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SPM- Oncology and Palliative Care > Nausea and Vomiting Management > Flashcards

Nausea and Vomiting Management Flashcards

1
Q

What is nausea?

A

Nausea is an unpleasant feeling of the need to vomit associated with autonomic symptoms (pallor, sweating, tachycardia, salivation)

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2
Q

What is vomiting?

A

The forceful propulsion of gastric contents through the mouth

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3
Q

What should you ask about in the history for a cancer patient with nausea and vomiting?

A 
When did it start?
Has it been constant or improved?
What did it look like?
Was there any blood in the vomit?
How did it start?
Has this happened before?
how has it been treated if it has happened before
Has anything helped to make it better or worse
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4
Q

How should you manage a patient complaining of nausea and vomiting?

A

Identify and correct any reversible causes- e.g. hypercalcemia, uraemia, GI infection

Non-pharmacological methods- avoid triggers, small frequent meals, ginger, mint

Pharmacological- Prescribe an anti-emetic

Correct any prescribing issues- PO route may no longer be suitable. Identify possible drug causes.

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5
Q

What are syringe drivers?

A

Syringe drivers are used for continuous subcutaneous infusions of drugs. This therefore gives continuous delivery via an alternative route to PO. They allow for rapid control of symptoms and easy dose adjustments by adjusting the drive rate.

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6
Q

What are some commonly used antiemetics?

A 
Metoclopramide
Cyclizine
Haloperidol
Ondansetron 
Levomepromazine
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7
Q

What are the symptoms of gastric stasis?

A 
Feeling of epigastric fullness
Early satiety
Large volume vomits
Hiccups
Regurgitation
Nausea quickly relieved by vomiting
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8
Q

What causes gastric stasis?

A

Drug side effects- anticholinergics, opioids
Gastric outflow obstruction- tumour, hepatomegaly, ascites
Gastritis

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9
Q

How should gastric stasis be managed?

A

Reduce intake to little and often
Reduce gastric secretions- PPI or H2 antagonist (Ranitidine)
Prokinetic agent: Dopamine Antagonists e.g. Metoclopramide, Domperidone

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10
Q

What is metoclopramide, how does it work?

A

Metoclopramide is an antiemetic that works as a prokinetic agent.

It is a D2 receptor antagonist and 5-HT4 agonist

Metoclopramide crosses the blood brain barrier so can worsen parkinson’s and cause EPSEs

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11
Q

What is the usual dose of metoclopramide?

A

10mg TDS PO

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12
Q

What are some side effects of metoclopramide?

A

Metoclopramide crosses the blood brain barrier. It can therefore cause EPSEs and worsen parkinson’s disease.

Caution in younger patients as there is a risk of oculogyric crisis.

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13
Q

What is an alternative to metoclopramide that does not cross the blood brain barrier?

A

Domperidone- this should be used in patients with parkinson’s or who develop EPSEs

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14
Q

Why does chemotherapy cause nausea and vomiting?

A

Chemotherapy targets cells with a rapid turnover, such as the GI mucosa. This is reduced when chemotherapy is taken and so there is irritation of the GI tract which causes nausea and vomiting.

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15
Q

What agent should be used to treat chemotherapy related nausea?

A

Ondansetron should be used

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16
Q

How does ondansetron work?

A

Ondansetron is a 5-HT3 antagonist

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17
Q

When should ondansetron be used?

A

Post chemotherapy
Post radiotherapy
Post surgery

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18
Q

What are two side effects of ondansetron?

A

1) Causes constipation- give laxative too

2) QT prolongation

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19
Q

How does cyclizine work?

A

It is a centrally acting anti-muscarinic and antihistamine

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20
Q

When is cyclizine used?

A

It is a good first line antiemetic in hospital

Useful for motion sickness and vomiting secondary to raised ICP

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21
Q

What is the dose of cyclizine?

A

50mg TDS IV/PO/SC

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22
Q

What are some side effects of cyclizine?

A

Antimuscarinic- dry mouth, constipation

Antihistamine- sedation

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23
Q

What condition should cyclizine be avoided in?

A

Heart failure

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24
Q

Why should cyclizine and metoclopramide not be prescribed together?

A

Metoclopramide is a pro-kinetic that treats gastric stasis, due to D2 antagonism.

Cyclizine slows gastric transit due to its antimuscarinic effect.

Therefore block the effects of each other.

