MANAGEMENT OF NAUSEA AND VOMITING IN
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MANAGEMENT OF NAUSEA AND VOMITING IN PALLIATIVE CARE. INCIDENCE OF NAUSEA AND VOMITING IN TERMINAL CANCER PATIENTS. Nausea: 50 - 60 % Vomiting: 30 %. MECHANISM OF NAUSEA AND VOMITING. vomiting centre in reticular formation of medulla activated by stimuli from:

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MANAGEMENT OF NAUSEA AND VOMITING IN PALLIATIVE CARE

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Management of nausea and vomiting in palliative care

MANAGEMENT OF NAUSEA AND VOMITING IN

PALLIATIVE CARE


Management of nausea and vomiting in palliative care

INCIDENCE OF NAUSEA AND VOMITING IN TERMINAL CANCER PATIENTS

Nausea:50 - 60 %

Vomiting:30 %


Management of nausea and vomiting in palliative care

MECHANISM OF NAUSEA AND VOMITING

  • vomiting centre in reticular formation of medulla

  • activated by stimuli from:

    • Chemoreceptor Trigger Zone (CTZ)

      • area postrema, floor of the fourth ventricle

      • outside blood-brain barrier (fenestrated venules)

    • Upper GI tract & pharynx

    • Vestibular apparatus

    • Higher cortical centres


Management of nausea and vomiting in palliative care

VOMITING

CENTRE

Cortex

CTZ

GI

Vestibular


Management of nausea and vomiting in palliative care

CAUSES OF NAUSEA & VOMITING

CHEMORECEPTOR

TRIGGER ZONE

VESTIBULAR

CORTICAL

PERIPHERAL

  • drugs

    • opioids

    • chemo

    • etc...

  • biochemical

    • ­Ca++

    • renal failure

    • liver failure

  • sepsis

tumor

opioids

anxiety

association

­ICP

  • radiotherapy

  • chemotherapy

  • GI irritation

    • inflammation

    • obstruction

    • paresis

    • compression


Management of nausea and vomiting in palliative care

PRINCIPLES OF TREATING NAUSEA & VOMITING

  • Treat the cause, if possible and appropriate

  • Environmental measures

  • Antiemetic use:

    • anticipate need if possible

    • use adequate, regular doses

    • aim at presumed receptor involved

    • combinations if necessary

    • anticipate need for alternate routes


Management of nausea and vomiting in palliative care

5HT

5HT

5HT

AREA

STIMULUS

RECEPTORS

Chemoreceptor

trigger zone

Drugs,

Metabolic

D

2

M

H

1

Motion/

Position

Vestibular

H1

M

VOMITING

CENTRE

Visceral

Abdominal

organs

D

2

­ ICP

H

Cortex

1

EFFECTOR

ORGANS

(usually use decadron)

5HT

H1

M

D2

Dopamine

Serotonin

Histamine

Muscarinic


Management of nausea and vomiting in palliative care

RELATIVE ANTIEMETIC RECEPTOR AFFINITIES

1250


Management of nausea and vomiting in palliative care

EXAMPLES OF ANTIEMETIC USE

  • haloperidol 0.5 - 1 mg po/sq/iv q6-12h

  • prochlorperazine 5 - 20 mg po/pr/iv q4-8h

  • CPZ 25 - 50 mg po/pr/iv q6-8h

  • methotrimeprazine 5 - 10 mg po/sl/sq q4-8h

  • metoclopramide 10 - 20 mg po/sq/pr q4-8h

  • domperidone 10 mg po q4-8h

  • scopolamine patch (Transderm-Vâ)

  • metoclopramide 10 - 20 mg po/sq/pr q4-8h

  • domperidone 10 mg po q4-8h

  • cisapride 10 mg po tid-qid

DOPAMINE

ANTAGONISTS

ANTIMUSCARINIC

PROKINETIC


Management of nausea and vomiting in palliative care

EXAMPLES OF ANTIEMETIC USE

  • dimenhydrinate 25 - 100 mg po/pr/[sq] q4-8h

  • promethazine 25 mg po/iv q4-6h (Not sq)

  • meclizine 25 mg po q6-12h

  • ondansetron 4 - 8 mg bid-tid po/sq/iv

  • granisetron 0.5 –1 mg po/sq OD - bid

  • dexamethasone 2 - 4 mg po/sq/iv OD-qid

  • lorazepam 0.5 - 1 mg po/sl q4-12h

H1

ANTAGONISTS

SEROTONIN

ANTAGONISTS

MISCELLANEOUS


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