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NAUSEA MANAGEMENT
Assessment: Conceptualize Underlying Causes: 13 "M's" of Emesis
Above Neck
1. Masses
2. Meningeal Irritation
3. Migraine / other
headaches
4. Movement
Causes
Above Neck
1. Masses
2. Meningeal
Irritation
Below Neck
5.
6.
7.
8.
9.
Motility
Mucositis
Mechanical obstruction
Myocardial infarction
Maternity
Systemic
10.
11.
12.
13.
Mentation
Medication
Microbes
Metabolic
Treat Underlying Cause
Treat Nausea
• Dexamethasone to
 inflammation / edema
• If tumor, treat to  mass effect
• If fluid collection, drain fluid
CTZ:
1. Dexamethasone
2. DA antagonist
3. H1 antagonist
• Dexamethasone to
 inflammation / edema
• If a tumor, treat to  mass effect
CTZ:
1. Dexamethasone
2. DA antagonist
3. H1 antagonist
3. Migraine
or other
headache
Treat headache to  pain,
associated symptoms
CTZ:
1. DA antagonist
2. H1 antagonist
4. MovementVestibular
stimulation
•  motion
• Treat inner ear infections
•  or stop offending medications
CTZ:
1. DA antagonist
2. H1 antagonist
Management
1. Treat underlying cause
2. Treat experience of nausea
Conceptualize likely neurotransmitters. Dopamine antagonists
are first choice. Titrate to effect using tCmax. Add medications from
different classes. Do not overlap mechanisms of action.
Causes
Below Neck
5. Motility
Treat Underlying Cause
Treat Nausea
If due to medications:
•  or stop responsible
medications
•  motility with prokinetic
medication
•  opioid inhibition of bowel
function with methylnaltrexone
CTZ:
1. DA antagonist
2. H1 antagonist
If due to gastroparesis, e.g.,
Diabetes:
 motility with prokinetic
medication
CTZ:
1. DA antagonist
2. H1 antagonist
Adapted from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at www.
IPCRC.net. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207.
NB: These are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. © Palliative Care & Hospice Programs, OhioHealth, 2013, 2014.
Permission to reproduce material is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed.
To reproduce for all other purposes, contact the Palliative Care & Hospice Programs at 1-888-278-6615 or visit IPCRC.net.
S1A
NAUSEA MANAGEMENT
Causes
Below Neck
Treat Underlying Cause
Treat Nausea
If due to gastric H+;  gastric pH with:
• Liquid antacid
• H2 blocker
• Proton Pump Inhibitor
6. Mucositis
If due to ASA or NSAIDs
( Prostaglandin E  relative
ischemia   mucous production):
• Ensure well hydrated
• Misoprostol (Prostaglandin E
analogue) to perfusion
• Proton Pump Inhibitor to
 gastric pH
CTZ:
1. DA antagonist
2. H1 antagonist
Causes
Below Neck
Treat Underlying Cause
Treat Nausea
7. Mechanical
obstruction
(continued)
If extraluminal compression,
e.g., adhesions, tumor:
• Dexamethasone to
 inflammation / edema
• If tumor, treat to  mass effect
• Surgery to stent or bypass
• Octreotide to  intestinal
volume
CTZ:
1. DA antagonist
2. H1 antagonist
8. Myocardial
Infarction
• Nitrates to  angina
• Optimize oxygenation / cardiac
perfusion
• Opioid analgesics to
 intractable pain
CTZ:
1. DA antagonist
2. H1 antagonist
If due to infection, e.g., H. Pylori,
Candida, CMV, Herpetic
 gastric erosions:
• Treat infection
•  gastric pH with H2 blocker or
Proton Pump Inhibitor
7. Mechanical
obstruction
If intraluminal obstruction,
e.g., constipation obstipation:
• Relieve impaction with enemas,
disimpaction
•  constipation with
stimulant ± osmotic laxatives
If 1st trimester,
 estrogen / progesterone
  gastric emptying:
• Eat small, frequent low-fat
meals
9. Maternity
CTZ:
1. DA antagonist
2. H1 antagonist
If 3rd trimester,
mass effect  mechanical
obstruction of bowel:
• Reposition
• Keep stool soft / moving with
stimulant ± osmotic laxatives
——————
Adapted from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at www.
IPCRC.net. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207.
NB: These are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. © Palliative Care & Hospice Programs, OhioHealth, 2013, 2014.
