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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3055_Библиотеки_им_академика_М_И_Перельмана.pdf
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Nausea
Nausea is an uncomfortable, subjective symptom which often
precedes vomiting. Nausea/vomiting is a protective mecha-
nism the body uses to expel toxins, unsavory food, etc. but can
also be triggered by emotional causes, side effect to medica-
tions, and can originate in the CNS or from the GI tract.
There are several complex neural mechanisms involved in
nausea and vomiting. The areas involved include the medulla/
nucleus tractus solitarius (vomiting center), cortex, chemore-
ceptor trigger zone (area postrema), upper GI tract, and/or
labyrinths. One or more of these areas can be affected.
Determining the underlying etiology of the nausea/vomiting
helps the clinician to choose the appropriate medication/
intervention that targets the specific receptor. Muscarinic,
dopamine, histamine, serotonin, opioid, and neurokinin neu-
rotransmitter receptors can be involved [5]. Antiemetics fall
into classes that target certain receptors.
When stacking medications, choose agents with different
mechanisms of action at the lowest, most effective dose and try
to avoid polypharmacy. Nausea/vomiting has many causes, but in
the palliative care population, it is more frequently a side effect
of chemotherapy or opioid use, is related to GI
obstruction/constipation, or can be as a result of CNS lesions
(Fig. 4.3).
Pain
Pain management can be divided into treatment for cancer
pain and non-cancer pain. A complete H&P should be per-
formed to determine the underlying etiology of the pain, and
efforts should be made to address the underlying cause. At
the end of life, opioids are the mainstay of treatment and a
necessary basic medication in the palliative care toolbox.
Opioids can be used for all types of pain—somatic, visceral,
and neuropathic as well for other symptoms such as dyspnea,
cough suppression, opioid withdrawal, and diarrhea control.
Existential pain should be differentiated from physical pain.
T.N. Goring
89
Nausea/Vomitting
Vestibular/CNS Mechanical
obstruction
GI Dysmotility/
Partial Obstruction
Asses for reversible
causes
Avoid polypharmacy
Determine etiology
and target specific
receptors
Chemoreceptor Trigger Zone
(CTZ)
Opioids/Anesthetics/Chemo
(not a surgical
candidate)
Motion sickness/
Vertigo
Histamine
Receptor
Dimenhydrinate
Diphenhydramine
Meclizine
Scopolamine
Acetylcholine
Receptor
Nasogastric
tube
Add Octreotide
SQ + Decadron
Dopamine
Receptor
Serotonin
Receptor
If fails, venting
gastrostomy
Chlorpromazine
Droperidol
Metoclopramide
Prochlorperazine
Promethazine
Ondansetron
Palonosetron
Granisetron
Ondansetron
Palonosetron
Granisetron
Metoclopramide
Chlorpromazine
Droperidol
Prochlorperazine
Promethazine
Dexamethasone
Lorazepam
Dronabinol
(2nd line)
Serotonin
Receptor
(1st line)
Dopamine
Receptor
(2nd line)
Solitary tract
nucleus/medulla
receptors
(3rd line)
Other
(1st line)
Fig. 4.3 Assessment and management of nausea and vomiting in palliative care (Modified from [5] Flake, Z. Am Fam
Physician. 2004 Mar 1;69(5):1169–1174)
4. End-of-Life Care/Pain Management/Palliative
90
Although controversial, evidence suggests that existential
pain can be managed with acetaminophen [6]. Neuropathic
pain is best treated by medications with neuropathic proper-
ties such as NSAIDS, some antidepressants and anticonvul-
sants, and topical agents. Always consider the side effect
profile of the medication and prescribe accordingly. The
World Health Organization (WHO) has developed a three-
step ladder for cancer pain relief [7]. When treating pain, first
assess for the underlying cause. For mild pain, non-opioid
pain relievers such as NSAIDS, acetaminophen, and tricyclic
antidepressants, and steroids are the drugs of choice. Patients
who have moderate pain may benefit from low-dose opioids,
in scheduled doses ± an adjuvant pain reliever such as those
given for mild pain. For more severe pain, strong opioids such
as morphine, hydromorphone, oxymorphone, or fentanyl are
the drugs of choice. Equianalgesic equivalent doses should be
taken into account in addition to the side effect profile,
metabolism/clearance of the drug, route of delivery, and cost.
Strong opioids have the potential for respiratory depression,
N/V, severe constipation, myoclonus, altered mental status,
and urinary retention. Ketamine, an NMDA receptor blocker,
can also be used for pain control in such cases as cancer-
associated neuropathic pain, ischemic pain, and regional pain
syndromes [8]. Anesthesia-based interventions (nerve blocks,
intrathecal pump, spinal stimulators) can be attempted to
address pain in certain regional pain syndromes. These inter-
ventions may be appropriate for patients with intractable
side effects secondary to opioid use and/or patients on exces-
sive doses of opioids by allowing the patient to significantly
reduce or eliminate opioid use entirely. Radiation therapy is
also a useful pain treatment modality, especially in cases of
cancer-related bone pain (Fig. 4.4).
