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Symptom Management in the Last Days of Life This Is About Managing Symptoms in the Last Days of Life Where the Dying Process Has Set In
Symptom management in the last days of life This is about managing symptoms in the last days of life where the dying process has set in. It assumes that the therapeutic aims are therefore: To allow the patient to die comfortably To support the family/carers and to start to prepare them for bereavement To discontinue any burdensome or irrelevant clinical procedures Key Prescribing Questions in the last days of life 1. Ahead of time Page a. Pre-emptive prescribing 1 b. Differences in specific circumstances 1 2. Once the oral route is lost a. What can be stopped? – managing co-morbidities at the end of life 2 (insulin; anti-epileptics; steroids; cardiac medicines) b. How to prescribe a syringe pump 3 i. Opioid conversion 4 ii. Combining drugs in a syringe – what can and can’t be mixed? 5 iii. Dosing other drugs 6 c. What can and can’t be given subcutaneously 7 3. Problems a. Uncontrolled symptoms (pain; restlessness; secretions; breathlessness; nausea; thirst) 8 b. Obtaining medicines out of hours 11 c. References and contact phone numbers 12 Pre-emptive prescribing The pre-emptive prescribing of p.r.n. medication for anticipated symptoms can avoid great distress. The cost is negligible and it saves time on the part of both families and out-of-hours health professionals. Typical maximum doses are described on page 22, but the doses needed by individuals vary widely: it is more important to assess the effectiveness of each p.r.n. before repeating or increasing doses – if a p.r.n. is ineffective, try a different approach or seek advice (see flow diagrams) A typical “pre-emptive p.r.n.” regimen for patients approaching the end of life might include: Morphine sulphate 2.5-5mg 1-4 hourly p.r.n. -
Future Directions for Intrathecal Pain Management 93
NEUROMODULATION: TECHNOLOGY AT THE NEURAL INTERFACE Volume 11 • Number 2 • 2008 http://www.blackwell-synergy.com/loi/ner ORIGINAL ARTICLE FBlackwell uturePublishing Inc Directions for Intrathecal Pain Management: A Review and Update From the Interdisciplinary Polyanalgesic Consensus Conference 2007 Timothy Deer, MD* • Elliot S. Krames, MD† • Samuel Hassenbusch, MD, PhD‡ • Allen Burton, MD§ • David Caraway, MD¶ • Stuart Dupen, MD** • James Eisenach, MD†† • Michael Erdek, MD‡‡ • Eric Grigsby, MD§§ • Phillip Kim, MD¶¶ • Robert Levy, MD, PhD*** • Gladstone McDowell, MD††† • Nagy Mekhail, MD‡‡‡ • Sunil Panchal, MD§§§ • Joshua Prager, MD¶¶¶ • Richard Rauck, MD**** • Michael Saulino, MD†††† •Todd Sitzman, MD‡‡‡‡ • Peter Staats, MD§§§§ • Michael Stanton-Hicks, MD¶¶¶¶ • Lisa Stearns, MD***** • K. Dean Willis, MD††††† • William Witt, MD‡‡‡‡‡ • Kenneth Follett, MD, PhD§§§§§ • Mark Huntoon, MD¶¶¶¶¶ • Leong Liem, MD****** • James Rathmell, MD†††††† • Mark Wallace, MD‡‡‡‡‡‡ • Eric Buchser, MD§§§§§§ • Michael Cousins, MD¶¶¶¶¶¶ • Ann Ver Donck, MD******* *Charleston, WV; †San Francisco, CA; ‡Houston, TX; §Houston, TX; ¶Huntington, WV; **Bellevue, WA; ††Winston Salem, NC; ‡‡Baltimore, MD; §§Napa, CA; ¶¶Wilmington, DE; ***Chicago, IL; †††Columbus, OH; ‡‡‡Cleveland, OH; §§§Tampa, FL; ¶¶¶Los Angeles, CA; ****Winston Salem, NC; ††††Elkings Park, PA; ‡‡‡‡Hattiesburg, MS; §§§§Colts Neck, NJ; ¶¶¶¶Cleveland, OH; *****Scottsdale, AZ; †††††Huntsville, AL; ‡‡‡‡‡Lexington, KY; §§§§§Iowa City, IA; ¶¶¶¶¶Rochester, NY; ******Nieuwegein, The Netherlands; ††††††Boston, MA; ‡‡‡‡‡‡La Jolla, CA; §§§§§§Switzerland; ¶¶¶¶¶¶Australia; and *******Brugge, Belgium ABSTRACT Background. Expert panels of physicians and nonphysicians, all expert in intrathecal (IT) therapies, convened in the years 2000 and 2003 to make recommendations for the rational use of IT analgesics, based on the preclinical and clinical literature known up to those times, presentations of the expert panels, discussions on current practice and standards, and the result of surveys of physicians using IT agents. -
Withdrawing Benzodiazepines in Primary Care
