Causes of Acid-Base Imbalances: Explanation and Examples

Vomiting: When a patient’s arterial blood gas shows an uncompensated metabolic alkalosis, it suggests an acute cause such as vomiting. Vomiting causes a loss of stomach acid, resulting in fewer H+ ions to bind to HCO3-, leading to more free HCO3- and resulting in a metabolic alkalosis.

Aspirin Overdose: An aspirin overdose typically causes an initial respiratory alkalosis followed by a metabolic acidosis with a raised anion gap. The respiratory alkalosis is the result of direct stimulation of the medulla, while the metabolic acidosis is caused by an accumulation of lactic acid due to an uncoupling of oxidative phosphorylation.

Anxiety: Hyperventilation associated with anxiety would cause a respiratory alkalosis. This is due to ‘blowing off’ carbon dioxide through hyperventilation, resulting in a decreased PaCO2 in the blood and an increased ratio of HCO3− to PaCO2, raising the pH and resulting in alkalosis.

Pulmonary Embolism: A pulmonary embolism would cause a respiratory alkalosis, usually accompanied by hypoxia or type I respiratory failure.

Respiratory Depression: Respiratory depression would cause a respiratory acidosis. Hypoventilation means that less carbon dioxide is blown off, resulting in an increase in PaCO2 in the blood, which decreases the pH.

Managing Bony Pain in Patients with Metastatic Carcinoma

The common assumption is that all bony pain in patients with metastatic carcinoma is solely due to bone metastases. However, it is important to consider other possible causes, especially if the pain is worsened by movement and has a different character from known bone metastases. Patients with advanced malignancy are prone to low-force fractures, particularly in the neck of the humerus, even without a history of trauma.

Before increasing opioid dosage or adding NSAIDs, it is crucial to confirm the diagnosis and immobilize the fracture site. A broad arm sling can often provide sufficient pain relief. Bisphosphonates should not be used unless hypercalcemia has been confirmed. When a fracture is suspected, an x-ray is a simpler investigation modality than a bone scan or MRI. However, an MRI may be necessary to provide detail if a pathological fracture requires surgical repair, such as a neck of femur fracture associated with metastatic deposit.

While dexamethasone can be used as an adjunct in pain management, it should not be the next step. Proper diagnosis and immobilization of the fracture site should be the primary focus in managing bony pain in patients with metastatic carcinoma.

Choosing the Right Opioid for Inadequate Pain Control

Explanation:

When a patient has inadequate pain control on a weak opiate and non-opiate combination, it’s important to consider switching to a strong opiate. However, choosing the right opioid requires careful consideration of the patient’s needs and potential risks.

One option is to stop codeine and start morphine sulphate modified release at a low dose, with the intention of titrating the dose slowly to reduce the risk of overdose. Short-acting morphine can be used for breakthrough pain, and the dose of the modified release morphine can be adjusted as needed.

On the other hand, switching to co-codamol or dihydrocodeine may not provide sufficient pain relief for this patient. Co-codamol at the same dose as the current codeine regimen would not improve pain control, while dihydrocodeine may require higher doses than morphine.

Finally, tramadol is a weak opioid and may not be effective for this patient’s level of pain. Instead, starting with a low dose of morphine and titrating slowly may be the best option for achieving adequate pain control while minimizing the risk of adverse effects.

Assessing Hospice Needs in Patients with Different Medical Conditions

End-of-life care is an important consideration for patients with certain medical conditions. Hospice care is recommended for patients with a life expectancy of less than six months and who are no longer seeking curative treatment. Patients with end-stage dementia, for example, have limited life expectancy and may require hospice care. On the other hand, patients with relapsing-remitting multiple sclerosis may have palliative care needs but do not require hospice admission. Similarly, patients with moderate chronic obstructive pulmonary disease may require palliative care but do not need hospice admission. In contrast, patients with locally advanced prostate cancer may require hospice care and have treatment options such as watchful waiting, external radiotherapy with hormone therapy, surgery, hormone therapy on its own, cryotherapy as part of a clinical trial, or high-frequency ultrasound therapy (HIFU) as part of a clinical trial. Understanding the hospice needs of patients with different medical conditions is crucial for providing appropriate end-of-life care.

Options for Managing Inadequate Pain Relief in a Patient on Opiates

When a patient on opiates experiences inadequate pain relief, there are several options for managing their medication. One option is to increase the dose of modified release morphine sulphate tablets (MST) while advising the patient to reduce the frequency of breakthrough medication, such as oramorph. However, caution must be taken to avoid overdose, and the patient should be aware of the risks of continuing their current regime.

Another option is to switch to a different opiate, such as oxycodone, but this may not be necessary if the patient is tolerating the current medication well. In this case, the dose of MST can be titrated cautiously and reviewed regularly.

A fentanyl patch may also be an option, but only if the patient is unable to take tablets due to eating or drinking difficulties.