Advance Care Planning
Every clinician should become comfortable with the aspects of
advance care planning. It is prudent to provide the patient and
family with information on availability and appropriateness of
T.N. Goring
91
life-sustaining treatments in the event that the patient is diag-
nosed with a terminal illness or is nearing the end of life.
Clinicians should inquire about the patient’s understanding of
these treatments and assess the patient’s values and wishes at
the end of life. Some examples of patient goals may be relief of
Pain
Mild
Non-opioids
+/- adjuvant
Acetaminophen
NSAIDS
Adjuvants - (TCA,
Anxiolytics)
Anesthesia-based Interventions
for ongoing pain or intolerable
side effects
Nerve blocks
Intrathecal Pain Pump
Nerve stimulator
Radiation for bone pain
Non-medication pain relievers
Topical agents
Massage
Physical Therapy
Acupuncture
Codeine
Oxycodone
Hydrocodone (low dose)
Morphine (low dose)
Morphine
Hydromorpone
Fentanyl
Oxymorphone
Methadone
Weak Opioid
+/- adjuvant
Document allergies
Strong Opioid
+/- adjuvant
Moderate Severe
Assess character, quality
duration, source,
location of pain
Nociceptive
Neuropathic
Inflammatory
Mixed category
Fig. 4.4 Management of pain in palliative care (Modified from
WHO Stepladder [7])
4. End-of-Life Care/Pain Management/Palliative
92
Advance Care Planning
Assess and re-assess patient’s
goals for treatment vs. supportive
care at EVERY visit
Estimate prognosis
DNR/Allow Natural Death
Order
End-of-Life wishesHealthcare Proxy Living Will
Fig. 4.5 Algorithm for advanced care planning
T.N. Goring
93
suffering, maintaining a certain quality of life, cure of disease,
prolongation of life, avoidance of CPR, intubation, and avoid-
ance of pain. The clinician should always inquire about patient
goals rather than make assumptions about what the patient
desires. Some patients have strong opinions about goals of
care. Advance care planning should include some of the
following:
• Inquire about “readiness” to have a goals of care (GOC)
conversation with the patient.
• Inquire about past GOC discussions and review previous
documentation.
• Determine the best estimate of prognosis and acknowl-
edge uncertainty.
• Assess patient’s understanding of his/her illness and prog-
nosis, assess expectations, and encourage realistic goals.
• Inquire about family support/caregivers.
• Confirm that the patient has a healthcare proxy (HCP)
and/or living will; discuss the definition of a do not resus-
citate (DNR) order, and document the patient’s wishes.
• Summarize wishes at end of life (EOL) and confirm
agreement.
• Show empathy when discussing EOL issues.
Readdress goals at follow-up visits to make sure ongoing
management is in line with evolving symptoms or progres-
sion of disease. Patients often fear abandonment by their
physician at the end of life, and they should be reassured that
this will not be the case (Fig. 4.5).
Hospice Care
Medicare defines four levels of hospice care [9] depending on
the patient’s needs:
Routine home care—is the most common level of care in the
USA and is defined as care administered where the patient
resides (private residence, assisted living facility, nursing
facility) on an as-needed basis. This level of care can be esca-
lated or reduced throughout the patient’s course of illness.
4. End-of-Life Care/Pain Management/Palliative
94
Respite care—is short-term, usually up to 5 days of inpatient
care where the patient is admitted to a contracted facility, not
because of the patient’s individual symptoms but solely to pro-
vide the caregiver a rest. Respite care is only provided “occa-
sionally” in accordance with Medicare or insurance rules.
Continuous care—is care intended to support the patient and
the caregiver during brief periods of crisis. Care can be pro-
vided at a minimum of 8 h but can be up to 24 h to achieve
control of the acute symptom, at which time the continuous
care returns to routine care. This care level is used when the
individual requires predominantly skilled nursing and can be
provided in the home or nursing facility.
Inpatient hospice—is care designated for those patients who
require management of an uncontrolled or distressing physi-
cal symptom. Examples include pain, intractable nausea,
SOB, delirium, wound care, and in cases where death is immi-
nent and family can no longer provide care at home. The
patient may be discharged from the inpatient facility to
resume routine home care if he or she improves.
Clinical Pearls
• Palliative care is specialized care for individuals with seri-
ous, often life-limiting illness.
• Patients with a predicted life expectancy of <6 months
qualify for hospice care.
• Shortness of breath can be managed with oxygen and opi-
oids at the end of life.
• A bowel regimen should be prescribed along with opioids
to reduce the risk of constipation.
• Try to identify the underlying etiology of nausea in order
to prescribe the antiemetic that interacts with the associ-
ated receptor.
• Opioids are the mainstay of treatment for cancer pain and
pain in the palliative care setting.
• Primary care physicians should feel comfortable discuss-
ing goals of care with patients.
• Advance directives should be discussed and documented
in the medical record.
T.N. Goring
95
• There are four levels of hospice care as defined by
Medicare.
Don’t Miss This!
• Do not forget to evaluate for reversible causes of SOB.
• Obstruction should be ruled out in a patient with
nausea/vomiting.
• Palliative care can be delivered concomitantly with
disease- directed therapies.
