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Hello, everyone and working to the weekly minded bleed webinar. And today we're going to TOB, joined by Dr Ana, which is, um, he's going to talk Teo one about pain, constipation, nausea and vomiting, which are all very important topics that we'll go to and contrary during our careers. The doctors and you can post questions in the comments on Facebook. If you think of anything going on, just pose the questions as we go. We'll have a Q and A session afterwards. And then, if any questions come up to your mind later on, just please feel free to Massachusetts on Facebook or on the mindedly website, and the session will be recorded and we will send out the link into comment section. And also, if you'd like Teo, have access to the recorded material, please make sure you're registered at mind. Oblique dot com slash webinar Um, richest rations. So I'm going to pose this link in the comments as well, so you can just use it to register later to get the access to the material on before we start. I would just like to get a quick shite I to our sponsor mg at please don't forget to sort iter mg foundation membership before you start shadowing. Because unless you have failed in a foundation, application for your student membership will cease to exist in the summer. And if this essential, they have any dent in them, it it covered Teo. So make sure you check it out on sign up for getting so what? I'm going to post in a common section in a second as well. Im and I were there, right? Very dirty. I'm just going to hand over to Dr Anna to take us for decision. Thank you dot Hi, guys. I'm an it is, um and I'm currently a lot doctor working in Yorkshire and number area. After finishing my left one of two. And tonight I was won't do a webinar on pain, constipation and nausea and vomiting, which are all three very big topics. So we'll try and go through them one by one. Thanks. Everyone was drawing on the Celexa. I appreciate was a lot going on. Lots of big sporting events. Please. Have you all here? So for start with 10 and move on the constipation. People were going through nausea, vomiting. Well, then move on a case study and a little bit of a question. And then, if you have any questions, please keep writing them in the comments on We can try and get them all answered at the end. Or, alternatively, if anybody has any interesting cases about an infusions that being involved in the care, anything to do with being constipation or nausea bombing, please do let us know because scrutiny share people's experiences. They were different. Healthcare professionals bid in different situations and, we're know, learn from each other. So first of this pain and peerless to find us unpleasant sensory and emotional experience associated with actual or potential tissue damage. And it's something that is really subjective. So something that might be 10 out of 10 pinto One person might only be a two or three hour 10 in to somebody else. For example, standing on a piece of leg for one person might be the worst thing in the world. But for another person who might have experienced a lot more severe pee in that, I think what you're talking about that didn't hurt at all. So pain is made up of different components physical, social, spiritually and psychological and as a junior doctor, it's your job to find out what's causing the person's pier and through history examination investigation, you need to find out what the different aspects of the patient's paying is in order to be able to investigate it and manage it. For example, you might see a patient who has a really distended stomach. Onda has a lot of ascites, and if they're complainant off abdominal pain than you think, right, well, that's it. That's what's causing the pain. But it might be that I've got something else going on in the background that is contributing to the pain. The World Health Organization has came up with this step by step guides to help healthcare professionals manage pain on health care. Professional goes off as a patient's pain is getting more out of hand, and it's not controlled, but also move back down the scale as a patient's pinion becomes less severe or if the started develop side effects, so we'll go through it one by one step. War is what I like to think offer symbol on algesia stuff that you can get over the counter, such as percent mall I Brufen on. Although people think or get percent more. Doesn't really have much effect, really, are the basis off in management next movement. The next stage we've got weak or B oId. That's Corden and Tramadol, and you would take these on top off the Similac Algesia that you just talked about. And although it's Customs Week will be always the people who have never had opioids before, the can be very strong. Then the top of the ladder, a strong will be I'd on. That's the morphines and you fentanyl, oxycodone or and these are very strong and can have a lot of side effects. And they're the top level analgesia on the human life. Just some other things. The consider is that the allure of pain killers is always best for a patient, and it is something that people can use more in the community. However, it's not always appropriate to give him a doozy of either all wrote, for sometimes people feel and sick, the bowel obstruction or the knee. Even end is the life. It's not possible to give all medication, and