PC\/ICU/ ADTiriC • CNS Drugs 2009,-23(1): 19-34 KtVltW MKIIWLC 1172-7047/I»/O(X)1«119/S4W5/C1 © 2009 Adis Dato Intocmation BV. All rights reserved. Withdrawing Benzodiazepines in Primary Care Malcolm Luder} Andre Tylee^ and ]ohn Donoghue^ 1 Institute of Psychiatry, King's College London, London, England 2 John Moores University, Liverpool, Scotland Contents Abstract ' 19 1. Benzodiazepine Usage 22 2. Interventions 23 2.1 Simple interventions 23 2.2 Piiarmacoiogicai interventions 25 2.3 Psychoiogical Interventions 26 2.4 Meta-Anaiysis ot Various interventions 27 3. Outcomes 28 4. Practicai Issues 29 5. Otiier Medications 30 5.1 Antidepressants 30 5.2 Symptomatic Treatments 30 6. Conciusions 31 Abstract The use of benzodiazepine anxiolytics and hypnotics continues to excite controversy. Views differ from expert to expert and from country to country as to the extent of the problem, or even whether long-term benzodiazepine use actually constitutes a problem. The adverse effects of these drugs have been extensively documented and their effectiveness is being increasingly questioned. Discontinua- tion is usually beneficial as it is followed by improved psychomotor and cognitive functioning, particularly in the elderly. The potential for dependence and addic- tion have also become more apparent. The licensing of SSRIs for anxiety disorders has widened the prescdbers' therapeutic choices (although this group of medications also have their own adverse effects). Melatonin agonists show promise in some forms of insomnia. Accordingly, it is now even more imperative that long-term benzodiazepine users be reviewed with respect to possible discon- tinuation. Strategies for discontinuation start with primary-care practitioners, who are still the main prescdbers. -
Hyoscine Butylbromide, Levomepromazine, Metoclopramide, Midazolam, Ondansetron
TRUST WIDE/DIVISIONAL DOCUMENT Delete as appropriate Policy/Standard Operating Procedure/ Clinical Guideline Policy and Procedure for the T34 Ambulatory Syringe Pump DOCUMENT TITLE: in adults (Palliative Care) DOCUMENT ELHT/CP22 Version 5.3 NUMBER: DOCUMENT REPLACES Which ELHT/CP22 Version 5.2 Version LEAD EXECUTIVE DIRECTOR DGM AUTHOR(S): Note Syringe pump policy task and finish group chaired by should not include Palliative Medicine Consultant names TARGET AUDIENCE: Medical and Nursing Staff 1 To provide a clear governance framework to ensure a safe and consistent approach to the use of the T34 Ambulatory Syringe Pump DOCUMENT 2 To provide details of how to set up and administer PURPOSE: medication by a T34 Ambulatory Syringe Pump 3 To provide easily accessible information about the common medicines used in a Syringe Pump Clinical Practice Summary. Guidance on consensus approaches To be read in to managing palliative care symptoms. Lancashire and South conjunction with Cumbria consensus guidance – August 2017 (identify which internal C064 V5 Medicines Management Policy documents) IC24 V4 Aseptic non touch technique (ANTT) policy East Lancashire Hospital NHS Trust – Policies & Procedures, Protocols, Guidelines ELHT/CP22 v5.2 May 2020 Page 1 of 77 Nursing and Midwifery Council - Standards for Medicines Management 2015 Dickman et al (2016) The Syringe Driver, 4th edition, Oxford Press T. Mitten, (2000) Subcutaneous drug infusions, a review of problems and solutions. International Journal of Palliative Nursing Vol 7, No 2. Twycross et al (2017) 6th Edition Palliative Care SUPPORTING Formulary and Palliative Care Formulary online, REFERENCES accessed June 2018 Twycross R., Wilcock A., (2001) Symptom Management in Advanced Cancer 3rd edition Radcliffe medical press Oxon. -
Approach to the Poisoned Patient
PED-1407 Chocolate to Crystal Methamphetamine to the Cinnamon Challenge - Emergency Approach to the Intoxicated Child BLS 08 / ALS 75 / 1.5 CEU Target Audience: All Pediatric and adolescent ingestions are common reasons for 911 dispatches and emergency department visits. With greater availability of medications and drugs, healthcare professionals need to stay sharp on current trends in medical toxicology. This lecture examines mind altering substances, initial prehospital approach to toxicology and stabilization for transport, poison control center resources, and ultimate emergency department and intensive care management. Pediatric Toxicology Dr. James Burhop Pediatric Emergency Medicine Children’s Hospital of the Kings Daughters Objectives • Epidemiology • History of Poisoning • Review initial assessment of the child with a possible ingestion • General management principles for toxic exposures • Case Based (12 common pediatric cases) • Emerging drugs of abuse • Cathinones, Synthetics, Salvia, Maxy/MCAT, 25I, Kratom Epidemiology • 55 Poison Centers serving 295 million people • 2.3 million exposures in 2011 – 39% are children younger than 3 years – 52% in children younger than 6 years • 1-800-222-1222 2011 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System Introduction • 95% decline in the number of pediatric poisoning deaths since 1960 – child resistant packaging – heightened parental awareness – more sophisticated interventions – poison control centers Epidemiology • Unintentional (1-2 -
