Head and Neck Cancer Centre

Life Kitchen

In the words of Beth Halliday, H&N Speech and Language Therapist:

'The South Tyneside and Sunderland NHS Trust Head and Neck Cancer Team were very fortunate to work alongside Life Kitchen in December 2018. Chef, food stylist and local Sunderland lad, Ryan Riley, has set up a cookery school for patients with Cancer who have experienced taste changes as a result of their treatment.

The Head and Neck Cancer Team at Sunderland  pushed Ryan's skills that bit further by introducing him to the impact H&N cancer treatment has on our patients. This can go way beyond taste changes, and includes sensitivities to spicy foods, seasoning or acidic foods in addition to varying levels of difficulty with textured diet.

Our H&N cancer patients found the opportunity invaluable in terms of socially connecting and talking about their cancer journey, with many reporting feeling relief that they were not the only ones affected.

Life Kitchen continues to offer sessions to all patients who have completed cancer treatment from their dedicated Cookery School in Mowbray Park. Details can be found online https://lifekitchen.co.uk/ or via your health professional.'

Trans-Oral Robotic Surgery (TORS)

TORS post-operative symptom management

Patient symptoms following TORS can vary greatly, therefore an individualised management plan is needed in dealing with these. This document sets out specific principles which apply to all TORS patients in addition to the general recommendations and management options needed to respond to symptom severity.

ORAL INTAKE

All TORS patients will have an NG tube inserted in theatre and a CXR in theatre recovery area to confirm the position of the NG tip. Medications should be prescribed in formulations suitable for administration via NG tube in the immediate post-operative phase. Please liaise with the ward Pharmacist for any help in prescribing.

SALT (Speech and Language Therapist) will assess the patient's swallowing post-operatively and advise when patients can safely start taking fluids and soft diet orally.

TONGUE OEDEMA

Patients will generally receive a dose of Dexamethasone 6.6mg iv intra-operatively.

Bruising of the tip of the tongue is expected during and after TORS. Some degree of tongue oedema is expected as well. If significant tongue oedema is present, please prescribe 3 further iv doses of Dexamethasone 6.6mg and seek senior opinion. In rare circumstances, patients may need to be intubated and spend a few days on ITU until the tongue swelling settles down. Rarely, do they need a tracheostomy.

ANTIBIOTICS PROPHYLAXIS

All TORS patients will receive a dose of Co-Amoxiclav 1.2g iv at induction. Post-operatively, patients should be prescribed Co-Amoxiclav 250/62 suspension 10mL TDS for 5 days prophylactically via NG.

Note: if penicillin allergic, Clarithromycin suspension 500mg BD for 5 days should be prescribed, again to be given via NG tube. Ensure to check for drug interactions as Clarithromycin is an enzyme inhibitor.

VTE PROPHYLAXIS

All TORS patients should have a VTE assessment completed and be prescribed VTE prophylaxis as appropriate and in accordance with Trust VTE policy. Patients should also wear TED stockings and be encouraged to mobilise early when safe to do so.

ANALGESIA

It is of utmost importance for Ward Staff to document accurate pain scores in order to interpret patient's analgesia requirements and monitor response to interventions.

Patient Controlled Analgesia (PCA)

Selected patients will be started on a PCA in theatre recovery, after discussion with a Consultant Anaesthetist. This will be in use for the first 24-48 hours post-operatively and must be reviewed on a daily basis. No other opioids should be prescribed whilst a PCA is in use.

Systemic pain relief

All TORS patients should be started on regular simple analgesia via NG tube:

• Paracetamol suspension 1g QDS
• Ibuprofen suspension 400mg TDS (unless contraindicated)

In addition, a regular strong opioid should also be started (once PCA, if in use, has been taken down). Which regime to prescribe depends on whether the patient has been using any opioid medications previously or whether the patient is opioid naive.

In opioid naive patients, the following regime is recommended:

• Morphine Sulphate oral suspension 10mg/5mL - Start 5mg QDS regularly
• Morphine Sulphate oral suspension 10mg/5mL - Start 5mg PRN, maximum 2 hourly
• Note: The rational for this regime is that MST sachets, which are the only modified release preparation that we administer to NG tubes, are only available in 20mg dose at their lowest strength. An initial dose of 20mg BD in an opioid naive patient is a large amount and can cause unnecessary adverse effects leading to discontinuation by the patient. Therefore, do not prescribe MST sachets until the patient is taking a total daily Morphine dose of 40mg/day.

In patients who are not opioid naive, e.g. patients who have been using significant doses of Morphine/Codeine/Tramadol in the lead up to surgery, or who have had a PCA in situ post-operatively, it may be appropriate to initiate a modified release Morphine product. We would recommend MST sachets to provide safe administration to an NG tube. The starting dose of MST sachets is:

• Morphine sulphate modified release 20mg BD
• Morphine sulphate oral suspension 10mg/5mL - start 5-10mg PRN, maximum 2 hourly

Topical pain relief

Prescribe:

• Difflam spray (Benzydamine 0.15% oral spray) PRN
• Lidocaine 100mg lollies PRN
• Note: Lidocaine lollies are an unlicensed product and patients will struggle to source this in the community. Only a small supply can be given on discharge. Please keep this in mind when discussing take home analgesia with patients and manage patients' expectations.

Neuropathic pain

If neuropathic pain is present post-operatively, start Gabapentin at 300mg ON for 3 days. Then increase the total daily dose by 300mg every 3 days (i.e. to 300mg BD, then 300mg TDS). Monitor closely for adverse effects (refer to BNF). Further increases can be made in increments of 300mg.

Care must be taken not to start at too high a dose or titrate too fast as this can increase the risk of adverse effects and patient might discontinue the medication.

• Note: Consider starting elderly patients, those with renal dysfunction and those taking other CNS depressant drugs on 100mg, and increasing in 100mg increments.

OTHER PRESCRIBING

• Proton pump inhibitor - please start a regular PPI e.g. Lansoprazole orodispersible tablet 30mg OD. This provides gastro-protection from both regular Ibuprofen and Dexamethasone use, in addition to reflux prophylaxis from NG tube presence and enteral feeding.
• Laxatives - please ensure regular laxatives are prescribed in liquid formulation to counteract the constipating effects of regular opioids.

APPENDIX 1: How to stop Gabapentin

Withdrawal of Gabapentin should be done gradually. The manufacturer recommends that tapering should be done over a minimum of one week. This refers to the total withdrawal period rather than interval between tapering steps.

In practice, the tapering of Gabapentin dose is done over a longer period of time and is largely dependent on the dose that the patient is taking and how long they have been taking it. An example reduction regime would look like this:

On discontinuation and reduction, patients should be monitored for withdrawal signs and symptoms. These include:

• insomnia
• nausea and vomiting
• headache
• anxiety
• hyperhidrosis
• diarrhoea

APPENDIX 2: How to stop Morphine

The Faculty of Pain Medicine of the Royal College of Anaesthetists recommends that opioids can be tapered by 10% weekly or two weekly. However, we also need to take into account the formulations that are prescribed so that reductions are also practical.

For example, if a patient is taking MST 30mg BD, the logical step down would be to reduce to 20mg BD for a week and then at this point, to switch back to regular Morphine Sulphate immediate release oral solution at 5mg QDS (with breakthrough of 5mg PRN, maximum 2 hourly) and then reduce to 5mg TDS, 5mg BD, until finally the patient is just requiring 5mg PRN 4 - 6 hourly.