scholarly journals Subcutaneous Tranexamic Acid: A Novel Approach to Managing Bleeding

2021 ◽  
Vol 8 (7) ◽  
Author(s):  
Sutherland A ◽  
◽  
Carey M ◽  
Miller M ◽  
◽  
...  
Keyword(s):  
Palliative Care ◽  
Squamous Cell Carcinoma ◽  
Literature Review ◽  
Tranexamic Acid ◽  
Subcutaneous Administration ◽  
Evidence Base ◽  
Subcutaneous Infusion ◽  
Novel Approach ◽  
Continuous Subcutaneous Infusion ◽  
Care Guidelines

We describe the case of a 68 year old with a transglottic squamous cell carcinoma, a tracheostomy and persistent blood stained tracheal secretions. Oral and intravenous Tranexamic Acid (TA) effectively controlled the bleeding. On losing both routes, we administered 2g of TA (20ml) by continuous subcutaneous infusion over 24 hours. Control of bleeding was maintained over 18 days until death. No site reactions were observed. A literature review was undertaken, however, none of the studies looked at the use of TA in an end of life or palliative care population. We identified 3 clinical palliative care guidelines relating to continuous subcutaneous administration of TA. Further use should be reported in the literature to build the evidence base surrounding this novel practice.

scholarly journals Continuous subcutaneous infusion for pain control in dying patients: experiences from a tertiary palliative care center

2020 ◽  
Vol 19 (1) ◽  
Author(s):  
Per Fürst ◽  
Staffan Lundström ◽  
Pål Klepstad ◽  
Peter Strang
Keyword(s):  
Palliative Care ◽  
Adverse Effects ◽  
Pain Control ◽  
Performance Status ◽  
Infusion Pump ◽  
Eastern Cooperative Oncology Group ◽  
Moderate Increase ◽  
Subcutaneous Infusion ◽  
Dying Patients ◽  
Continuous Subcutaneous Infusion

Abstract Background Continuous subcutaneous infusion (CSCI) via ambulatory infusion pump (AIP) is a valuable method of pain control in palliative care. When using CSCI, low-dose methadone as add-on to other opioids might be an option in complex pain situations. This study aimed to investigate the effects, and adverse effects, of CSCI for pain control in dying patients, with particular interest in methadone use. Methods This was an observational cohort study. Imminently dying patients with pain, admitted to specialized palliative inpatient wards and introduced on CSCI, were monitored daily by staff for symptoms (Integrated Palliative Care Outcome Scale - IPOS), sedation (Richmond Agitation and Sedation Scale – RASS), performance status (Eastern Cooperative Oncology Group - ECOG) and delirium (Confusion Assessment Method - CAM). Results Ninety-three patients with a median survival of 4 days were included. Of the 47 patients who survived ≥3 days, the proportion of patients with severe/overwhelming pain decreased from 45 to 19% (p < 0.001) after starting CSCI, with only a moderate increase in morphine equivalent daily dose of opioids (MEDD). Alertness was marginally decreased (1 point on the 10-point RASS scale, p = 0.001), whereas performance status and prevalence of delirium, regardless of age, remained unchanged. Both patients with methadone as add-on (MET, n = 13) and patients with only other opioids (NMET, n = 34), improved in pain control (p < 0.05 and 0.001, respectively), despite that MET patients had higher pain scores at baseline (p < 0.05) and were on a higher MEDD (240 mg vs.133 mg). No serious adverse effects demanding treatment stop were reported. Conclusions CSCI via AIP is an effective way to reduce pain in dying patients without increased adverse effects. Add-on methadone may be beneficial in patients with severe complex pain.

