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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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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


VOMITING

CENTRE

Cortex

CTZ

GI

Vestibular


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


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


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



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


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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