Download Proposed Standards and Guidelines

Proposed Standards and Guidelines
Management of Nausea and
Vomiting in Palliative Care
General Principles
• Nausea and vomiting are experienced by 50-60% of
patients with advanced cancer. 1
• Nausea and vomiting are more common in certain groups
of patients i.e. <65 years old, females and certain
malignancies e.g. gastric and breast cancer. 1
• Patients with advanced malignancy may develop nausea
and vomiting from causes unrelated to the cancer e.g. gall
bladder disease or gastroenteritis.1
• Anti-emetics are neurotransmitter-blocking agents and are
effective at different receptor sites (see Figure 27.1).3
• The choice of anti-emetic will be influenced by the cause
of vomiting.4
• They may be administered by a variety of routes. It is
suggested that the intramuscular and intravenous routes
of delivery of anti-emetics should be avoided.4
• It is considered standard palliative care practice to use
different anti-emetics depending on the aetiology of
Nausea and vomiting. Systematic reviews have not shown
evidence to support this approach neither is there
evidence to refute it. Expert opinion of the network group
recommends continuing with using the aetiology based
approach.
• Treatment of nausea and vomiting should involve
discussion with the patient in treatment decision making.
Guidelines
Guidelines
• Patient assessment should include a full history, examination and
investigations where appropriate.1 [Level 4]
• The history should include details of the volume, content and timing
of vomiting . Nausea should be specifically enquired for and rated,
along with any diurnal pattern or associated features which may
suggest a cause.1 [Level 4]
• A biochemical profile, including corrected calcium, should be checked
in patients with nausea and / or vomiting unless they are in the dying
phase.1 [Level 4]
Guidelines
• Reversible causes should be treated where appropriate. These
include: drugs, constipation, hypercalcaemia, cough, anxiety and
gastric irritation.3,4 [Level 4]
• Non-pharmacological measures which may be useful in the
management of nausea and vomiting include: psychological
measures, transcutaneous electrical nerve stimulation (TENS),
complementary therapies and advice on posture and diet.1,3[Level 4]
• If nausea is severe or protracted, early use of the parenteral route
should be considered. Gastric stasis can cause nausea and oral antiemetics may be in-effective in this situation. 1,3 [Level 4]
Guidelines
• A continuous subcutaneous infusion (CSCI) via a syringe
driver should be considered for:
• Patients who have vomiting lasting more than 24 hours.
• Patients who have nausea unresponsive to oral antiemetics for more than 24 hours.11
• Patients who are unable to swallow
• Patients who are suspected to have malabsorption [Level
4]
Guidelines
• Various subcutaneous regimens are suggested in Table
27.2.
• A single stat subcutaneous injection should be given at the
same time as setting up the CSCI and breakthrough antiemetics should always be prescribed.11 [ Level 4]
Guidelines
• In cases of nausea and or vomiting due to bowel
obstruction please refer to Guidelines for the
Management of Bowel Obstruction (plan to add link to
guidelines or reference)
• Autonomic neuropathy is common in advanced disease
and may cause gastroparesis. This may contribute to
terminal restlessness . Consider using a nasogastric tube
to remove gas and liquid from the stomach. This may
restore comfort and the tube can then be withdrawn. 11
[Level 4]
Guidelines
• If a nasogastric tube is left in-situ, prescribe cyclizine or
levomepromazine to alleviate the nausea caused by
pharyngeal stimulation.11 [Level 4]
• The European Medicines Agency has recommended
restrictions to the duration of use of metoclopramide and
domperidone. Within palliative care it is common to use
these off licence in terms of duration, dosing and
indication. The risk/benefit of off licence prescribing
should be considered in association with patient
preference and communicating the risk to the patient.
Information should be offered as available.
Updated Table 27.2
Standards
Standards
1. Any patient with a history of nausea and vomiting should
have a full assessment including a history, clinical
examination and appropriate investigations to try and
identify a cause for the symptoms.1 [Grade D]
2. Appropriate anti-emetics should be prescribed on a
regular and as required basis.11 [Grade D]
Standards
3. If a patient is vomiting or nauseated for more than 24
hours or in cases of suspected malabsorption, antiemetics should be given via the parenteral route.11
[Grade D]
4. If combinations of anti-emetics are required, drugs with
different but complementary actions should be used.2, 3
[Grade D]
Standards
5. Prokinetic agents such as Metoclopramide or
Domperidone should not be prescribed if complete
intestinal obstruction is suspected.2, 3 [Grade D]
6. Symptoms of nausea and vomiting should be reviewed on
a regular basis where possible i.e. 24-48 hourly basis until
symptoms controlled [Grade D]
Standards
7. The patient should be involved in the plan for
management and clinicians should ensure that they have
had the opportunity to understand the underlying cause
of the nausea and vomiting where possible.