Permission to reproduce material is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed.
To reproduce for all other purposes, contact the Palliative Care & Hospice Programs at 1-888-278-6615 or visit IPCRC.net.
S1B
NAUSEA MANAGEMENT
Systemic
Causes
10. Mentation,
e.g., anxiety,
stress
11. Medications/
Treatments
12. Microbes
Treat Underlying Cause
Treat Nausea
Supportive care to reduce
anxiety, underlying stress:
• Behavior modification
• Guided imagery
• Hypnosis
Diffuse effect:
Centrally acting
medications
If during chemotherapy
• Prophylactic antinauseants
• Modify dose of chemotherapy
See Chemotherapy
Emetogenicity Table
If during radiation therapy
• Prophylactic antinauseants
• Modify dose of chemotherapy
See Radiation
Emetogenicity Table
If other medications,
e.g., opioids, anticholinergics
• Prophylactic anti-nauseants
•  or stop responsible
medications
CTZ:
1. DA antagonist
2. H1 antagonist
If due to systemic infections /
sepsis:
• Treat underlying infection
• Reduce fever
Systemic
Causes
Treat Underlying Cause
Treat Nausea
If hypercalcemia due to metastases:
• Rehydrate with NaCl; diurese with
furosemide
• Dexamethasone
• Bisphosphonates, e.g., pamidronate,
zoledronic acid; if caused treatable
13. Metabolic
If hyponatremia due to dehydration:
• Stop diuretics, including alcohol and
caffeine, e.g., coffee, tea
• Rehydrate with NaCl containing
fluids:
- Orally: soups, sport drinks, red
vegetable juices
- Parenterally: 0.9% NaCl
CTZ:
1. DA antagonist
2. H1 antagonist
If liver failure, reduce toxins with
lactulose, rifaximin, neomycin
If renal failure, dialyze to reduce toxins
CTZ:
1. DA antagonist
2. H1 antagonist
Adapted from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at www.
IPCRC.net. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207.
NB: These are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. © Palliative Care & Hospice Programs, OhioHealth, 2013, 2014.
Permission to reproduce material is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed.
To reproduce for all other purposes, contact the Palliative Care & Hospice Programs at 1-888-278-6615 or visit IPCRC.net.
S1C
NAUSEA MANAGEMENT
Non-Pharmacological Management: Acupuncture, behavior modification, hypnosis, imagery, modification of eating
habits / odors
Pharmacological Management
Dopamine Antagonists
Haloperidol 0.5-2 mg PO / SC / IV
q 12-24 hrs
Metoclopramide 10-20 mg PO / SC / IV q 6 hrs
Prochlorperazine 10-20 mg PO q 6 hrs
Prochlorperazine 25 mg PR q 12 hrs
Olanzapine 5-10 mg PO daily
Serotonin Antagonists
Ondansetron 4-8 mg PO / SC / IV q 6 hrs
Granisetron 1 mg PO / IV daily or q 12 hrs
Dolasetron 200 mg PO / IV daily
Palonosetron 0.25 mg PO / IV daily
Histamine Antagonists
Diphenhydramine 25-50 mg PO / SC / IV
Meclizine 25-50 mg PO q 6 hrs
Hydroxyzine 25-50 mg PO q 6 hrs
Promethazine 25 mg PO / PR q 6 hrs
Promethazine 12.5-25 mg IV q 6 hrs
Acetylcholine Antagonists
Scopolamine patch 1-3 TD q 72 hrs
Scopolamine 0.1-0.4 mg SC / IV q 4 hrs
Central Action
Dexamethasone 2-20 mg PO / SC / IV daily
Dronabinol 5-25 mg PO/24 hrs div q 2-4 hrs
Lorazepam 0.5-2 mg PO / SC / IV q 8 hrs
Inoperable Obstruction
Octreotide 100-400 mcg or more SC / IV q 8 hrs
or 10-80+ mcg/hr SC infusion
Scopolamine 0.1-1.0+ mg/hr SC infusion
Glycopyrolate 0.1-1.0+ mg/hr SC infusion
div = In divided doses
Adapted from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at www.
IPCRC.net. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207.
NB: These are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. © Palliative Care & Hospice Programs, OhioHealth, 2013, 2014.
Permission to reproduce material is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed.
To reproduce for all other purposes, contact the Palliative Care & Hospice Programs at 1-888-278-6615 or visit IPCRC.net.
S1D