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Palliative care > Nausea and vomiting > Flashcards

Nausea and vomiting Flashcards

1
Q

What’s anticipatory nausea and vomiting?

A
  • usually associated with chemotherapy
  • N/V occurs before a new chemotherapy cycle in response to conditioned stimuli such as smells, sights and sounds of the treatment room etc
  • it is when a person has experienced N/V related to chemo

Pathophysiology: generated by the cerebral cortex through the fear and anxiety related to the memory of previous experience

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2
Q

What’s regurgitation?

A

Regurgitation → backflow of fluid in the body

  • usually across partially or wholly failing valve mechanism
  • it can happen passively (e.g. when pressure on the stomach is applied)
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3
Q

What’s expectoration?

A

Expectoration → to expel secretions from the lungs (ie coughing up)

  • secretions in the back of the throat can trigger a gag reflex and make someone nauseated or to vomit (therefore may be confused with actual vomiting)
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4
Q

What’s the vomiting centre?

Type of receptors

A

Medulla Oblongata

  • muscarinic receptors in the medulla oblongata
  • when they are stimulated → vomiting reflex
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5
Q

What other (4) parts send the signals to the medulla oblongata and stimulate vomiting reflex?

+ their receptors

A
  • vestibular nuclei (cochlear)→ muscarinic and histamine receptors
  • chemoreceptor trigger zone → 5HT receptor, Dopamine 2 receptor
  • higher brain centres → muscarinic receptors, D2 (triggered by repulsive vomiting)
  • peripheral (GI &Viscera) → enterochromaffin cells in the stomach (5HT receptors)

*all these stimulate vomiting reflex

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6
Q

What cancers metastasise to the brain?

A
  • breast
  • lung
  • melanoma
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7
Q

Metoclopramide

  • class
  • receptors it acts on
  • SEs
A

Metoclopramide

Class: Prokinetic agent

Receptors: D2 & 5HT4 & 5HT3

SEs:

  • can cause colic
  • parkinsonian features
  • oculogyric crisis (especially in kids and youth, so don’t prescribe)
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8
Q

Domperidone

  • class
  • receptors it acts on
  • contraindication
A

Domperidone

Class: prokinetic agent

Receptors: D2

Contraindication: not in HF as it is cardiotoxic

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9
Q

Haloperidol

  • class
  • receptors it acts on
  • SEs
  • contraindications
A

Haloperidol

Class: butyrophenone

Receptor: D2

Haloperidol is good n nausea and vomiting but also with confusion (as it has a sedating effect)

SEs: extrapyramidal side effects, sedation, prolong QT

Contraindications: cardiac problems (cytotoxic) Parkinson disease and above

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10
Q

Cyclizine

  • class
  • receptors it acts on
  • SEs
A

Cyclizine

Class: antihistamine

Receptors: H1 and muscarinic cholinergic

SEs: constipation, irritation at SC site

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11
Q

Levomepromazine

  • class
  • receptors it acts on
  • SEs
A

Levomepromazine

Class: Phenothiazine

Receptors: H1 & 5HT2 & muscarinic & D2

*used often as it acts on broad-spectrum receptors (as antagonist)

SEs: drowsiness at higher doses, constipation, anti-muscarinic (but all these are milder due to broad spectrum action)

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12
Q

Ondansetron

  • class
  • receptors it acts on
  • SEs
A

Ondansetron

Class: 5HT3 antagonist

Receptors: 5HT3

  • It acts on gut specific receptors
  • Good for chemotherapy induced nausea

SEs: constipation

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13
Q

Lorazepam

class

receptors

indicaiton

A

Lorazepam

Class: benzodiazepine

Receptor: GABA

Indication: for anxiety/ anticipatory nausea

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14
Q

What drug and why do we commonly prescribe with cyclizine SC?

A

small amount of dexamethasone to minimise injection site irritation

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15
Q

Antibiotics commonly cause nausea?

A
  • Flucloxacillin
  • Clarithromycin
  • Metronidazole (with alcohol)
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16
Q

Diet advise in N/V

A
  • eat little and often (rather than large meals)
  • carbs are better tolerated (fats and proteins delay gastric emptying)
17
Q

Can we use metoclopramide + cyclizine?