it said, you've got think of different boots, whether that be a patch, whether it be so continuous. I have a knee thing to stop. The pain should be and pin another thing to consider is and use off insides. So there. Yet I Brufen and this stuff that you know you can get over the counter. We have to be careful with these in Albany patients and then the worst patients who have taken steroids or unequal glints because the can increase your risk of stomach ulcers and then that they come blades so the patients have to be monitored. Coursey and often long poor form inhibit is at the same time. So just moving on this green something convergence and that's this is what you need when you move him between different formulations of medication or different types of medication. This is a few off commonly used conversions that I have Is that my own clinical practice? But this lots of different conversions between many different medications in many different formulations, and we'll comports the link to the Scottish National Guidelines on Doors conversions in the chat. That would be something people will be interested in. Additionally, if you were unsure as a do new doctor, it's always best either check your local guidelines or get seeing you support if you need it, because these will be. I can be very strong and you don't want to give anybody too much of certain medication. Another point out is just that the doors of Paris at mall In patients that I wonder, 50 kg is reduced since they're having 1 g four times a day, and we have 500 mg four times a day. And that's especially important in people who might have lost a lot weight recently, often elderly creations. Another thing to talk about is breakthrough pain and breakthrough pin is and paying people might experience on top off their normal analgesia that take it. And so you prescribe painkillers what's called ER and and that would be if a person was experiencing more peeing it with certain time that could be given, actually peeing killers on top of their normal background analgesia. So the breathing you normally prescribe just 16 to 1 10 off then tool daytime doors. But if the person is requiring a lot of PR own medication in a day, it might be that their background medication needs increasing. In order to combat this new pin in patients I haven't got very good renal function too often under each. If our 30 you would want to switch that medication from morphine to oxycodone or or Alphin a little because they're a little bit more kind of to the kidneys. So moving other side effects off opioids on this awful side effects. And that can be quite common, especially when people first start taking strong and jesu. I've had patients in my own practice who have actually not wanted to take the medication that's been described because the side effects are so severe. So I had a gentleman who was having awful hallucinations from morphine when he was in severe pain has to get the PSA pending taken out. And he actually said that rather have the stomach pain that experience the hallucinations that he was having from the IV. More thing that could be quite common. So constipation is something that we'll talk about a little bit like that. But it's very common when taking opioids nausea vomitin again. It's something that we'll talk about it, and that's often a side effect that happens when a person starts taken or builds. Initially, sedation and drowsiness, and also a lot of other side effects. Dry mouth. Loosen a shin access wedding. And this is only a few very other rat side effects that can happen infrequently. People can get over your toxicity, and this can be very scary. Is a junior doctor who's just starting out in the wards you get an urgent call or crash call from the nurse is saying that something's happening. Someone's and Hudson something someone's got will be on toxicity. So these are the symptoms that often occur with all your toxicity on the treatment, for this is not sore, and it can be a hard balance given a lot, Um, because you don't want your patient to be in peeing and reverse all of the opioids effects. But you also don't want them to have a region. It's Jesus on nor was able to it. I think the man thing to have a home here with or be on toxicity is it shouldn't be something that you manage. It's a junior doctor by yourself. That's something we really do. You get seen any support, really, For one reason. That a patient might become much have toxicity is because off a decline in their renal function, meaning that the kidneys are excreted in the morphine as quick as possible. Nephew is building up in the system, and that's why it's becoming toxic on this part of your it assessment. When you saw a patient who did have a reduced is yes, you would take usually his blood test to see how they're renal function was doing. And that might be the source off the toxicity on every stage of the who pay and ladder. It may just mentions a difference, and these are other types of medications, which aren't classically. You'll be oId you publish that multi. I grew friends that can help insert in situations and relieve and occasions pain in specific situations. So some examples of which are almost like now I know. When I first started out, I didn't think that some of these medications would have such a big effect that the do. But it's a medications who have hard liver metastases have steroids