Subcutaneous levetiracetam for the management of seizures at the end of life

2017 ◽  
Vol 8 (2) ◽  
pp. 129-135 ◽  
Author(s):  
Anna Elizabeth Sutherland ◽  
John Curtin ◽  
Victoria Bradley ◽  
Olivia Bush ◽  
Maggie Presswood ◽  
...  
Keyword(s):  
Palliative Care ◽  
Literature Review ◽  
End Of Life ◽  
Terminal Care ◽  
Seizure Control ◽  
Case Reports ◽  
Subcutaneous Administration ◽  
Case Series ◽  
Comprehensive Literature Review ◽  
Randomised Controlled

ObjectivesTo report the results of a combined case series analysis of subcutaneous levetiracetam (Keppra) for the management of seizures in palliative care patients.MethodsA comprehensive literature review on the use of subcutaneous levetiracetam was performed, and these data were combined with a prospective observational audit of its use in terminal care undertaken in a regional palliative care network.Results7 papers were identified from the literature review-four case reports and three observational case series-reporting on a total of 53 cases where subcutaneous levetiracetam was administered.We report 20 further cases of subcutaneous levetiracetam administration from a prospective observational audit. Doses ranged from 250mg to 4000 mg daily. Oral to subcutaneous conversion ratios where stated were 1:1. Levetiracetam was reported as the sole administered antiepileptic drug (AED) in eight cases, and no seizures were reported until death in five cases. Five were switched back to enteral levetiracetam. In seven cases, levetiracetam was combined with AEDs to provide seizure control at the end of life. There was one report of a sterile abscess after 25 days of continuous subcutaneous administration.ConclusionsCombined analysis of 73 reported cases of subcutaneous levetiracetam suggests this treatment may have a role in the management of seizures at the end of life. However, randomised controlled trials are urgently needed to establish the efficacy and tolerability of subcutaneous levetiracetam administration. If proven to be safe and effective, subcutaneous levetiracetam offers the potential to prevent and treat seizures without causing unnecessary sedation at the end of life.

Aligning guidelines and medical practice: Literature review on pediatric palliative care guidelines

2017 ◽  
Vol 15 (4) ◽  
pp. 474-489 ◽  
Author(s):  
Eva De Clercq ◽  
Michael Rost ◽  
Nadia Pacurari ◽  
Bernice S. Elger ◽  
Tenzin Wangmo
Keyword(s):  
Palliative Care ◽  
Literature Review ◽  
Medical Practice ◽  
Multidisciplinary Care ◽  
Pediatric Palliative Care ◽  
Concurrent Administration ◽  
Research Guidelines ◽  
Team Research ◽  
Care Guidelines ◽  
Number Of Publications

ABSTRACTObjective:Palliative care for children is becoming an important subspecialty of healthcare. Although concurrent administration of curative and palliative care is recommended, timely referral to pediatric palliative care (PPC) services remains problematic. This literature review aims to identify barriers and recommendations for proper implementation of palliative care for children through the looking glass of PPC guidelines.Method:To identify studies on PPC guidelines, five databases were searched systematically between 1960 and 2015: Scopus, PubMed, PsycINFO, the Web of Science, and CINAHL. No restrictions were placed on the type of methodology employed in the studies.Results:Concerning barriers, most of the papers focused on gaps within medical practice and the lack of evidence-based research. Common recommendations therefore included: training and education of healthcare staff, formation of a multidisciplinary PPC team, research on the benefits of PPC, and raising awareness about PPC. A small number of publications reported on the absence of clear guidance in PPC documents regarding bereavement care, as well as on the difficulties and challenges involved in multidisciplinary care teams.Significance of results:Our results indicate that a critical assessment of both the research guidelines and medical practice is required in order to promote timely implementation of PPC for pediatric patients.

scholarly journals Pharmacological strategies used to manage symptoms of patients dying of COVID-19: A rapid systematic review

2021 ◽  
pp. 026921632110132
Author(s):  
Laura Heath ◽  
Matthew Carey ◽  
Aoife C Lowney ◽  
Eli Harriss ◽  
Mary Miller
Keyword(s):  
Systematic Review ◽  
Palliative Care ◽  
Holistic Approach ◽  
Narrative Synthesis ◽  
Inclusion Criteria ◽  
Pharmacological Interventions ◽  
Pharmacological Management ◽  
Subcutaneous Infusion ◽  
Advanced Search ◽  
Continuous Subcutaneous Infusion

