Palliative care of emergencies

Palliative care of emergencies

Superior vena cava obstruction (SVCO)

If SVCO is suspected discuss with an oncologist within 24 hours. The investigation of choice is a CTPA (CT Pulmonary Angiogram). It is usually due to malignant involvement of upper mediastinal lymph nodes or a right upper lobe lung cancer, intraluminal thrombus may also be a feature1.

Symptoms and signs: headache; breathlessness; swelling of face and arms; fixed raised JVP; dilated veins on chest wall and around costal margin.

Initial treatment consists of dexamethasone 16 mg daily orally aiming to reduce any oedema around the tumour. Definitive treatment may include insertion of a vascular stent, radiotherapy or chemotherapy.

Hypercalcaemia of malignancy

Normal range: adjusted calcium 2.1–2.6 mmol/L

The majority of calcium circulates bound to albumin, but a small amount is present as the physiologically active “ionised” calcium. The adjusted calcium or “ionised” calcium should be used when the patient has a low albumin2,3,4

Corrected calcium (mmol/L) = measured calcium + (0.02 x [40-albumin g/l]).

Occurs in about 10–20% of patients affected by cancer. It is generally indicative of a poorer prognosis in solid tumours.

 

Symptoms and signs:

Confusion, drowsiness, nausea and vomiting, thirst, polyuria, constipation, lethargy, bradycardia and coma.

Severity of symptoms are not necessarily indicative of the level of hypercalcaemia.

Generally when managing hypercalcaemia, an adjusted calcium level greater than 3.0 should be treated whether the patient is symptomatic or not.

Treatment :

It is important to carefully balance the benefits versus burdens of treating hypercalcaemia in a patient with advanced disease, considering the care setting, previous history of hypercalcaemia and patient preferences.

Treatment includes parenteral rehydration and use of intravenous bisphosphonates.

Bisphosphonates start to take effect after 48 hours to lower serum calcium, however the maximum effect may not be seen for 5 to 7 days. Bisphosphonates therefore may not be indicated in a patient whose estimated prognosis is very short.

Discontinue any calcium, vitamin D or vitamin A supplements.

Review and consider discontinuing any drugs which may affect renal blood flow e.g. NSAIDs, diuretics, ACE inhibitors, Angiotensin II receptor antagonists.

Renal function and albumin should be checked prior to giving infusion. In renal failure consult product literature for dosing guidance.

Recent studies have shown zoledronic acid to be superior to pamidronate in terms of more rapid onset and longer duration of action but please refer to your local policy for guidance4.

•   Ensure the patient is appropriately hydrated before giving a bisphosphonate (e.g 1–3 litres of parenteral sodium chloride 0.9%) volume and rate should be adjusted according to age and other co-morbidities

•   Depending on local policy pamidronate or zoledronic acid is used:-

Either:

•   Disodium pamidronate  IV infused at a rate not exceeding 1 mg/min (see manufacturer’s guidance for patients with renal impairment):- 

Corrected calcium (mmol/L) Pamidronate (mg) 0.9% saline (mL)

< 3

30

250

3 – 3.5

60

250

> 3.5

90

500

•   However one systematic review of bisphosphonate use4 states that 90mg pamidronate may be given irrespective of the initial calcium level, in order to increase the likelihood of successful and sustained normocalcaemia.

Or:

•   Zoledronic acid IV 4mg in 100 mL 0.9% saline infused over 15 minutes at least

•   Repeated infusions of bisphosphonates carry an increased risk of developing osteonecrosis of the jaw (rare before 4 months of treatment). Patients should avoid invasive dental procedures while receiving ongoing bisphosphonate therapy

Monitoring

•   Repeat calcium levels are best monitored at 5–7 days post infusion as it takes this length of time for the bisphosphonate to have reached its maximum effect. It is advisable to recheck the calcium level when patient experiences symptoms or every 3-4 weeks


Management of resistant / recurrent hypercalcaemia

•   For resistant hypercalcaemia (hypercalcaemia not responding to initial bisphosphonate therapy at appropriate dose) seek specialist palliative care advice

•   Recurrent hypercalcaemia, that has recurred within a short time (e.g. 1 to 2 weeks) after previous appropriate treatment may represent advancing disease and may be less likely to respond to further treatment. If required, a further dose can be administered at 5–7 days. Seek specialist palliative care advice


Metastatic Spinal Cord Compression (MSCC)⁶

This occurs in 5–10% of cancer patients, the most common underly- ing tumours being lung, breast and prostate (40% of all cases). Early detection has a significant outcome on morbidity and mortality.