on that has been completely believe, so much so that they're not need and the large daughters of more thing that previously see needed simulate with this foster nets and born here so we'll move on now to constipation. Constipation is a very common symptom for many people on For a lot of people, it isn't something that the would necessarily have to come to hospital for. Tell him that can often be sorted out in the community and often doesn't even need medical attention. But it is something that can be quite debilitating, especially if it's causing. A lot of here in elderly patients can cause them to be a lot more confused. And there's something that, as a junior doctor, you can manage yourself and you can feel like you really have helped the patient if you can help solve the constipation. So some of the courses of constipation and might be changing diets because of an infection on my B and caused by new medication some of the side effects of medications such as the opioids on that might be because of a change in diet, just not eating quite right. And that's especially true when patients come in the hospital on get given hospital food, which isn't always the nicest, and it's often very different to food for eaten at all. So to help find out what's causing the constipation as a junior doctor. You try and take history. Try and find out if the side, any new medications recently and then try and do some investigations. The see if there's anything else going on that might be influencing and causing the constipation. The minister for treatment for constipation is laxatives on. Often doctors form of preference over which laxatives they think that works well, and I'm sure we all develop this in your own clinical practices. So softener laxative Such a stuck, you say it's sodium, and then it's still soft in the work on the call on and the take about 60 it. I was having effect this then hydrating laxatives, and that's the lactulose, or medical. And they increased the water content off the still minute easy in the past with the hydration that's identification has to drink a lot of water themselves to help the blacks of those work. Really, they don't have a stimulant laxatives such a center of ice Kordell, and they increased the contractions in the colon and trying to push the steel out. There's also other types of laxatives spoke, forming lubricants, all of which can have an effect and help resolve constipation. One thing to consider is if you do have occasion in hospital, who's describe a lot of laxatives and then the develop diarrhea, it might be that would give them a little bit too many laxatives and have gone too far the other way. And if so, you would have to be juiced on down and try and get that balance. Just write with what's going on. Additionally, it might be the occasion. Need laxatives while they're in hospital, while they're not as active as the youth, normally are not having the same diet, maybe not drinking as much, so they might need a laxative wild of in hospital. But when they get discharged, it might be that the drawer needed any further. This will be something that you would come salutation on when they're being discharged. Sometimes, however, having all relaxants doesn't always work on. Instead, the patient might need to have a PR examination, and that's examination em to see of the patients back passage to see if there's any stool that is sort of stuck there, and the might need an enema or suppository to help move that along and clear that bowels out. Not the nicest topic I'm sorry if anybody's eating it and dinners. So moving onto our last colic, nausea and vomiting, there's many different causes of nausea and vomiting, and again, this might be due to the medication, such as the or be on 21st. Starting out might be due to where patients malignancy is if it's pressing on a certain kind of nerve or in a certain place. My pictures cause a little bit discomfort on that might also just be done, you anxiety. So when I don't know when I feel really notice myself, I feel start feeling a lot. That second door want to eat anything. So there's many different causes for nausea and vomiting. So the different types off different story, different reasons why you mix might be prescribed it on the screen on the number one indicated on Imitrex listed. And Cytisine has an antihistamine and and he called Allergic Mechanism of Action. Haloperidol is centrally acting on Dansetron is a five year T three receptor antagonist, and Metoclopramide is a broken etiquette, the same with analgesia. And if you can give the anemic or really that is, the best method of action is this could be something that could be replicated in the community. However, if somebody is nausea or vomiting, it isn't always appropriate to give them or medication. Therefore, you have to think of IV so could just to try and get that anemic into them to try and get in vale a little bit better. Another thing is metoclopramide and can be given in Parkinson's disease as it blocks the door, but mainly sector, and would worsen the symptoms of a patient who has Parkinson's disease. And this is just a few of the examples of what Imitrex you might give in different situations, although there is a first line anemic suggested for different scenarios. My often they got the onion that extra work for lactation or the patient has an idea leg, which works well for them. And if