If the patient requires multiple doses of breakthrough medication, the BNF recommends reviewing the dose of longer-acting analgesia.

Ultimately, the best course of action will depend on the individual patient’s needs and condition, and a full review of their medication and pain management plan should be performed if necessary.

Comparison of Medications for Nausea and Vomiting in Patients with Parkinson’s Disease

Patients with Parkinson’s disease may experience nausea and vomiting due to gastric stasis or other underlying conditions. When selecting a medication to treat these symptoms, it is important to consider the patient’s history of Parkinson’s disease and the potential for extrapyramidal side-effects.

Domperidone is a good option for treating nausea caused by gastric stasis because it does not cross the blood-brain barrier, reducing the risk of extrapyramidal effects. Cyclizine is typically used for movement-related or intracranial disease-related nausea and vomiting. Dexamethasone may be considered if other medications are ineffective, but it is primarily used for intracranial disease-related nausea and vomiting. Haloperidol is not recommended for patients with Parkinson’s disease due to its potential to increase extrapyramidal symptoms. Metoclopramide is a first-line prokinetic for motility disorder-related nausea and vomiting, but its use should be carefully monitored in patients with Parkinson’s disease due to the risk of extrapyramidal effects.

Overall, the choice of medication for nausea and vomiting in patients with Parkinson’s disease should be made on a case-by-case basis, taking into account the patient’s individual medical history and potential risks and benefits of each medication.

Comparison of Duration of Analgesic Effects of Different Opioids

When it comes to managing pain, opioids are often prescribed. However, different opioids have varying durations of analgesic effects. Here is a comparison of the duration of analgesic effects of some commonly used opioids:

– Transdermal fentanyl: This option has the longest duration of analgesic effect, lasting for 48-72 hours.
– Oral Oramorph® SR: This slow-release option has an effect that lasts for 8-12 hours.
– Oral oxycodone: This option has an effect that lasts for 3-6 hours.
– Oral hydromorphone: This option has a duration of action of 3-6 hours.
– Oral methadone: This option has an effect that lasts for 3-8 hours.

It is important to note that the duration of analgesic effect can vary depending on factors such as the individual’s metabolism and the dosage prescribed. It is crucial to follow the prescribing physician’s instructions and to report any adverse effects or concerns.

The Importance of Pain Control in Palliative Care

Pain is a crucial aspect of palliative care management. It is a multifaceted symptom that can impact a patient’s mobility, appetite, sleep, and overall quality of life. Addressing pain may involve improving mobility, which can help patients get out of bed and move around more easily. Pain control is also associated with better appetite and sleep, as well as reducing anxiety and improving general quality of life. Therefore, pain control is an essential component of palliative care that can significantly enhance a patient’s well-being.

Myths about Hospice Care: Debunked

Hospice care is often misunderstood, leading to misconceptions about who can receive it and what it entails. Here are some common myths about hospice care debunked:

Myth #1: Hospice care is only for patients with terminal cancer.
Fact: Patients with any terminal diagnosis can seek hospice care, not just those with cancer. Commonly, patients with chronic lung disease, dementia, and neurodegenerative disorders benefit from hospice care.

Myth #2: Patients must be bed-bound to receive hospice care.
Fact: Mobility status does not affect admission to hospice. Patients in hospices often take part in activities and may be fully mobile.

Myth #3: Patients must have a ‘do not resuscitate’ (DNACPR) decision to receive hospice care.
Fact: Although most patients will have a DNACPR decision in a hospice, this is not a requirement.

Myth #4: Patients must have uncontrolled pain to receive hospice care.
Fact: While some patients may be admitted to a hospice for pain control, hospices are able to treat other symptoms, and pain control can be addressed in other settings, depending on the patient’s needs and wishes.

Hospice care and palliative care both focus on quality of life care for the patient and address adjustment to illness and end-of-life issues. Both forms of care address pain and symptom control issues for patients. However, hospice care is for patients who are no longer actively seeking curative treatment and have a terminal diagnosis with a life expectancy of 6 months or less. In contrast, for palliative care treatment, patients may still be undergoing aggressive treatment and do not have to be terminally ill. It is important to understand the facts about hospice care to make informed decisions about end-of-life care.

Medications for Delirium and Hallucinations

Delirium is a common condition in elderly and unwell patients that can cause hallucinations and agitation. Haloperidol is the preferred treatment for these symptoms. It is an anti-psychotic medication that can effectively manage hallucinations and agitation associated with delirium.

Benzodiazepines like lorazepam and diazepam have anxiolytic and sedating effects but do not treat hallucinations. Midazolam can be used to treat anxiety and induce sedation but is not effective in treating hallucinations.

Hyoscine bromide is a medication used to treat respiratory secretions in patients with a weak cough and is not indicated for the treatment of delirium or hallucinations. It is important to actively diagnose and manage delirium in patients to provide appropriate treatment and improve outcomes.