Background: COVID-19 has tragically resulted in over 2.5 million deaths globally. Despite this, there is a lack of research on how to care for patients dying of COVID-19, specifically pharmacological management of symptoms. Aim: The aim was to determine the dose ranges of pharmacological interventions commonly used to manage symptoms in adult patients dying of COVID-19, establish how effectiveness of these interventions was measured, and whether the pharmacological interventions were effective. Design: This was a rapid systematic review with narrative synthesis of evidence, prospectively registered on PROSPERO (ID: CRD42020210892). Data sources: We searched MEDLINE, EMBASE, CINAHL via the NICE Evidence Health Databases Advanced Search interface; medRxiv; the Cochrane COVID-19 Study Register; and Google Scholar with no date limits. We included primary studies which documented care of patients dying of COVID-19 under the care of a specialist palliative care team. Results: Seven studies, documenting the care of 493 patients met the inclusion criteria. Approximately two thirds of patients required a continuous subcutaneous infusion with median doses of 15 mg morphine and 10 mg midazolam in the last 24 h of life. Four studies described effectiveness by retrospective review of documentation. One study detailed the effectiveness of individual medications. Conclusions: A higher proportion of patients required continuous subcutaneous infusion than is typically encountered in palliative care. Doses of medications required to manage symptoms were generally modest. There was no evidence of a standardised yet holistic approach to measure effectiveness of these medications and this needs to be urgently addressed.

Subcutaneous magnesium in the advanced cancer setting

2017 ◽  
Vol 8 (2) ◽  
pp. 191-193 ◽  
Author(s):  
Stephen J Fenning ◽  
Steinunn R Boyce ◽  
Paul Wilson ◽  
Fran Stretton
Keyword(s):  
Ovarian Cancer ◽  
Hospital Admissions ◽  
Subcutaneous Administration ◽  
Advanced Ovarian Cancer ◽  
Syringe Pump ◽  
Subcutaneous Infusion ◽  
First Case ◽  
Continuous Subcutaneous Infusion ◽  
Cancer Setting ◽  
High Output

Hypomagnesaemia can arise from a variety of causes but is particularly prevalent in cancer populations. This case report describes a patient with recurrent symptomatic hypomagnesaemia, on the background of advanced ovarian cancer and a high-output ileostomy, who was successfully managed on a daily continuous subcutaneous infusion of magnesium via a syringe pump. There is limited published information on the subcutaneous administration of magnesium and, to our knowledge, this is the first case to report its routine delivery over 24 hours in a syringe pump. This novel but effective approach for administering magnesium can be delivered in the community and can, therefore, prevent repeated hospital admissions for patients with recurrent symptomatic hypomagnesaemia who would otherwise need intravenous replacement.

scholarly journals Filling Gaps on Stability Data: Development, Validation and Application of a Multianalyte UHPLC-DAD Method to Determine the Stability of Commonly Administered Drugs in Different Carrier Solutions Used in Palliative Care

Analytica ◽  
2020 ◽  
Vol 1 (1) ◽  
pp. 33-43
Author(s):  
Christian Steuer ◽  
Ursina Müller ◽  
Fiona Haller ◽  
Peter Wiedemeier
Keyword(s):  
Palliative Care ◽  
Internal Standard ◽  
Reversed Phase ◽  
Decision Makers ◽  
Carrier Solution ◽  
Subcutaneous Infusion ◽  
Continuous Subcutaneous Infusion ◽  
Stability Data ◽  
The Stability ◽  
Parenteral Drug

In palliative care, continuous subcutaneous infusion (CSCI) is common practice for drug administration when oral application of drugs is not feasible or not reliable anymore. However, use of CSCI is limited to chemical stability of drugs and their combination in carrier solution. To determine the stability of different mixtures of commonly used drugs in palliative care, a multi-analyte UHPLC-DAD method controlled by an internal standard was successfully developed. The method was validated in terms of specificity, accuracy, precision, and linearity across the calibration range. Seven analytes could be separated within 10 min by C18-reversed phase chromatography. The method was successfully applied to close gaps in stability data and complete missing data for decision makers in health care units. Our results indicated the stability of binary mixtures and one ternary mixture in 0.9% saline and 5% glucose as carrier solutions. The obtained data will support pharmacists in palliative care for the preparation of parenteral drug solutions in the future.

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