so, there's no hard and fast rule for which, on you men it needs to be used, and it can vary between patient patient. If there's any doubt over which anemic to give, you can always speak to politics carotene, especially if the patient is new. In the end of the life. Captains are just there to support people who are dying. The I had there to help with symptomatic treatment. And if this vision do you just not getting on top of their normals, you're not getting talking the vomiting and maybe quick chatter then in the media, that helped with the best week to move forward. So moving forward to our case that he missed the end. It's a 78 year old man who was a telescope with abdominal pian before he has any investigations, is asking for analgesia and on your medic. And this is very common when you work in the inning or location. So there to see nurse's that to see doctors, that Maura there to get themselves sword, get this since and sort out and often don't want to speak to anybody until of hard, something to help them a little bit. So what would you do on what you're going to prescribe? Um, give me a minute assault to see what you think and please the reply in the comments. And we have a bit of a discussion possible. Okay, well, and firstly, I think I would hope everybody would go and see if the patient and try and take history and examine them, if possible. you would want to find out what analgesia and emetics that already had a form because you're gonna get percent more left before I was. So if they've had that in the house, we can't give them that again, and you want to find out that had any allergies or intolerances, you don't want to be given anybody an allergic reaction or making the more on well from a medication that we can avoid. Give it. And depending on what Mr Em has already hot, you would then want to work with the whoop in like a day. And since the cause off his nausea and vomiting at the moment is or know which one to give cyclizine and cycling cycles in. So he is 50 mg TDs, and that's all normal or dull or IV. And however, if I remember, if if anybody's ensure and algesia give up any and what anemic scared gets in your support, really so moving on Mr. MRI's have been in hospital. Some food is sadly being diagnosed with colon malignancy with for metastases. What medication would you consider prescribing for experience, nausea and his constipation? And how would you decide what you aboard describe give you single minutes. So again you would want to consider what Mr End is already being prescribed, moving up the hoop in like, if necessary and also providing on prescribing breakthrough analgesia in case he has any flare ups pin for his for metastases. He would also want to consider this phosphinates on. You may want to get in contact with them. Other members off the multi discriminating. So people like all thought X rays your therapy, occupational therapy really able to help with equipment to help relieve pin. So if he's gotten a lot thinner on walking or if he's getting a lot of needy in these feet, depending when the form test these are, they may be able to get AIDS is a walk and stay walking for him. Specialized shoes to help with the pain and that might save being given medication on then have new one that side effects from medication occasional therapy but also be able to help with equipment around the house to help make things easier. With the gas a gentleman's nausea it would again the cyclizine, But if the site listening hadn't been working for him off the last few days, I would want to consider something else. Maybe Ondansetron. Nike walking helps Mr M and is constipation and might say that this gentleman isn't somebody who gets constipation from his or beyond, and it sort that is great. He might just want to put laxatives on the, uh, way. However, it Mr and is somebody who's suffering from conservation you'd want to think about. Maybe center Casella is normally the Lexuses of choice. When people have constipation from that will be always well between. That is very helpful to help combat kids. It's a panty, and then it's normally the specialist. Nurses are gonna set X trainees and consultants who can always help come and help and just people's pain medication to try and get that right balance for the patient so that liver go quality of life. So, unfortunately, Mr and sadly, subsequent meditates and canola thirties or medication he's currently having more finito milligrams or really beat is analgesia. So what we would just switch to on what would you prescribe? I give you a few minutes to think about it. So because the gentlemen can't have any old medications anymore, anything of a different route on It sounds like this gentleman is unfortunately reaching the end of his life and therefore wouldn't be appropriate to be given IV medication that maybe think about some coat medication on to kind of. Let the doors of sub coat anything about what the gentleman's tour daily intake of more vein is. And that's 30 a day so 60 total. And then you would divide it by two to find out the doors of moving so court to give for 24 hours. So the answer will be 30 mg with regular prn's is needed. And then that background amount can be increased if needed to combat any nuclear if the nursing team or family or the medical team Fortification was in a lot of discomfort and other forms that you can think of is maybe a patch, but