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25
What are some metabolic causes of nausea and vomiting?
``` Renal failure- Uraemia Liver failure Hypercalcaemia Hyponatremia Sepsis ```
26
What drugs should be used to treat chemical or metabolic nausea and vomiting, due to stimulation of the CTZ?
Stimulation of the chemoreceptor trigger zone involves D2 receptors and 5HT receptors. Treatment for chemical (drugs) or metabolic nausea and vomiting therefore involves: Haloperidol- D2 antagonist Levomepromazine- Multiple receptors Ondansetron- 5- HT3 Antagonist
27
When should haloperidol be used for N+V?
If it is thought to be due to drugs or metabolic stimulation of the CTZ.
28
How does haloperidol reduce N+V?
Haloperidol is a D2 receptor antagonist. This prevents stimulation of D2 receptors at the CTZ.
29
What is the dose of haloperidol for antiemetic action?
1.5mg-3mg SC/PO
30
What are some side effects of haloperidol?
EPSEs- due to dopamine blockade Sedation QT prolongation
31
When is levomepromazine used?
Used commonly in palliative care, use for drug or metabolic induced nausea These cause stimulation of the CTZ via D2 and 5HT receptors
32
What are some side effects of levomepromazine?
Sedation | Postural hypotension
33
What are some symptoms of raised ICP?
``` Headache Nausea and vomiting Worse when coughing/sneezing or bending forward Worse when lying down Classically a morning headache Papilloedema ```
34
What agent might be used to treat nausea and vomiting due to raised ICP?
Cyclizine- antimuscarinic and antihistamine activity Treat the cause of raised ICP- e.g. high dose steroids if brain mets
35
What antiemetic is recommded for treatment of motion sickness?
Cyclizine
36
Why should metoclopramide not be combined with ondansetron?
Risk of serious cardiac arrhythmia
37
How does metoclopramide work?
D2 antagonists- passes through BBB so can cause EPSEs
38
How does cyclizine work?
Antihistamine and antimuscarinic
39
How does haloperidol work?
D2 antagonism
40
How does ondansetron work?
5-HT3 antagonist
41
How does levomepromazine work?
Lots of receptors are targeted
42
What are some causes of constipation?
Drugs- opiates, ondansetron, anticholinergics, diuretics Diet- low fibre, poor fluid intake Reduced activity- sedentary lifestyle, inability to get to the toilet Electrolyte imbalance- hypercalcaemia, hypokalemia Bowel obstruction- malignancy, strictures, scarring, adhesions Hypothyroidism Neurological conditions- spinal cord compression, GBS
43
What should you ask about in the history for a patient with constipation?
``` When did you last open your bowel? What is normal for you? Are you passing any air? It not this is total obstruction What are their stools like? Hard, softt Recent drug changes? ``` Do a PR.
44
What are some basic rules for managing constipation?
If stool is hard- needs a softener | If stool is soft- needs a stimulant
45
How do stimulant laxatives work?
This increase the amount of peristalsis
46
Give an example of a stimulant laxative
Senna Bisacodyl Danthron- used only in terminal care as carcinogenic
47
What type of laxative should be used in opioid induced constipation?
Stimulant laxative e.g. Senna
48
When are stimulant laxatives contraindicated?
Stimulant laxatives are contraindicated if there is bowel obstruction as they could cause bowel perforation.
49
When should stool softeners be used?
If patients are constipated with hard stools
50
Give an example of a stool softener
Docusate sodium | Osmotic laxatives- Lactulose/ Movicol
51
How do osmotic laxatives work?
They draw fluid into the bowel, patients therefore require a good fluid intake
52
What suppositories may be used to treat constipation?
Bisacodyl- causes anorectal stimulation Glycerol- draws fluid into the rectum to soften and lubricate the stool These are often required by patients on high dose opiates
53
What is likely to cause bowel obstruction in palliative care patients?
GI malignancy causing obstruction External compression with gynaecological malignancy This is called malignant bowel obstruction
54
What indicates true obstruction rather than constipation?
Failure to pass any gas
55
What are the features of bowel obstruction?
Constipation Distension Colicky abdominal pain Failure to pass any gas
56
If the patient does not have colicky pain and bowel sounds are absent what does this suggest?
This suggests that there is a paralytic component- the bowel is not contracting. This is an ileus.
57
How should malignant bowel obstruction be managed?
If possible relieve the obstruction. This is done surgically with tumour resection or bowel stenting. Medical management- Steroids can reduce oedema around tumours and relieve obstruction Reduce colicky pain with opiates and antispasmodics such as buscopan Antiemetics Antimuscarinics to reduce secretions? Keep hydrated
58
How should antiemetics be given in malignant bowel obstruction?
Any medications can no longer be given PO. Syringe driver for continuous subcutaneous infusion. If no colic, paralytic ileus- Prokinetic such as metoclopramide (D2 antagonist) If colic- cyclizine, haloperidol, levomepromazine
59
What agents can be given to reduce secretions in malignant bowel obstruction?
Buscopan is antispasmodic and anti secretory due to its actions on anti-muscarinic receptors. Buscopan is hyoscine butylbromide
60
How does buscopan help in malignant bowel obstruction?
It is antimuscarinic and antispasmodic Therefore reduces secretions and smooth muscle contraction
61
What are some side effects of buscopan?
Dry mouth | Constipation
62
How should buscopan be given for malignant bowel obstruction?
Subcutaneously
63
What is octreotide?
This is another anti-secretory It works quicker than buscopan and is given by syringe driver or BD SC injection It is more expensive than buscopan
64
What is important to consider at the mouth for patients with malignant bowel obstruction?
Patients are prone to developing a dry mouth and this can be very uncomfortable. Ice chips can help with this. Pineapple juice also helps.

SPM- Oncology and Palliative Care (10 decks)

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