 

Symptoms and signs:

NICE recommends that in the following instances the MSCC coordinator (e.g. Acute Oncology Nurse Specialist, on call Consultant Oncologist/Spinal Surgeon/Neurosurgeon7)

(i) is contacted within 24 hours to discuss the care of patients with cancer and any of the following symptoms suggestive of spinal metastases:

•   pain in the middle (thoracic) or upper (cervical) spine

•   progressive lower (lumbar) spinal pain

•   severe unremitting lower spinal pain

•   spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)

•   localised spinal tenderness

•   nocturnal spinal pain preventing sleep

(ii) is contacted immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency:

•   neurological symptoms including radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction

•   neurological signs of spinal cord or cauda equina compression

Immediate treatment :

Oral dexamethasone 16 mg daily.

If a patient with suspected MSCC is considered fit for investigation and treatment an urgent MRI of the whole spine is the investigation of choice.

 

Corticosteroid use and withdrawal in MSCC

•   Unless contraindicated (including a significant suspicion of lymphoma) offer all patients with MSCC a loading dose of at least 16 mg of dexamethasone as soon as possible after assessment, followed by a short course of 16 mg dexamethasone daily while treatment is being planned

•   Continue dexamethasone 16 mg daily in patients awaiting surgery or radiotherapy for MSCC. After surgery or the start of radiotherapy the dose should be reduced gradually over 5–7 days and stopped. If neurological function deteriorates at any time the dose should be increased temporarily

•   Reduce gradually and stop dexamethasone 16 mg daily in patients with MSCC who do not proceed to surgery or radiotherapy after planning. If neurological function deteriorates at any time the dose should be reconsidered.

•   Monitor blood glucose levels in all patients receiving corticosteroids

See also Corticosteroids


Major haemorrhage⁷ ⁸

Clinically significant bleeding occurs in 6-10% of patients with advanced cancer, often this may be internal.

The most common primary cancer sites include:-

•   Lung

•   Head and neck

•   Upper GI

 

The risk of bleeding can be affected by other factors such as:-

•   Coagulopathy (includes patients on aspirin and NSAIDs, anti-coagulant therapy or intrinsic coagulation problems, such as bone marrow failure)

•   Proximity of the tumour to major blood vessels

•   Presence of fungating or infected wounds

Sensitive exploration of the patient and carer’s understanding of the clinical situation and potential risk for significant bleeding may reduce distress by providing a clear plan of action in the event.

The carer and health care professional can best support the patient by remaining calm and where possible close to the patient. Dark coloured towels may be helpful in disguising the appearance of the blood.

Anticipatory prescribing with an anxiolytic/sedative such as midazolam (buccal or IM) is the recommended management in the event of an acute terminal bleed9. Seek specialist palliative care advice If required.

 

References

1.  Chan KS et al. Palliative medicine in malignant respiratory diseases. Pp 598. In: Doyle D, Hanks G, Cherny N and Calman K. (editors) Oxford Textbook of Palliative Medicine. 3rd edition. Oxford University Press, New York. 2005.

2.  Bower M and Cox S. Endocrine and metabolic complications

of advanced cancer. Pp 687-690. In: Doyle D, Hanks G, Cherny N and Calman K. (editors) Oxford Textbook of Palliative Medicine. 3rd edition. Oxford University Press, New York. 2005.

3.  Major P et al. Zoledronic acid is superior to pamidronate in the treatment of hypercalcaemia of malignancy: a pooled analysis of two controlled clinical trials. Journal of Clinical Oncology,

2001, 19:558-567.

4.  Twycross R, Wilcock A (Eds). Palliative Care Formulary: Fourth

Edition. Palliativedrugs.com Ltd 2011.

5. Lamy O, Bruckhardt P. Hypercalcaemia of malignancy , diagnosis and treatment.Am J Cancer 2002;1(4):277-292.

6. National Institute for Health and Clinical Excellence.

Metastaticspinal cord compression:diagnosis and management of patients at risk of or with spinal cord compression.(Clinical guidelines 75) London:NICE,2008. Available from : www.nice.org.uk/CG75 Last accessed 8 November 2011].

7.  Prommer E . Management of bleeding in the terminally ill patient. Haematology 2005;10(3):167-175

8. Perira J, Phan T. Management of bleeding in patients with advanced cancer. Oncologist 2004;9:561-570.