A Guide to Symptom Relief in Palliative Care, 6th Edition

Claud Regnard, Mervyn Dean, Claude Regnard, Jo Hockley, Claud F B Regnard

• Publisher: CRC Press
• Year: 2022
• eBook ISBN: 9780429533495
• Edition: 6
• Topic: Medicine
• Subtopic: Anesthesiology & Pain Management

This established and well-regarded Guide describes the management of patients with advanced disease. Its foundation is a clinical decision-making approach in which the patient's information guides the professional's approach to appropriate management. This Sixth Edition has been fully updated, reflecting the latest advances in knowledge and care of cancer and non-cancer patients with advanced disease, including children and people with severe communication difficulties. Sections on symptoms other than pain and emergencies are set out alphabetically, with the Emergencies section now located at the end of the book for ease of reference. The Drug Information section has been extensively updated, and colour and design refinements introduced throughout for greater clarity and emphasis. All references continue to be categorised to make their evidence base clearer. Maintaining the high standard set by previous editions over the past quarter-century, this continues to be the definitive guide to palliative care symptom relief for professionals in a wide variety of caring environments.

Other physical symptoms

DOI: 10.1201/9780429083921-4

1. • Ascites
2. • Bleeding
3. • Bowel obstruction
4. • Constipation
5. • Diarrhoea
6. • Dyspepsia
7. • Dysphagia
8. • Fatigue, drowsiness, lethargy and weakness
9. • Malignant ulcers and fistulae
10. • Nausea and vomiting
11. • Nutrition and hydration problems
12. • Oedema and lymphoedema
13. • Oral problems
14. • Respiratory problems
15. • Skin problems
16. • Terminal phase (the last hours and days) and bereavement
17. • Urinary problems and sexual difficulties

Ascites

CLINICAL DECISION AND ACTION CHECKLIST

1. Could the symptoms and signs have a different cause?
2. Is the prognosis short?
3. Is the ascites causing distress?
4. Will the patient tolerate diuretics?
5. Is the ascites recurring?

KEY POINTS

• • Paracentesis offers immediate relief but poor long- term control.
• • Combination diuretics offer useful long- term control in some patients.

INTRODUCTION

The development of ascites usually carries a poorer prognosis in both cancer and liver disease.^1,2 Nevertheless, median survival in malignant ascites is nearly 6 months, and can be longer in ovarian carcinoma.³ The commonest causes of malignant ascites are primary tumours of breast, ovary, colon, stomach, pancreas and bronchus. Symptoms of ascites include nausea, vomiting, abdominal distension or pain, oedema (legs, perineum or lower trunk), and breathlessness due to diaphragmatic splinting.⁴

Types of ascites

Four types can be identified:⁵

Raised hydrostatic pressure: Caused by cirrhosis, congestive heart failure, inferior vena caval obstruction or hepatic vein occlusion caused by thrombus, or by compression from tumours or metastases in the liver or abdomen.

Decreased osmotic pressure: Caused by protein depletion (nephrotic syndrome, protein losing enteropathy), reduced protein intake (malnutrition) or reduced production (cirrhosis).

Fluid production exceeding resorptive capacity: Caused by infection or intraabdominal tumours.

Chylous: Due to obstruction and leakage of the lymphatics draining the gut.

TREATMENT

Diuretics, paracentesis and peritoneovenous shunting are still the mainstay of treatment,^6–8 although the evidence for all three is weak.⁸

Diuretics

Diuretics have long been a useful treatment for long- term control in cirrhotic ascites.⁹ Patients with liver metastases (and resulting portal hypertension) are most likely to respond to diuretics.^8,10 A serum- ascites albumin gradient greater than 11 g/L is a simple way of selecting such patients, especially in non- cirrhotic patients.^8,11,12 Patients with a high gradient have circulating blood volume depletion and consequent activation of the renin/ aldosterone system,¹³ so spironolactone is the diuretic of choice. Its use with furosemide is well established.^14–16 The aim is a weight loss of 0.5–1 kg/day and if peripheral oedema is present high doses can be tolerated.^17–19 However, diuretics can cause electrolyte disturbances and hypotension. They also need to be used with caution in patients with poor renal or hepatic function.

Paracentesis

This is helpful for short- term symptom relief. Insertion methods vary from using a peritoneal dialysis (PD) catheter attached to a standard PD collection bag, to using a large bore IV cannula or a suprapubic trochar and catheter. The use of 0.5% bupivacaine as local anaesthetic for the puncture site allows pain- free drainage for up to 8 hours if necessary.

Puncture sites should be away from scars, tumour masses, distended bowel, bladder, liver or the inferior epigastric arteries that run 5 cm either side of the anterior midline. The best sites are in the left iliac fossa (at least 10 cm from the midline) and in the midline suprapubically (the bladder must be empty). A lateral approach is advisable in patients with distended bowel – marked distension is a contraindication to paracentesis.

As a check, the needle used for the local anaesthetic can be used to check if ascitic fluid is present before inserting the drainage tube. If there is any uncertainty, ultrasound should be arranged. Ultrasound is increasingly being used routinely, especially if the ascites is loculated.^20,21

Volume drained: In malignant ascites it is safe and effective to drain up to 5 litres over a few hours without intravenous fluid replacement, even in children.^6,22,23 Most symptoms can be relieved after only 2-hours drainage, although it may take 72 hours after drainage has stopped before severe breathlessness improves.²⁴ Patients with other causes of ascites can have much larger volumes drained but to avoid hypotension this may need an albumin infusion, the administration of midodrine 5–10 mg,²⁵ or drainage over several days.²⁶ However, in patients with distended abdominal organs or intraabdominal tumour masses, draining t...

Table of contents

• Cover
• Title
• Copyright
• Preface
• Acknowledgements
• Contents
• Introduction
• Getting started
• Managing pain
• Other physical symptoms
• Psychological symptoms
• Difficult decisions
• Drug Information
• Emergencies
• Index