Nausea and

Vomiting Julia Newell

Jan Siddall 2016

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

Other options Venting Gastrostomy

NG free drainage

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)

Any questions?