68: Management of Nausea and Vomiting Flashcards
Symptoms associated w N/V
-Pallor
-tachycardia
-diaphoresis
Etiology of N/V
-influenza
-intestinal pathogen
-ulcers/GERD
-pancreatitis
-cholecystitis
-obstruction
-tumors
-DM gastroparesis
Etiology of N/V
-CNS disorders: anxiety, tumors, HA
-acute or chronic pain
-excess food and alcohol
-pregnancy
Tx-induced causes of N/V
-chemo
-radiation
-anesthesia
-ab procedures
Drug-induced N/V
-anti-neoplastic agents
-opiod
-aspirin, NSAIDs
-iron
-some antibx (tetra, erythro)
-estrogens (high doses)
-anti-parkinsons meds
-SSRIs
Complications of N/V
-pt discomfort
-dehydration
-malnutrition
-aspiration pneumonia
-anxiety
-compromise therapy
-decreased QOL
Assessment of NV
-dehydration?
-severity on a scale of 0-10
Patho of nausea/vomitting
????
Non-pcol tx of NV
- determine cause and clear liuid + IV hydration
- Dietary
-avoid fatty, fried, sweet, spicy, no hot (temp) foods
Nonpharma tx of NV
-avoid senses that trigger
-fresh air
-avoid sudden movements and bright lights
-acupressure 3 fingers above wrist
Relief band
-acupressure?
-helps tummy return to normal rhytym of 3 cycle/min
-nerve stimulation
Drug therapy for NV
-Antihistamines/anticholinergics
-phenothiazines
-serotonin antagonists
-Neurokinin-1 antagonists
-Butyrophenones
-Metoclopramide
-Corticosteroids
-Cannabinoids
Antihistamines-anticholinergics drugs
-Meclizine
-Dimenhydramine
-Scopolamine
Antihistamines-anticholinergics MOA
-block histamine/muscarinic receptors in CTZ and NTS centers
-interrupt visceral afferent pathways
-moderate to severe
Antihistamines-anticholinergics side effects
-drowsiness
-sedation
-dry mouth
-constipation
-blurred vision
Phenothiazines
-Prochloraperazine
-Promethazine
-Chlorpromazine
Phenothiazines MOA
-dopamine inhibition at CTZ
-std of care prior to 5-HT3 antagonists
phenothiazine side effects
-dizziness
-sedation
-dry mouth
-HYPOtension
-EPS
Serotonin antagonist Drugs
-ondansetron
-Franisetron
-Palonosetron
-Dolasetron
Serotonin antagonist moa
-serotonin inhibition at CTZ, VC, and GI tract
-no suppository forms!
serotonin antagonist side effects
-mild HA
-dizziness
-fatigue
-constipation
-maybe QT prolongation
Ondansetron and Granisetron
-multiple dosage forms
-generic
-low cost
Palonosetron
-longest DOA 40 h t1/2
-brand only $$
-no PO form
Dolasetron
-PO only
-SS
Neurokinin-1 ANTAgonists drugs
-Aprepitant
-Fosaprepitant
-Rolapitant
NK-1 Antagonist moa
-neurokinin receptor inhibition at CTZ, VC, and GI
-used primarily for CINV
NK-1 antagonist side effects
-fatigue, hiccups, constipation, dec appetite
Butyrophenones
-Haloperidol and Droperidol
-dopamine inhibition at CTZ
-RARELY use risk of EKG probs
Metoclopramide
-dopamine inhibition
-serotonin inhibition at high dose
-EPS at high dose, give w bendryl
Corticosteroids (dexamethasone)
-inhibit cortical input into vomit center ?
-enhances the efficacy of any other antiemetics!
Cannabinoids
-bind cannabinoid receptor in brain
-sedation, dry mouth, euphoria, dysphoria, flushing, visual changes
Route admin RANKED
- PO tablet
- ODT
- PR
- IV
- IM
Tx of motion sickness
-Scopolamine
-Dimenhydrinate
-Meclizine
Scopolamine (transderm scop)
-apply patch before needed
-72 hours
-motion sickness
Dimenhydrinate
-dramamine
-motion sickness
-50mg
-PO 30-60 min before
Meclizine
-25mg
-Bonine, Dramamine less drowsy
-Zentrip
-PO 30-60 min before
-motion sickness
Tx of NV secondary to gastroenteritis or pain
-ondansetron 4-8mg q8-12h PRN (IV/ODT/PO)
-Promethazine 12.5-25mg q4-6h prn (IV/IM/PO)
Post-op NV (PONV)
-v common w older inhaled agents
-pt w multiple risk factors are highest risk
-most common complication associated w surgery
Risk factors for PONV
-WOMAN
-nonsmoker
-hx of PONV
-hx of motion sickness
Anesthetic risk factors of PONV
-intra opertaive use of volatile anesthetics (less w propofol)
-use of nitrous oxide
-type of surgery (laparoscopy, craniotomy, ENT)
Tx of mod to high PONV
-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
tx of highest risk PONV
-always use 2 agents
-5-HT3 + metoclopramide or aprepitant
Tx of breakthrough PONV
-use agent from dif class if within 6 hours of og dose
-amisulpride
Aprepitant
-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
Amisulpride (Barhemsys)
-5-10mg IV infused over 1-2 mintures
-selective dopamine2 and 3 antagonist
-tx breakthrough PONV
-NOT indicated for prophylaxis
-QT prolongation
Monitoring efficacy of antiemetic therapy
-volume
-freq and duration
-nausea rating
-ability to eat
-PRN doses
-QOL ratings
monitoring toxicity of antiemetic therapy
-sedation/drowsiness
-dizziness
-diarrhea
-HA
-anticholinergic SE
-EPS
