Aims and Objectives AIM To increase your knowledge and confidence in the causes
and treatment of nausea and vomiting in palliative care
patients
OBJECTIVES By the end of the session you will be able to
Describe the various patterns of N+V
Describe the biochemical and physical pathways involved
Consider appropriate investigations/interventions
Be aware of anti-emetics and their receptor activity
Select the appropriate first line antiemetic regime
Background - Why is it
important?
It’s a common and debilitating symptom
Affects up to 70% patients with advanced cancer
There are many mechanisms, patterns and treatments
It usually a has a single cause
Ranked as a highly distressing symptom, often more so than pain or breathlessness
An accurate assessment and a good understanding of the mechanics of nausea and vomiting is important to guide best effective treatment
Definitions Nausea: Unpleasant feeling of need to vomit accompanied by autonomic symptoms (pallor, cold sweat, salivation, tachycardia, diarrhoea)
Retching: Rhythmic laboured spasmodic movements of the diaphragm & abdominal muscles
(usually occurs with nausea and results in vomiting – but not always)
Vomiting: The forceful propulsion of gastric contents through the mouth
Regurgitation: Effortless expulsion of foodstuffs – e.g. oesophageal obstruction
Ask the right questions Is it Nausea? Retching? Vomiting?
When: did it start? Time(s) of day? Constant/not?
What: does vomit look like? Amount? Blood?
How: did it start? How has it been treated so far?
Why: Exacerbating (& relieving) factors
Why identify cause/s…?
1. Some causes are treatable and so potentially
reversible
2. Each antiemetic targets a specific pathway /
‘cause’
Assessment Distinguish between vomiting, expectoration and
regurgitation
Note contents and volume
Assess relationship between nausea and vomiting
Record severity
Review drug regime (opioids, digoxin etc)
Examine mouth, pharynx and abdomen
Check plasma urea, creatinine, calcium, albumin, digoxin as appropriate
Examine fundi if raised intracranial pressure possible
Reason for accurate
assessment
Being able to recognise patterns of N&V
Identifying likely cause in individual patients
Once this is understood we can plan treatment
by:
Understanding mode of action of commonly
used anti-emetics
Prescribing most appropriate antiemetic
Choosing most appropriate route
Negotiating with patient to ensure compliance
Potential Causes of nausea
and vomiting Drugs
opioids, chemotherapy,
digoxin, etc etc etc
Radiotherapy Especially gut area
Biochemical Hypercalcaemia,
uraemia
Liver failure
Gastric stasis
Bowel obstruction
Upper/lower
Constipation
Raised intracranial pressure
Cerebellar metastases
Anxiety, fear, conditioned response
5HT3 Antagonists: Drugs: Ondansetron/Granisitron
chemotherapy/radiotherapy
Side effects:
Constipation, headache
Substance P antagonist:
Drug: Aprepitant Phosaprepitant prevent acute and
delayed sickness that can be caused by chemotherapy
given to patients whose nausea and vomiting was severe and was not controlled by the usual anti-emetic regimen
Management Correct the reversible Pain, infection, cough, hypercalcaemia, raised ICP, constipation, address fears/anxieties
Non drug treatment Control malodour e.g from colostomy or fungating wound
Fresh air. Good oropharyngeal hygiene. Suitable distractions. Nurse in the upright position. Avoidance of emetogenic smells and foods.
Avoidance of situations in which N&V is a conditioned response.
Drug treatment – depends on pattern and cause…..
Metoclopramide Pathways:
Peripheral : Prokinetic
- gastric stasis, functional bowel obstruction
Central : Chemoreceptor Trigger Zone (CTZ)
- metabolic induced: ie opioids, hypercalcaemia
Dose :10mg pre-meal tds PO or 30-120mg Continuous Subcutaneous Infusion (CSCI)
Side Effects: extrapyramidal, colic, diarrhoea
In renal impairment need dose reduction
NB Domperidone: has same action as metoclopramide
Haloperidol Pathway:
Central: Chemoreceptor Trigger Zone (CTZ)
- most metabolic causes of vomiting (e.g. hypercalcaemia, renal failure).
Dose: 0.5 - 10mg PO/CSCI
Long half life
Can be given as a once daily dose at night
Side effects: sedation, extrapyramidal
Cyclizine Pathway: Central: vomiting centre - antihistamine and anti muscarinic
Has peripheral antimuscarinic effect which blocks action of
prokinetic drugs ie metoclopramide/domperidone NB: Drugs with antimuscarinic effects should not be used
concurrently with prokinetic drugs.
Dose: 50mg tds PO/ 150mg CSCI
Side effects: sedation, urine retention, dry mouth, constipation
NB: Can be skin irritant as S/C injection and not compatible with all drugs in CSCI
Levomepromazine (Nozinan) Pathway:
Central: acts at many receptor sites, therefore a broad spectrum antiemetic
2nd line: only used if 1st line antiemetics do not work
Dose: 6 – 25mg OD PO, 6.25-25mg CSCI
Side effects: reflect broad spectrum activity – sedation, constipation, hypotension
NB: has sedative properties, so can be used for agitation in higher doses
Other Side effects
IV Metoclopramide + IV Ondansetron:
may cause serious cardiac arrhythmias
Metoclopramide/Domperidone +
Cyclizine Metoclopramide/Domperidone
are motility agents while
Metoclopramide (and others) Oculogyric
crisis Especially in young women
Remember… Different antiemetics act at different points in the
vomiting mechanism – the drug must be appropriate to the cause of the nausea and vomiting.
Always: identify cause
treat reversible cause identify emetic pathway which is triggering vomiting
If using > 1 antiemetic:
- combine drugs with different actions - do not combine drugs which are antagonistic
(blocking) select antiemetic for identified pathway
Extra-pyramidal side effects Akathisia
Dystonia
Tardive Dyskinesia
Parkinsonism
Tremor
Rigidity
Bradykinesia
Haloperidol, metoclopramide (especially high dose) and
levomepromazine can all
cause these.
Non pharmacological
measures
Rest
Reassurance
Fresh air
Remove predisposing stimuli
Oral hygiene
Small appetising snacks
Cold drinks/ice lollies
Complimentary therapies:
- acupressure
- behavioural strategies
Aims and Objectives
Aims
Defining Bowel Obstruction
Examine the symptoms
Management Options
Complications
Objectives
An understanding of bowel obstruction
Definition of Bowel Obstruction
A blockage to a section of the bowel, reducing the motility of the contents of the gut.
Can be partial or complete
Can fluctuate between partial and complete making diagnosis difficult
Cause of Bowel Obstruction
Anything which causes an obstruction
Hard faeces
Foreign body
Tumour (internal)
Tumour (pressure on bowel)
Symptoms Nausea: persistent, fullness
Vomiting: large volume? faeculant?
Abdominal pain
Colic pain: wave like, spasm
Constipation: - can mimic bowel obstruction - impaction/overflow
Medical management
Nausea and vomiting
If no colic = metoclopramide in syringe driver
If colic = haloperidol + hyoscine butylbromide
(buscopan) in syringe driver
Large volume vomits
hyoscine butylbromide (buscopan)
octreotide
Reduction of colic:
hyoscine butylbromide (buscopan)
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