Strategisk Regnskabsanalyse Og Værdiansættelse Af H. Lundbeck A/S
Copenhagen Business School Hovedopgave 2011 Institut for Regnskab HD-R (Regnskab og og Revision Økonomistyring) Strategisk regnskabsanalyse og værdiansættelse af H. Lundbeck A/S Vejleder: Udarbejdet af: Ole Sørensen Mikael Thaarup Robertsen Institut for Regnskab og Revision Cpr. nr. 300880-XXXX Copenhagen Business School Afleveret 16. maj 2011 EXECUTIVE SUMMARY H. Lundbeck A/S is an international pharmaceutical company focused on development and marketing of treatment for diseases within the central nerve system (CNS). Lundbeck has in the last few years had an outstanding financial performance, but in the same period the value of the company’s stock are at a historical low. On top of that the largest Nordic bank Nordea had a sell recommendation and a target price of 85 DKK as late as end of 2010. Has the sell recommendation and the low target price a justification due to the fact that Lundbeck’s blockbuster product Cipralex®/Lexapro® will lose patent protection in 2012 in the US and 2014 in the remaining of the world? The derived objective of the thesis has been to create a reliable valuation of Lundbeck taking into account the current business, including products and research pipeline, the historic financial performance and the financial outlook for the future. The objective of the strategic analysis has been to obtain the required knowledge about the business, the industry and the society that all influence the future growth scenario. The conclusion on this underlying strategic analysis was that the industry is under pressure from both public health service providers and generic competitors. At the same time the potential marked for CNS products is increasing due to demographic changes and increasing income levels in more recent developed countries. -
Sandostatin® Injection
Sandostatin® octreotide acetate Injection Rx Only T2002-XX XXXXXXXX DESCRIPTION Sandostatin® (octreotide acetate) Injection, a cyclic octapeptide prepared as a clear sterile solution of octreotide, acetate salt, in a buffered lactic acid solution for administration by deep subcutaneous (intrafat) or intravenous injection. Octreotide acetate, known chemically as L-Cysteinamide, D-phenylalanyl-L-cysteinyl-L-phenylalanyl-D-tryptophyl-L-lysyl-L- threonyl-N-[2-hydroxy-1-(hydroxymethyl)propyl]-, cyclic (2→7)-disulfide; [R-(R*, R*)] acetate salt, is a long-acting octapeptide with pharmacologic actions mimicking those of the natural hormone somatostatin. Sandostatin® (octreotide acetate) Injection is available as: sterile 1 mL ampuls in 3 strengths, containing 50, 100, or 500 mcg octreotide (as acetate), and sterile 5 mL multi-dose vials in 2 strengths, containing 200 and 1000 mcg/mL of octreotide (as acetate). Each ampul also contains: lactic acid, USP............................................................ 3.4 mg mannitol, USP .............................................................. 45 mg sodium bicarbonate, USP.............................qs to pH 4.2 ± 0.3 water for injection, USP ........................................ qs to 1 mL Each mL of the multi-dose vials also contains: lactic acid, USP ........................................................... 3.4 mg mannitol, USP .............................................................. 45 mg phenol, USP ................................................................ 5.0 mg sodium -
Acute Poisoning: Understanding 90% of Cases in a Nutshell S L Greene, P I Dargan, a L Jones
