
Clonazepam 0.25-0.5 mg po tid
Phenytoin 100-200 mg po tid

Muscle Relaxants
Can be effective as analgesics

Topicals
EMLA Cream - can be used for post-herpetic pain & such!
Topical Capsaisin 0.025- 0.075 tid

Strontium 89 & Sumarium 159
Peak effect in 4-6 weeks lasting 3-6 months

STEROIDS
High doses are effective that can last for several weeks but to beused for a few days only.




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Terminal Restlessness:
A common syndrome that occurs in patients with varying diagnoses & appears during their last days of life. It occurs in up to 40% of patients during the last 48 hours of life. Symptoms include: frequent non-purposeful motor activity, inability to concentrate, inability to relax, fluctuating levels of consciousness & cognitive failure, disturbances in sleep patterns, & can progress to a state of agitation. We must distiguish this syndrome from delirium. Management includes the use of opiods if pain is the cause of the symptom. Otherwise haloperidol 0.5-5.0 mg po is the best treatment. Other treatments include:
Chlorpromazine 12.5-50 mp PO,PR,IM
Lorazepam 1-2 mg/hr SL
Diazepam 2-10 mg SL,PO, PR,IM
Nembutal Suppository 60-120 mg PR
Risperidone 1.5 mg bid
Chlorpromazine up to 100 mg/hr
Midazolam
Phenobarbital
Also consider changing the environment.

Dyspnea:
Interventions include the use of morphine or other opioids (relief in 95% of patients). Can use long-acting opiods if needed. Othe interventions include th euse of bronchodilators & corticosteroids.

WHO PAIN LEVEL
Level I: Mild Pain
use NSAIDS & adjuvants
pain scale 1-3/10

Level II: Moderate Pain
use mild opiods, NSAIDS, & adjuvants
pain scale 4-6/10

Level III: Severe Pain
use strong opiods, also use NSAIDS & adjuvants
pain scale 7-10/10