A

No, as they have antagonistic effects

18
Q

Chemical causes of N/V (3)

A
  • Drugs → e.g. opiates, antibiotics, chemotherapy
  • Toxins → e.g. ischaemic bowel, tumour products
  • Metabolic → organ failure, electrolyte imbalance, ketoacidosis
19
Q

GI-related causes of N/V (4)

A
  • Pharyngeal irritation → Herpes, Candida, excess of sputum
  • Gastric stasis → anticholinergics/ opiates, mechanical resistance (ascites, organomegaly)
  • Stretch of GI tract → constipation, mesenteric mets
  • other GI irritation → e.g. reflux
20
Q

Cranial causes of N/V

A
  • raised ICP → cerebral primary or mets, intracranial bleeding
  • meningism → inflammation, irritation by tumour, cerebral infections
21
Q

Other (2) causes of N/V

A
  • movement associated → vestibular, visceral distortion, motion sickness
  • anxiety and anticipatory
22
Q

Common reversible causes of N/V + their management

A
  • severe pain → good pain control
  • infection → antibiotics
  • cough → treat underlying cause/opioids and antitussives
  • hypercalcaemia → rehydration and IV bisphosphonates
  • gastric irritation → stop irritant drugs (e.g. NSAIDs, use of PPI/H2 antagonists)
  • oropharyngeal candida→ nystatin/ fluconazole and good mouth care
  • constipation → laxatives, rectal measures, altering constipating meds
  • tense ascites → consider paracentesis
  • raised ICP → use corticosteroids
  • emetogenic drugs → stop or reduce dose
  • anxiety → pharmacological and psychological meanagement
23
Q

Features of vomiting due to gastric stasis

A
  • large volume of vomits
  • infrequent vomiting
  • relief of symptoms after vomiting
  • also: oesophageal reflux, epigastric fullness, early satiety, hiccups
24
Q

Symptoms of N/V due to gastric outflow obstruction

A
  • symptoms similar to gastric stasis e.g. large volume of vomits, relieve after vomiting
  • forceful vomiting
  • rapid dehydration
25
Q

‘Squashed stomach syndrome’

  • whats that
  • feature of N/V due to this
A

‘Squashed stomach syndrome’ → reduction in the gastric cavity by tumour or external compression

Symptoms:

  • infrequent vomiting
  • relief after vomits
  • low volume vomits
26
Q

Symptoms of N/V due to oesophageal blockage

A
  • vomiting soon after eating/ drinking
  • vomits consist of what has just been swallowed
  • sensation of food sticking
27
Q

Symptoms of N/V due to bowel obstruction

A
  • intermittend nausea (often relieved by vomiting)
  • worsening nausea
  • faeculant vomit as obstruction progresses
  • abdominal pain (may be colicky)
  • abdominal distention (may be absent if obstruction is high)
28
Q

Symptoms of N/V due to increased ICP

A
  • efortless vomiting (often in the morning)
  • vomiting may be associated with headache and papilloedema

*neurological signs e.g. photophobia may be absent

29
Q

Symptoms of N/V associated with:

  • motion - associated emesis
  • chemically induced nausea
  • anxiety-related nausea
A
  • motion - associated emesis → N/V on movement
  • chemically induced nausea → constant nausea, variable vomiting
  • anxiety-related nausea → may be triggered by a previously experienced stimulus; relieved by distraction
30
Q

What types of drinks to have in N/V?

A
  • cool rather than hot
  • fizzy rather than still (except when in obstruction)
  • citrus flavoured (possibly are better tolerated)
31
Q

Drugs used in management of N/V due to gastritis, gastric stasis, bowel obstruction (due to peristaltic failure)

A

Prokinetic anti-emetics

  • metoclopramide
  • domperidone

Alternatives: Ondansetron, cyclizine

32
Q

Drugs used in the management of N/V due to chemicals (drug, toxins metabolic causes)

A

Anti-emetics acting principally on chemoreceptor trigger zone

  • Haloperidol
  • Ondansetron
33
Q

Drugs used in the management of N/V due to raised ICP or vestibular symptoms

A

Anti-emetic acting peripherally in the vestibular system and vomiting centre

  • Cyclizine
  • *Add dexamethasone due to irritation of the skin in SC route*
34
Q

Which anti-emetic to use when the cause of vomiting is unknown or if the anti-emetics specific for identified cause (e.g. metoclopramide for gastric stasis) failed?

A

Broad-spectrum anti-emetics

Levomepromazine

35
Q

What other anti-emetics we can add to levomepromazine (broad-spectrum) when any other therapy fails?

A
  • Levomepromazine + 5HT3 antagonist (e.g. ondansetron)
  • Levemepromazine + benzodiazepine (e.g. lorazepam or midazolam)
  • Levomepromazine + dexamethasone (stop dexamethasone if no benefit after one week)
36
Q

What two anti-emetics can worsen constipation?

A
  • 5HT3 antagonists → ondansetron
  • anticholinergics → e.g. cyclizine, hyoscine butylbromide/hydrobromide
37
Q

Nabilone

- MoA

  • when to use?
A

Nabilone

MoA: cannabinoid drug; central actions at the level of the cerebral cortex

Use: potentially helpful in managing intractable N/V uncontrolled by other drugs

38
Q

Aprepitant

  • MoA
  • when to use
A

Aprepitant

MoA: Neurokinin-1 (substance P) receptor antagonist

Use: given 1 hour prior first dose of chemotherapy

Palliative care (11 decks)

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