204 REVIEW Postgrad Med J: first published as 10.1136/pgmj.2004.027813 on 5 April 2005. Downloaded from Acute poisoning: understanding 90% of cases in a nutshell S L Greene, P I Dargan, A L Jones ............................................................................................................................... Postgrad Med J 2005;81:204–216. doi: 10.1136/pgmj.2004.024794 The acutely poisoned patient remains a common problem Paracetamol remains the most common drug taken in overdose in the UK (50% of intentional facing doctors working in acute medicine in the United self poisoning presentations).19 Non-steroidal Kingdom and worldwide. This review examines the initial anti-inflammatory drugs (NSAIDs), benzodiaze- management of the acutely poisoned patient. Aspects of pines/zopiclone, aspirin, compound analgesics, drugs of misuse including opioids, tricyclic general management are reviewed including immediate antidepressants (TCAs), and selective serotonin interventions, investigations, gastrointestinal reuptake inhibitors (SSRIs) comprise most of the decontamination techniques, use of antidotes, methods to remaining 50% (box 1). Reductions in the price of drugs of misuse have led to increased cocaine, increase poison elimination, and psychological MDMA (ecstasy), and c-hydroxybutyrate (GHB) assessment. More common and serious poisonings caused toxicity related ED attendances.10 Clinicians by paracetamol, salicylates, opioids, tricyclic should also be aware that severe toxicity can result from exposure to non-licensed pharmaco- -
The Role of A6 Subunit-Containing GABAA Receptors in Behavioral
OLGA Yu VEKOVISCHEVA The Role of a6 Subunit-containing GABA Receptors in Behavioral Effects of A Alcohol and Drug Treatments ACADEMIC DISSERTATION To be presented, with the permission of the Faculty of Medicine of the University of Tampere, for public discussion in the auditorium of Tampere School of Public Health, Medisiinarinkatu 3, Tampere, on May 23rd, 2003, at 12 oclock Acta Universitatis Tamperensis 928 University of Tampere Tampere 2003 ACADEMIC DISSERTATION University of Tampere, Medical School University of Turku, Department of Pharmacology and Clinical Pharmacology Finland Supervised by Reviewed by Professor Esa R& Korpi Professor Sture Liljequist University of Helsinki Karolinska Institutet Docent Mikko Uusi-Oukari Docent Tomi Taira University of Turku University of Helsinki Professor Simo Oja University of Tampere Distribution University of Tampere Bookshop TAJU Tel +358 3 215 6055 PO Box 617 Fax +358 3 215 7685 33014 University of Tampere taju@utafi Finland http://granumutafi Cover design by Juha Siro Printed dissertation Electronic dissertation Acta Universitatis Tamperensis 928 Acta Electronica Universitatis Tamperensis 251 ISBN 951-44-5662-9 ISBN 951-44-5663-7 ISSN 1455-1616 ISSN 1456-954X http://actautafi Tampereen yliopistopaino Oy Juvenes Print Tampere 2003 3 CONTENTS CONTENTS 4 LIST OF ORIGINAL PUBLICATIONS 6 ABBREVIATIONS 7 ABSTRACT 8 1. INTRODUCTION 9 2. REVIEW OF THE LITERATURE 11 2.1. The inhibitory γ-aminobutyric acid system. General overview 11 2.2. GABAA receptors 12 2.2.1. Molecular biology of GABAA receptors 12 2.2.2. Diazepam as a classical benzodiazepine modulator of 14 GABAA receptors 2.2.3. Ethanol as a modulator of GABAA receptor function 15 2.3. -
Study of CNS Depressant and Behavioral Effects of Cyclopyrrolone Compound Zopiclone in Different Animal Models
id10341328 pdfMachine by Broadgun Software - a great PDF writer! - a great PDF creator! - http://www.pdfmachine.com http://www.broadgun.com ISSN : 0974 - 7532 Volume 4 Issue 4 Research & Reviews in Trade Science Inc. BBiiooSScciieenncceess Regular Paper RRBS, 4(4), 2010 [173-176] Study of CNS depressant and behavioral effects of cyclopyrrolone compound zopiclone in different animal models Uma A.Bhosale*1, Anand A.Bhosale2 1Dept. of Pharmacology SKNMC, Narhe (Ambegaon) Pune-41, (INDIA) 2Dept. of Pathology SKNMC, Narhe (Ambegaon) Pune-41, (INDIA) E-mail : [email protected] Received: 10th September, 2010 ; Accepted: 20th September, 2010 ABSTRACT KEYWORDS Objectives: To evaluate CNS depressant and behavioral effects of zopiclone Incline plane; in comparison with BZD (lorazepam) by using different animal models. Pentobarbitone Methods: Pharmacological assays used for evaluating CNS Depressant sleeping time; activity are righting reflex test, pentobarbitone sleeping time potentiation, Rota rod apparatus; Rota rod apparatus and Incline plane performance test in albino mice. Open Zopiclone. field apparatus (OFT) was used to study behavioral effects. Data analyzed ’s unpaired-‘t’ test and p<0.05 considered significant. by student Results: Zopiclone (7.5mg/kg p.o.) did not inhibit the Righting reflex however sig- nificant (p<0.001) potentiation of Pentobarbitone sleeping time and de- creased fall off time in Rota rod as well as inclined plane test (P<0.05, P<0.02 respectively) were observed. In OFT increased in exploration (P<0.001) suggestive of anxiolysis was observed. Conclusions: Zopiclone (7.5mg/kg p.o.) has weak CNS Depressant activity and more selective behavioral activity compared to BZDs. -