it would really depend why the patient wasn't able to have all medication anymore again. This could be very frightening. When you first started out, was a junior doctor anything? Well, what am I going to do with all these numbers or to the old me? And if you have any doubt all getting your support, discuss with the pharmacists discussed with polyps, carotene paying teams. You seen your colleagues, the consultants, the table who can help, You know, probably done this multiple times, and you can learn from then still where to go muscle. If this patient was becoming more drowsy to did, then they'll get a little bit too much playing cholest. You'll reduce the doors down, try and get that good balance between being controlled on side effects. So now, from the end of the Webinar, it's any comments or questions and hopefully answer or some so sour can also joining. Or is anybody go? Any comments or anything like that store? Thank you very much on a and also thank you everyone for getting involved. And in the scenario is there have been a lot of comments on the on the chat, and but no one has asked questions so far. So I'm going to Teo hand over to something in a second to lead a Q and A session. But before I do that, I just wanted Teo. Let everyone know that we're going to post a feedback form later on. I'm going to post the link in the comment section and and is going to um, give everyone a QR code. Please make sure you fill into feedback for him to get the certificate for attending dissection. And also just be very specific. And that will help us help us approved the sessions. And make sure you're getting two moves out of the weekly webinar ease on DS was be a specific. It's possible. And I will know 100 over to use some saline and afford a, um, the A session. Um, so please, uh, Post any questions that you might have in the chart books in the government section? Thank you on. But I think that was a really useful webinar on down. Please, everyone feel free to awesome questions. So we've got one first from a friendly in, um, so in last question on a y subculture favorite over IV. So some cough is favorite over IV when people reaching the ends of the lights because I am putting a cannula in a patient can be quite painful under uncomfortable for patient to have that little plastic tube in then, so the Symbicort Needle is a lot smaller. A lot more discreet on can often be placed in it somewhere that doesn't and medications not concerned by it's instead of being in the wrist or at the elbow, it could be just talked in over their shoulders, and the patient doesn't know that it's there. It doesn't. It's very easily, and so it doesn't cause much discomfort on can give slow release analgesia rather than and having a ball. It's effect that the IV medication can have also the some paper, and they're the ones can often be quite damaged, especially if they've had a lot of chemotherapy over the years. Different, like a lot of blood tests Sylvia's, and sometimes it is quite hard to get a cannula it into a person to give him IV medication. So and subcultures gives you another method to get some pain killers into somebody you know. So give other medications, of course. Give Andi medics give medication to help secretions, and it can also give IV fluids. Buy some coq if need be. Million. Thank you. That that's that's exactly right. Like to mention another question. Would you still use center in colon malignancy? Because in a call on a malignancy, it may be obstructing. So I imagine a simulant Yeah, that's it. It is a very good question. And you would want a rule out bowel obstruction before you give center. If there was no bowel obstruction on the investigations, then you would be fine to use. Senna and I have seen it used in people with our concept. Yes, um, pretty in. And also, I would just add to that is like, imagine exactly right. So, yeah, of course, you wouldn't want to give, like, steps to someone with bowel cancer is having obstruction. You may want to give some nausea or vomiting meds that might help them symptomatically. And then, yeah, you wouldn't mind. Is that appropriate? Another one? Um, is it appropriate to use the who pain ladder to step up in to step up in a sudden acute onset pain So it can be? But if I want completely honest, it just depends on the sudden acute pain on his vacation specific. So if normally very fit and well, patient came in, hadn't taken any energy, is you'd all my people we looked into go straight in there with 10 mg of IV morphine for somebody who's completely or beyond naive hasn't had any pain killers. Where was for somebody who is just take a lot of pain killers. You might be more lenient to give them very strong painkiller, so you would just work. So, yes, I suppose you would just work up an acute opinion and just see what the patient's like. If the patient is crying out until you agree, it might not be realistic to give them just Paris. At morning you have to combine two things straight away, but just all is very patient specific. Do you have anything that's a That's a muscle? Um, no, I completely agree. I mean, for some, someone got a headache and you can always start with paracetamol. Add it with some codeine That might help is like he said. Everyone responds differently to pain killers and, you know, some work, quite another. So, like said you're very hard. It's very hard to give her just