• Rule out stool impaction in cases of chronic constipation.
• If giving multiple medications to control N/V, choose
medications with different mechanisms of action.
• When treating pain, begin with non-opioid analgesics, if
appropriate.
• Goals of care discussions should happen early and often if
a patient has a potentially life-threatening illness.
References
1. CAPC. About palliative care; 2016.
2. CMS. Medicare hospice benefit; 2016. P. 1–17.
3. Banzett RB, Adams L, O'Donnell CR, Gilman SA, Lansing RW,
Schwartzstein RM. Using laboratory models to test treatment:
morphine reduces dyspnea and hypercapnic ventilatory response.
Am J Respir Crit Care Med. 2011;184(8):920–7.
4. American Gastroenterological Association, Bharucha AE, Dorn
SD, Lembo A, Pressman A. American Gastroenterological
Association medical position statement on constipation.
Gastroenterology. 2013;144(1):211–7.
5. Flake ZA, Scalley RD, Bailey AG. Practical selection of antiemet-
ics. Am Fam Physician. 2004;69(5):1169–74.
6. Randles D, Heine SJ, Santos N. The common pain of surrealism
and death: acetaminophen reduces compensatory affirmation fol-
lowing meaning threats. Psychol Sci. 2013;24(6):966–73.
7. World Health Organization. Cancer pain relief. Geneva: World
Health Organization; 1986. p. 1986.
8. Prommer EE. Ketamine for pain: an update of uses in palliative
care. J Palliat Med. Apr 2012;15(4):474–83.
9. NHPCO. Hospice levels of care; 2016.
4. End-of-Life Care/Pain Management/Palliative
97© Springer International Publishing AG 2018
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-319-68379-9_5
Chapter 5
Care of HIV Patients
Elizabeth R. Jenny-Avital
Historical Perspective and the Evolution
of the Current State of the Art
In 1981, a prescient CDC report described five cases of
Pneumocystis carinii pneumonia (now referred to as
Pneumocystis jiroveci pneumonia, PJP) that were associated
with cytomegalovirus (CMV) infection and mucosal candi-
diasis occurring in previously healthy gay men [1]. Soon
after, the CDC reported 26 gay men with an unusual cancer,
Kaposi’s sarcoma, also associated with unusual infections
that were indicative of defective cell-mediated immunity
(PJP, CMV, toxoplasmosis, cryptococcosis) [2]. These senti-
nel clinical observations suggested an acquired cell-medi-
ated immunodeficiency which became known as the acquired
immunodeficiency syndrome (AIDS) in 1982. Infections,
which do not occur in normal hosts but which occur by virtue
of an immune defect, are termed “opportunistic infections”
(OIs). The AIDS-associated OI s were associated with a
markedly depressed CD4 (helper T) lymphocyte count
E.R. Jenny-Avital, MD, M Phil (*)
Department of Medicine, Albert Einstein College of Medicine,
Jacobi Medical Center, 1400 Pelham Parkway South, ACS Clinic,
Bldg 1, Suite 146, Bronx, NY 10461, USA
e-mail: Elizabeth.Jenny-Avital@nbhn.net
98
(<200/mm
3
). With time, the spectrum of unexpected OIs and
malignancies broadened as did the risk groups affected.
Intravenous drug users (IDUs), hemophiliac men and
women who were sexual partners of IDUs, hemophiliac or
bisexual men, and their offspring also had AIDS. The human
immunodeficiency virus (HIV) was isolated in the early
1980s [3, 4, 5]. Since 1985, blood products in the USA have
been screened for HIV. Detailed epidemiologic studies
showed that HIV was transmitted sexually, by contaminated
blood and from infected mother to child during pregnancy,
childbirth, or breastfeeding, but not by casual household and
family contact [6].
About 2 weeks after exposure to HIV, an acute, intense
viremia ensues. This may be associated with a clinical mono-
nucleosis like seroconversion illness, consisting variably of
fever, rash, sore throat, lymphadenopathy, diarrhea, and/or
aseptic meningitis. Not infrequently, a concurrent sexually
transmitted disease (STD) or group A beta strep in the throat
obscures recognition of acute HIV. During acute HIV infec-
tion, profound CD4 cell destruction in lymphoid tissue, espe-
cially in the gut, occurs, and HIV establishes itself in its
reservoirs by integrating into the host DNA of CD4-bearing
cells. As an immune response supervenes, the acute HIV vire-
mia declines to a “set point” which varies from hundreds to
hundreds of thousands. The viral load set point accounts for
about half of the variability of HIV progression without treat-
ment and characterizes most of the duration of untreated
infection [7, 8, 9]. Acute HIV is highly transmissible compared
to chronic HIV in part due to the high-grade viremia of acute
HIV but also because the viral strains detected during sero-
conversion are better adapted for transmission, while the viral
strains detected during chronic HIV are better adapted to
persistence in the host. Greater severity of seroconversion
symptoms is associated with a higher subsequent set point and
faster disease progression. The rationale for initiating
antiretroviral therapy (ART) during acute infection is to limit
the profound immunologic damage associated with acute
infection, to reduce the viral reservoirs that are established as
E.R. Jenny-Avital