Question of the Day Archives: Monday, December 5, 2016 Question: Calcium Oxalate Is a Widespread Toxin Found in Many Species of Plants
Question Of the Day Archives: Monday, December 5, 2016 Question: Calcium oxalate is a widespread toxin found in many species of plants. What is the needle shaped crystal containing calcium oxalate called and what is the compilation of these structures known as? Answer: The needle shaped plant-based crystals containing calcium oxalate are known as raphides. A compilation of raphides forms the structure known as an idioblast. (Lim CS et al. Atlas of select poisonous plants and mushrooms. 2016 Disease-a-Month 62(3):37-66) Friday, December 2, 2016 Question: Which oral chelating agent has been reported to cause transient increases in plasma ALT activity in some patients as well as rare instances of mucocutaneous skin reactions? Answer: Orally administered dimercaptosuccinic acid (DMSA) has been reported to cause transient increases in ALT activity as well as rare instances of mucocutaneous skin reactions. (Bradberry S et al. Use of oral dimercaptosuccinic acid (succimer) in adult patients with inorganic lead poisoning. 2009 Q J Med 102:721-732) Thursday, December 1, 2016 Question: What is Clioquinol and why was it withdrawn from the market during the 1970s? Answer: According to the cited reference, “Between the 1950s and 1970s Clioquinol was used to treat and prevent intestinal parasitic disease [intestinal amebiasis].” “In the early 1970s Clioquinol was withdrawn from the market as an oral agent due to an association with sub-acute myelo-optic neuropathy (SMON) in Japanese patients. SMON is a syndrome that involves sensory and motor disturbances in the lower limbs as well as visual changes that are due to symmetrical demyelination of the lateral and posterior funiculi of the spinal cord, optic nerve, and peripheral nerves. -
DBL™ Octreotide Solution for Injection Contains 0.05 Mg, 0.1 Mg Or 0.5 Mg of Octreotide As Octreotide Acetate
NEW ZEALAND DATA SHEET 1. PRODUCT NAME DBL™ Octreotide 0.05 mg/mL, 0.1 mg/mL and 0.5 mg/mL solution for injection 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each 1 mL vial of DBL™ Octreotide solution for injection contains 0.05 mg, 0.1 mg or 0.5 mg of octreotide as octreotide acetate. Excipients with known effect DBL™ Octreotide solution for injection contains less than 1 mmol (23 mg) sodium per dose; i.e. essentially ‘sodium-free’. For the full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM DBL™ Octreotide is a clear colourless solution for injection. 4. CLINICAL PARTICULARS 4.1 Therapeutic indications For symptomatic control and reduction of growth hormone (GH) and IGF-1 plasma levels in patients with acromegaly who are inadequately controlled by surgery or radiotherapy. Octreotide treatment is also indicated for acromegalic patients unfit or unwilling to undergo surgery, or in the interim period until radiotherapy becomes fully effective. For the relief of symptoms associated with functional gastro-entero-pancreatic (GEP) endocrine tumours: Carcinoid tumours with features of the carcinoid syndrome Vasoactive intestinal peptide secreting tumours (VIPomas) Glucagonomas Gastrinomas/Zollinger-Ellis syndrome, usually in conjunction with proton pump inhibitors, or H2-antagonist therapy Insulinomas, for pre-operative control of hypoglycaemia and for maintenance therapy GRFomas. Octreotide is not an antitumour therapy and is not curative in these patients. For prevention of complications following pancreatic surgery. Version pfdoctri11020 Supersedes: pfdoctri10719 Page 1 of 16 Emergency management to stop bleeding and to protect from re-bleeding owing to gastro- oesophageal varices in patients with cirrhosis.