Nausea and Vomiting Flashcards
What is N/V?
- Nausea is the subjective feeling of a need to vomit
- Vomiting is the physical expulsion of gastric contents
- Retching is dry heaves
- Regurgitation food from pharynx or esophagus
Why do we treat N/V?
N/V is a self-limiting condition
• Mild symptoms of N/V can be treated with OTC agents
• It is easier to prevent N/V than treat it (e.g. motion sickness)
Acute complications of N/V – Dehydration – Esophageal tearing – Electrolyte imbalance – Malnutrition – Aspiration
Etiology of N/V
- Motion sickness
- Pregnancy (NVP)
- Viral gastroenteritis
- Overeating
- Food poisoning
- Drug therapy
- Disease states
Environmental Factors: Non-pharmacological Tx
• Exposure to fresh air in sleeping quarters
• Rest and relax
• Avoid odors that elicit N/V (raw fish, tobacco smoke)
• Travel where motion is minimal (front of the bus, wings of an airplane)
– Drive, if possible
• Avoid reading during travel
Diet/meal alterations: Non-pharmacological Tx
• Small sips of carbonated fluids (ginger ale) or fruit juices
• Consume crackers/dry toast
• Avoid overeating and excess alcohol intake
• Eat smaller meals 4-5x/day
• Avoid:
– greasy, fried foods
– spicy or acidic foods
Acupressure: Non-pharmacological Tx
MOA: Stimulation of the P6 acupuncture point located bilaterally on inner forearm
• Advantages:
– Can be used concurrently with anti-emetic pharm therapy
– An alternative for patients who want to avoid pharm agents
Acupressure: Sea Band, Travel aides
– Does not cause sleepiness
– Can be used with antiemetic therapies
– Has been used in children as young as 2 yr
– Use before onset or when sx first occur
Acustimulation:
• Adverse effect: mild, self-limiting rash
– Contains latex, avoid use with latex allergy
– The product is to be worn on one wrist
Pharmacologic options for N/V
OTC agents
- Antihistamines
- Antacids
- Histamine-2-receptor antagonists (H2-RA)
- Proton pump inhibitor (PPI)
- Bismuth subsalicylate (BSS)
- Phosphorated carbohydrate solution (PCS)
- Pyridoxine (vitamin B6) – mainly used for NVP
Antihistamines (AE, Special Pop, PE)
Indication: Prevention/tx of N/V due to motion sickness
Adverse events: – Drowsiness – Anticholinergic effects • Blurred vision, constipation, urinary retention, dry mouth – CNS reactions • Hallucinations & psychosis
Caution use in special populations
- Elderly: falls, BPH, glaucoma, resp, CNS AEs
- Lactating: reduce milk, secreted in milk
- Pregnancy: emphasize non-pharm, doxy
- Children: age limits, avoid in < 2, no etc dose labeled for < 6
Patient Education
– Be aware of other agents that also cause sedation (TCAs, BZDs)
– Avoid combining with alcohol
– Minimize operating vehicle or machinery
– Many other products contain an antihistamine (topicals, combination cold therapies): avoid concurrent use
– To prevent N/V of motion sickness, take 30-60 min before and continue taking them
Antacids (AE, PE)
Indication: nausea associated with excessive or disagreeable food intake.
• Adverse events: – Constipation (Aluminum products) – Diarrhea (Mg containing products) – Chalky taste – Caution use in patients with renal disease
• Patient education:
– Be aware of the different amounts elemental calcium in various antacid products (Tums, TumsEX, Tums Ultra)
– Maximum dosage (# of tablets) varies
– Take ~30 minutes after meals
H2-RAs / PPIs
• Indication: Nausea associated with excessive or disagreeable food intake. Sx: infrequent heartburn, dyspepsia, indigestion, and upset stomach.
• Adverse events:
– Dizziness and Headache
– GI (diarrhea and constipation)
Bismuth Subsalicylate (BSS)
• Indication: Nausea associated with excessive or disagreeable food intake.
• Adverse events:
– Bad taste!
– Discoloration of stool & tongue (‘black tongue’)
• Cautions:
– Avoid in patients with salicylate allergy (aspirin)
– Avoid in children/teens who are recovering from chicken pox/viral illness (Reye’s syndrome)
• Don’t use in children <18 years
• Patient education
– For liquids: shake well
– May refrigerate liquid formulation for better taste
– With or without food
Phosphorated carbohydrate solution
• Indication: Nausea associated with excessive or disagreeable food intake and by intestinal or stomach flu.
• Adverse Effects and Cautions
– Diarrhea (due to formulation)
– Do not use in patients with diabetes or fructose intolerance
• Patient education
– Do not dilute
– Avoid liquid consumption 15 minutes before and after for maximum effect
Complementary & Herbal Remedies
• Ginger
– In a variety of products (ginger ale, ginger root, extracts)
– PROS:
• Does not produce CNS depressant effects
• Effective for postoperative nausea, NVP, and motion sickness
– CONS:
• Optimal dose?
• Not FDA approved for treatment of N/V
• Others – Chamomile – Lemon balm – Peppermint – Artichoke – Cannabinoids
• “Buyer Beware” Established efficacy remains in question.
Pregnancy (line of defense, avoid)
• 1st Line:
– Non-pharm: env, diet/food changes
– Prevent dehydration
• 2nd Line:
– Acupressure or Acustimulation Bands
– Phosphorated carbohydrate solution
– Doxylamine + Pyridoxine
• Avoid – Other antihistamines (none FDA-app) – Avoid all anti-HM in lactating women – H2-RAs – PPIs – Bismuth subsalicylate
Children (line of defense, avoid)
1st Line:
– Non-pharm (env, diet/food changes)
– Prevent dehydration
• 2nd Line :
– Phosphorated carbohydrate solution
– Acupressure or Acustimulation bands
– Antihistamines for motion sickness (dose no longer listed on OTC package <6 years old), FDA cautions
• Avoid
– Bismuth subaliclate <18 (Reye’s)
