Palliative Care Flashcards
how many patients with any type of cancer get nausea and/or vomiting
70%
what is nausea
unpleasant feeling of the need to be sick, often with autonomic features (hot, skin stands on ends, sweaty, salivation)
what extra questions should you ask in a history of nausea and vomiting
triggers, volume, pattern
exacerbating and relieving factors, including individual and combinations of drugs tried and routes used
bowel habit
medication – consider drugs that may:
contribute to the nausea and vomiting
cause harm
not take effect due to the nausea and vomiting
exclude regurgitation as this will require a different approach. If suspected consider seeking advice
check for other concurrent symptoms.
what should you look for on exam in a patient with nausea and vomiting
general review for signs of dehydration, sepsis and drug toxicity
central nervous system
abdomen (for example organomegaly, bowel sounds, succussion splash)
check temperature, pulse and respiration
what causes of N&V affect the cerebral cortex
emotions, sight, smell, raised ICP, anxiety
what part of brain controls vomiting
vomiting center
what receptors for N&V are in the cerebral cortex and what anti emetic drugs target them
GABA, NK1, 5HT
Dexamethasone, Aprepitant, Benzodiazepines
what receptors for N&V are in the vestibular centre and what anti emetic drugs target them
H1, ACh
Cyclizine, Levomepromazine, Hyoscine
what stimulus affects the vestibular centre causing N&V
motion
what receptors for N&V are in the chemoreceptor trigger zone and what anti emetic drugs target them
D2, 5HT, Ach
Haloperidol, Levomepromazine, Ondansetron
what things can trigger the chemoreceptor trigger zone causing N&V
metabolic (uraemia, Ca), drugs
what receptors for N&V are in the GI tract and what anti emetic drugs target them
5HT, D2, Ach
Metoclopramide, Levomepromazine, Ondansetron, Dexamethasone
(Caution in obstruction- prokinetic drugs can cause perforation)
what can trigger the receptors in the GI tract causing N&V
GI distension, stasis, tumour mass, constipation, XRT
how does cerebral disease cause N&V and how does it present
Compression / irritation by tumour, raised ICP, anxiety
Clinical picture:
Worse in morning
Associated headache
how does N&V caused by oncological (chemo/radio) treatments present
Predictable from history
Often nausea is the main complaint
what can cause impaired gastric emptying
Locally advanced cancer, drugs, radiotherapy damage to gut, autonomic neuropathy
what is the clinical picture of N&V caused by impaired gastric emptying
Not usually nauseated
very nauseated after eating
Large volume vomits
Feels better after being sick
what can cause chemical/ metabolic N&V
Medication, advanced cancer, sepsis, kidney or liver impairment, biochemical
Think: Calcium, Sodium, Magnesium, Urea
what is the chemical picture of N&V caused by chemical/ metabolic
persistent nausea
little relief from vomiting
what is the non pharmacological management of N&V
Regular mouth care
Keep bowels moving to avoid constipation contributing
Encouraging small meals, rather than large meals
Avoid cooking or preparing food
A calm and reassuring environment
Acupressure bands (for example Seaband®)
Acupuncture
Psychological approaches
what is anticipatory nausea
when being anxious about being sick makes you feel/ be sick
what is seen on X ray in small bowel obstruction
vulvulae coniventes
what is malignant bowel obstruction
bowel obstruction in the context of intra-abdominal cancer/ non intra-abdo cancer with clear intraperitoneal disease
Obstruction may still be due to benign causes in advanced cancer
Eg; Adhesions, post-radiotherapy (up to 50% in colorectal ca)
Also constipation may contributory factor
what are the causes of malignant bowel obstruction
mechanical:
-intraluminal
-intramural
-extra mural extrinsic compression
(Omental deposits, peritoneal deposits, nodal deposits)
adynamic ileus:
-tumour infiltration of mesentery, muscle or nerves
what is the difference between complete and partial (subacute) bowel obstruction
Complete- nothing can get past, completely occluded
Partial- some passage through bowel but bowel not working properly so have majority of symptoms of complete
what cycle occurs in bowel obstruction
secretion- distention- secretion:
Proximal accumulation of secretions Distension of gut Further secretions Reduced absorption of water and sodium Inflammatory response - gut wall oedema Increased motor activity Increased intra-luminal pressure – hypoxia, gangrene and perforation
what causes colic pain in obstruction
increased peristalsis of bowel
what is the clinical presentation of bowel obstruction
Nausea Vomiting Pain Continuous or Colicy Anorexia/thirst Systemic symptoms from underlying cancer Reduced then absent bowel motions/flatus Paradoxical diarrhoea Gradual onset over weeks
what is the surgical management for bowel obstruction
‘Drip and suck’ before surgery (NG tube brings up all of fluid and given IV fluids)
Bowel rest
NBM (nil by mouth)
Not comfortable, tube is very large
Surgical treatment
Resection
Palliative colostomy or ileostomy
Self expanding metallic stent
when palliative consider QOL
what is the medical management for bowel obstruction
If partial obstruction promote resolution: antiemetic and prokinetic agents= metoclopramide
Laxatives - Docusate or movicol to soften stool in partial obstruction
Relieve pain and colic:
Opioids (will cause constipation)
Hyoscine butylbromide for colicky pain (will slow down the bowel)
Reduce vomiting to acceptable level for patient without use of NG tube:
Metoclopramide 30mg / 24 hours if not contra-indicated and partial/subacute obstruction
Relieve nausea
Relieve thirst
Fluids (will loose lots of GI fluids, not drinking as much)
Steroids (to reduce inflammation, especially If you have nodal disease)
Dexamethasone – 8-16mg / 24hours
Anti-secretory agents
Buscopan (Hyoscine butylbromide) – slows bowel down
Octreotide - 300-900 mcg/24 hours in CSCI (somatostatin analogue, potent secretion reducer)
is metoclopromide an antiemetic or an prokinetic
both
should you give metoclopramide if a patient already has colic pain
no- risk perforation
should patient who are vomiting be given oral medications
no
will not be absorbed
what is a common reversible cause of bowel obstruction
constipation
how do you pick which antiemetic to use
use history and exam to find cause of nausea and vomiting- pick drug that will target to right receptor