one answer that fits everybody. Exactly. Another question. How would you manage constipation in hypothyroidism? Hi, Paul. So it was a hyper yeah, high poll, but it so And it depends by the what the hypothyroidism is causing the constipation. Is that what we're thinking? If that if that's the case, we would want to replace there thyroid, like with levothyroxine to try and get their bowels working again. Is that Yeah, I would agree. Actually, in that case targeting the underlying A Z well, as the symptoms, you know, constipation. You can always give her the meds. But if they're having hypothyroidism, it's on managed and the elixir. So if it's a side effect of medication, that might be that you need to change the medication that taken for the hypothyroidism to combat that. Yeah, yeah, I know that, like, mentioned is always important to have a medicine. Reconciliation is why Why would be something to do with that? Definitely. And that's what it be. Enough comes in handy. Think Constipation's pharmacist. That is a side effect for everything. Oh, yeah, One of those on there. Uh huh. So Oh, so, uh, post I Idec to me on levo thyroxine was was that the person has just, um, Karefa like that, So Okay, yeah. So if they're post thyroidectomy on levothyroxine and still having constipation, I think that's, uh okay. But I think I'd still probably start out with something like Senna. Just because Santa is a medication is quite easy to take. So quite often people take a once on the night, and I really just have a big effect. So it starts off something general like that. It's a stimulant, and I would also try and do some investigations and see if the level off the thyroid function is correct and save the levothyroxine. Is that the right doors? Because it might be something on the line that's causing the constipation, but also try and just give them lifestyle advice trying to They're very hydrated mobile. A lot of fiber in the diet still want to get beginning them too much medication that affects the levothyroxine and causes them more problems. Yeah, I've completely understand, really. It will definitely depend on the individual the circumstances, particularly as they just had surgery so they could be a much different things going on. So you're like image. I completely agree. Any other questions? Not for the minute. Know any other questions that I can see? If anything, has you wanted to add Central? I don't know any of the any cases you've been involved in being. Think my head, I in terms of like I think you mentioned some key things. So things like paracetamol, which is very common. Always think about the patient's weight under whether they're already has, particularly if they're less than 50 kg, you have to reduce the dose. Uh, something like morphine. Remember that in those with a K, it can have more of a nephrotoxic effects than, um, oxycodone, oxycodone, And you can have oxycodone immediate release that you may want to give them with some breakthrough oxycodone modified release, which which you mentioned anyway, No vomiting drugs. I mean, a lot of these you have the be enough to use, and you also get used to them something like psychology and 40 mg on the doses you you become quite familiar with. So I think I think you mentioned a lot of the key point. So, um, no, I think that that's off the top of my head. Those were closing of the important things you mentioned. Right. Um, I think there are no further questions in the chapter, the moment. And as I mentioned before, you feel free to send us any questions you might have. Um, but we have another one that just popped up, like just this one and then, ah, record I get for it. So, um so Yeah, yeah, sure. Oh, yeah. One more question. So what would you do if you add in cold on the, um say the next day that it made no difference or it worked for a now hour or two. Then war off. All right. So I think the first thing you need to look at is the door saying Of course, game so you can have up to 240 mg a deer of cording, which is 60 mg four times a day. So if the patient is on the maximum dose of Corden and then not get in any effect, then you would want to step up and move up the who. Latter. However, if the patients only taking smaller doses of cording with a p 30 or if they were just having a PR and rather than regular, you would want optimized according taking before he moved up. So to go on to mention that and he on medication is great for Breakthrough pin. For for a patient who has a constant background pain, it's better to take regular medication rather than just having it when the pain comes on, so I would want optimize the cording before wasn't working. Would want to move up the pain either. Exactly. You know, I think that's exactly the right thing to do. There. Perfect. Um, thank you, Anna. And some. So, for a decision today, I think it was very informative and very useful for everyone who's about to the bartender. Career is left one, um, And for doctors and Endo, um, we're going to Teo. We're going to finish here as they make sure everyone has a time. Teo, get to where they need to get for football. Um, Andi, please make sure you bet. History 40 mg you for the week of revenue or East. Um, join us next week at a regular time. So eight PM on a Wednesday. And make sure to sign up for that. She's dissection is defined as medic. Um, thank you very much. Everyone on heavy. Nice evening.