Miscellaneous

*** ANIMEA: • Haemoglobin < 7, or sudden blood loss # Light headedness, dizziness, palpitation, dyspnoea, fatigue, generalized weakness • 1 unit of blood raises HG 1 g/dl • Benefits lasts 1-2 days • Transfuse for special occasion or good prog!

*** NOT RECOMMENDED: • Mixed agonist-antagonists: Pentazocine (Talwin), Butorphanol (Stadol), Nalbuphine (Nubain), Dezocine (dalgan), compete with agonists à withdrawal • Demoral: breakdown product epiletogenic

*** PRECHEMOTHERAPY TREATMENT: • Vomiting ¢ Central mechanism ** Antiemetic before chemotherapy; Zofran IV, benadryl, Compazine ** Dexamethasone: 6-10 mg oral / parental starting before therapy then Q 6 hrs x4 ** Reglan 1-2mg / kg IM / IV / 30 minutes before & after ** combination • Reglan + Ativan + Dexamethazone ** Dronabinol (tetrahydrocanna-binol)

*** HIV: • > 60% experience pain • intense pain is associated with fear, anxiety, depression, poor quality of life • Neuropathy, CNS involvement • Opportunistic infection are common, treat if not terminal • Headache: Cryptococcus, Toxoplasmosis, Lymphoma • Poor Nutrition • Pain • Painful peripheral Neuropathy • Wt. Loss • Fever • Diarrhoea • Dementia • Retrosternal discomfort: Esophagitis due to candida, Herpes virus, CMV, GERD • Rectal pain: Herpes until proven otherwise ** Acyclovir 200-800mg 5x/day for 5 days, remain on 200mg 3x/day • Gonorrhoea and Chlamydia ** Amoxicillin 3 grams orally and Tetracycline • Herpes Zoster; Acute: ** Acyclovir 800mg 5x/day for 5 days, Tegretol, TCA • Kaposi’s (KS): ** Radiation therapy • FEVER: T cells are under 100, PCP, Myrobacterium Avium lymphoma, include Cryptococcus, CMV, toxo, candidiasis, KS, drug reaction to sulfa. N Octreotide (Sandostatin) in AIDS- related diarrhoea 100-500mcg Sq tid • good symptom management • Total care

*** FEVER: # U.T.I, URI, infection, Dehydration, wound *Rx: ** Fluids ** Cooling: ice packs, axial, groin or cooling blanket ** Tylenol ** Aspirin ** Water Sponging ** Antibiotics in appropriate patients, avoid close to death

*** HYPERCALCEMIA: > 12 mg/dl = 80% die within one year # Cancer of lung, prostate, breast, head & neck; hypernephroma # presenting S/S in MM = Multiple Myeloma, T cell Lymphoma, Hyperparathyroidism # drowsiness, Confusion, lethargy, fatigue, Polyuria, Polydipsia, anorexia, dry mouth, nausea, vomiting, severe weakness, constipation, coma, S/S resemble OD of morphine & typical worsening hospice pt., hyporeflexia, Ÿ alkaline phosphates (not in MM) *Rx: ** Ÿ Fluid intake, mobilize pt ** D/C Dyazide (Thiazides) ** Decadron ** Lasix ** 1.V.F NS>3L/d ** Calcitonin: 200-400 1 U SQ q 12 hrs. ** Aredia 60 mg / 250 cc 1.V. over 4-8 hrs ** Calcitonin 200 units QD nasal spray ** Oral phosphate ** Oral steroids ** Hormone • Chronic Hypocalcaemia: ** exercise ** Ÿ fluids ** Didronel 200 –400 mg PO / day ** no vit A&D A no extra calcium ** Prednisone • Levels above 14.0 mg/dL require IV re-hydration with 2 to 3 litters normal saline per day with potassium supplements (monitor serum electrolytes) combined with Didronel (etidronate) 7.5 mg/kg/day in 250 cc over 2 hrs for 3 days or Aredia

*** ODOR: • Wound: Yogurt, Dakin’s Solution chemical or surgical debridement • Ostomy: activated charcoal, Aspirin crushed in bag • Incontinence: *Rx appropriately • ionizer • infection: Antibiotics • Flagyl or Clindamycin • Topical: ** Bacitracin, ** Neosporin ** Bactroban • Topical Antifungal: ** Clotrimazote (Lotrimin), ** Miconazole (Monistat) • Tea Tree Oil

*** PHYSICIAN ASSISTED SUCIDE: NO-NO-NO • no right to PAS by US Supreme Court • Oregon is the only state where PAS is legal (as of 1999) • their intent is to shorten life • Hospice intends to comfort, do not shorten or prolong the inevitable in dying • don’t give license to kill to those who were trained to save & cure

*** ANTI COAGULATION: • May be ok in DVT/PE to control symptoms ** Coumadin: decrease the dose by 50% or stop • to reverse: vit K po/IM effective in 4 hrs.

*** BLEEDING: Local measure • 1:1000 adrenaline soaked dressing • Reverse Coumadin by Vit K, oral/I.M. • No blood transfusion • Heavy Sedation in terminal event • Radiation • 1% alum for hematuria / Skin Bleed / Rectal bleed • nasal pack • ICE • keep wet colourd towels

*** CANDIDIASIS: Sore white plaques, Painful Dysphagia, # following antibiotic or steroids or radiation *Rx: ** Nystatin, ** Ketoconazole

***Adrenaline : Epinephrine
Uses
minimal external bleed
skin
cardiac arrest
anaphylaxis
bronchospasm
Rx:
Soak gauze in 1:1000, apply directly to bleeding points with little pressure
Anaphylaxis : 0.3 – 0.5 mg SC or IM 1:1000 (Epipen)
use in Asthma, COPD (half dose in CAD patients)

 

*** Carbamazepine (Tegretol)
Anticonvulsant
Uses: Epilepsy, Trigeminal neuralgia, bipolar, neuropathic pain, RLS
Caution: bone marrow supression, reduce doses in renal / hepatic impairment
Pointers:
CYP 450 enzyme:
inc Carbamazepine level by inhibitors: Cimetidine, Conazoles, Fluoxetine, Haloperidol, Octeriotide, Risperidone
decrease effects of Alprazolam, Amitriptyline, Clonazepam, Dexamethasone, Flecanide, Haloperidol, Methadone, Warfarin,
Serotonin crises with SSRIs
hepatotoxic with Acetaaminophine
monitor plasma concentration
Supply:
Chewable 100 mg
Tab 200 mg
Oral susp 100 mg / 5ml
Rx: 800-1200 mg / d in divided dosage, follow the level

*** TERMINAL DEHYDRATION: benefit • keeps pt dry, No IVF, comfort family, educate, chaplain, involve team

*** EXCESSIVE SWEATING: ** Anticholinergic, Prednisone 20mg/day QD or divided dosage •

*** SURGICAL OPTIONS IN HOSPICE: • Paracentesis • colonic tumor resection for obstruction in appropriate • Tracheostomy • PEG tube for feeding • Colostomy • central line • Pick line • Fractures

*** STRENGTH: ** No med will restore ** vitamin may help ** blood: no help ** depressed: anti-depression