Download Nausea & Vomiting

Nausea & Vomiting
‘made easy’
First steps
What is the cause?
 Non-medical treatment
 Medical treatment

1st line
 Other options

Scale of the problem

Occurs in 40-70% patients with
advanced cancer

1/3 will have more than 1 contributing
factor

1/3 will need more than 1 anti-emetic
Non-medical treatment

Calm environment & good ventilation
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Frequent small snacks
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Avoid sight & smell of food eg cooking
Gastric stasis - causes
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Drugs

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‘Squashed stomach syndrome’


Opioids
tumour, enlarged liver, ascites
Outflow obstruction

tumour
Gastric stasis - symptoms
Epigastic discomfort
 Fullness
 Early satiety
 Exacerbated by eating / relieved by
vomiting
 Large volume vomits (undigested food)

Gastric stasis - management

Prokinetic agent
metoclopramide 10-20mg tds (oral)
40-80/24hrs sc infusion
 Also consider



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Domperidone (less side effects but not sc)
PPI to reduce acidity
Steroids 8-12mg dexamethasone for 7 days
2nd line

Cyclizine 50mg tds po/sc (150mg/24hrs sc infusion)
bowel distension
Chemically-induced nausea causes

Drugs (10-30% on inititation of opioid)


Metabolic

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antibiotics, anticonvulsants, antidepressants,
cytotoxics, steroids, digoxin, NSAID’s
renal or hepatic failure, hypercalcaemia,
hyponatraemia, ketoacidosis
Toxins

ischaemic/obstructed bowel, tumour effect,
infection
Chemically-induced nausea symptoms

Constant nausea

Vomiting is variable in volume & timing

May be other features of drug toxicity
Chemically-induced nausea management

Haloperidol po/sc 1.5-3mg od/bd
2.5-10 mg/24hrs sc infusion

Also consider
Correct the correctable
 Metoclopramide (gastric stasis) 10mg tds

Raised intracranial pressure –
causes
Intracranial tumour
 Cerebral oedema
 Intracranial bleed
 Meningeal infiltration by tumour
 Skull metastases
 Cerebral infection

Raised intracranial pressure –
symptoms

Nausea worse in the morning

Headache

Nausea and/or vomiting provoked by
head movement
Raised intracranial pressure –
management

Cyclizine 50mg tds (oral)
150mg/24hr sc infusion

Also consider
High dose steroid: dexamethasone 16mg od
 Hyoscine hydrobromide

Kwells 300mcg qds
 0.8-3.6mg/24hr sc infusion

If at first you don’t succeed…

Consider adding a second agent

Different mechanisms of action
eg haloperidol with cyclizine

Avoid antagonistic action
cyclizine counteracts the prokinetic affect of
metoclopramide

Consider levomepromazine
‘broad spectrum’ antiemetic
 6.25-12mg (1/4 -1/2 tablet)po
or 5-25 mg sc/sc infusion over 24hrs
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Summary
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Gastric stasis


Chemically-induced


metoclopramide
haloperidol
Raised intracranial pressure

cyclizine

Consider additional or 2nd line treatment
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Don’t forget the effect of anxiety & pain