68: Management of Nausea and Vomiting

Question 1

Symptoms associated w N/V

Answer 1

-Pallor
-tachycardia
-diaphoresis

Question 2

Etiology of N/V

Answer 2

-influenza
-intestinal pathogen
-ulcers/GERD
-pancreatitis
-cholecystitis
-obstruction
-tumors
-DM gastroparesis

Question 3

Etiology of N/V

Answer 3

-CNS disorders: anxiety, tumors, HA
-acute or chronic pain
-excess food and alcohol
-pregnancy

Question 4

Tx-induced causes of N/V

Answer 4

-chemo
-radiation
-anesthesia
-ab procedures

Question 5

Drug-induced N/V

Answer 5

-anti-neoplastic agents
-opiod
-aspirin, NSAIDs
-iron
-some antibx (tetra, erythro)
-estrogens (high doses)
-anti-parkinsons meds
-SSRIs

Question 6

Complications of N/V

Answer 6

-pt discomfort
-dehydration
-malnutrition
-aspiration pneumonia
-anxiety
-compromise therapy
-decreased QOL

Question 7

Assessment of NV

Answer 7

-dehydration?
-severity on a scale of 0-10

Question 8

Patho of nausea/vomitting

Answer 8

????

Question 9

Non-pcol tx of NV

Answer 9

1. determine cause and clear liuid + IV hydration
2. Dietary
   -avoid fatty, fried, sweet, spicy, no hot (temp) foods

Question 10

Nonpharma tx of NV

Answer 10

-avoid senses that trigger
-fresh air
-avoid sudden movements and bright lights
-acupressure 3 fingers above wrist

Question 11

Relief band

Answer 11

-acupressure?
-helps tummy return to normal rhytym of 3 cycle/min
-nerve stimulation

Question 12

Drug therapy for NV

Answer 12

-Antihistamines/anticholinergics
-phenothiazines
-serotonin antagonists
-Neurokinin-1 antagonists
-Butyrophenones
-Metoclopramide
-Corticosteroids
-Cannabinoids

Question 13

Antihistamines-anticholinergics drugs

Answer 13

-Meclizine
-Dimenhydramine
-Scopolamine

Question 14

Antihistamines-anticholinergics MOA

Answer 14

-block histamine/muscarinic receptors in CTZ and NTS centers
-interrupt visceral afferent pathways
-moderate to severe

Question 15

Antihistamines-anticholinergics side effects

Answer 15

-drowsiness
-sedation
-dry mouth
-constipation
-blurred vision

Question 16

Phenothiazines

Answer 16

-Prochloraperazine
-Promethazine
-Chlorpromazine

Question 17

Phenothiazines MOA

Answer 17

-dopamine inhibition at CTZ
-std of care prior to 5-HT3 antagonists

Question 18

phenothiazine side effects

Answer 18

-dizziness
-sedation
-dry mouth
-HYPOtension
-EPS

Question 19

Serotonin antagonist Drugs

Answer 19

-ondansetron
-Franisetron
-Palonosetron
-Dolasetron

Question 20

Serotonin antagonist moa

Answer 20

-serotonin inhibition at CTZ, VC, and GI tract
-no suppository forms!

Question 21

serotonin antagonist side effects

Answer 21

-mild HA
-dizziness
-fatigue
-constipation
-maybe QT prolongation

Question 22

Ondansetron and Granisetron

Answer 22

-multiple dosage forms
-generic
-low cost

Question 23

Palonosetron

Answer 23

-longest DOA 40 h t1/2
-brand only $$
-no PO form

Question 24

Dolasetron

Answer 24

-PO only
-SS

Question 25

Neurokinin-1 ANTAgonists drugs

Answer 25

-Aprepitant -Fosaprepitant -Rolapitant

Question 26

NK-1 Antagonist moa

Answer 26

-neurokinin receptor inhibition at CTZ, VC, and GI -used primarily for CINV

Question 27

NK-1 antagonist side effects

Answer 27

-fatigue, hiccups, constipation, dec appetite

Question 28

Butyrophenones

Answer 28

-Haloperidol and Droperidol -dopamine inhibition at CTZ -RARELY use risk of EKG probs

Question 29

Metoclopramide

Answer 29

-dopamine inhibition -serotonin inhibition at high dose -EPS at high dose, give w bendryl

Question 30

Corticosteroids (dexamethasone)

Answer 30

-inhibit cortical input into vomit center ? -enhances the efficacy of any other antiemetics!

Question 31

Cannabinoids

Answer 31

-bind cannabinoid receptor in brain -sedation, dry mouth, euphoria, dysphoria, flushing, visual changes

Question 32

Route admin RANKED

Answer 32

1. PO tablet 2. ODT 3. PR 4. IV 5. IM

Question 33

Tx of motion sickness

Answer 33

-Scopolamine -Dimenhydrinate -Meclizine

Question 34

Scopolamine (transderm scop)

Answer 34

-apply patch before needed -72 hours -motion sickness

Question 35

Dimenhydrinate

Answer 35

-dramamine -motion sickness -50mg -PO 30-60 min before

Question 36

Meclizine

Answer 36

-25mg -Bonine, Dramamine less drowsy -Zentrip -PO 30-60 min before -motion sickness

Question 37

Tx of NV secondary to gastroenteritis or pain

Answer 37

-ondansetron 4-8mg q8-12h PRN (IV/ODT/PO) -Promethazine 12.5-25mg q4-6h prn (IV/IM/PO)

Question 38

Post-op NV (PONV)

Answer 38

-v common w older inhaled agents -pt w multiple risk factors are highest risk -most common complication associated w surgery

Question 39

Risk factors for PONV

Answer 39

-WOMAN -nonsmoker -hx of PONV -hx of motion sickness

Question 40

Anesthetic risk factors of PONV

Answer 40

-intra opertaive use of volatile anesthetics (less w propofol) -use of nitrous oxide -type of surgery (laparoscopy, craniotomy, ENT)

Question 41

Tx of mod to high PONV

Answer 41

-1-2 agents -only 1 if propofol is used -5-HT3 antagonists are DOC -all classes can be used -drugs asmined at end of procedure

Question 42

tx of highest risk PONV

Answer 42

-always use 2 agents -5-HT3 + metoclopramide or aprepitant

Question 43

Tx of breakthrough PONV

Answer 43

-use agent from dif class if within 6 hours of og dose -amisulpride

Question 44

Aprepitant

Answer 44

-treat in pt at highest risk of PONV -40mg PO 1-3 hours before anesthesia -may be better than ondansetron 4mg at 24 and 48h post-op

Question 45

Amisulpride (Barhemsys)

Answer 45

-5-10mg IV infused over 1-2 mintures -selective dopamine2 and 3 antagonist -tx breakthrough PONV -NOT indicated for prophylaxis -QT prolongation

Question 46

Monitoring efficacy of antiemetic therapy

Answer 46

-volume -freq and duration -nausea rating -ability to eat -PRN doses -QOL ratings

Question 47

monitoring toxicity of antiemetic therapy

Answer 47

-sedation/drowsiness -dizziness -diarrhea -HA -anticholinergic SE -EPS