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Cancer Care > Palliative Care: Nausea And Vomiting > Flashcards

Palliative Care: Nausea And Vomiting Flashcards

1
Q

N&V is the …..most troublesome symptom for cancer patients

A

Second

Occurs in up to 70% with advanced disease

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2
Q

What percentage does it affect with non malignant end stage disease?

A

Up to 50%

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3
Q

Is it true that vomiting even daily, without nausea is usually better tolerated?

A

Yes

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4
Q

Nausea and vomiting in palliative care is often multi-factorial, but which are most common?

A

Gastric stasis

Chemical disturbance

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5
Q

What causes are there?

A 
Infection 
Metabolic
Gastric stasis 
GI disturbance
Neurological 
Psychological 
Drug related 
Organ damage
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6
Q

What infections can cause N&V?

A 
Gastroenteritis 
Thrush
Pneumonia
UTI
Viral labyrinthitis
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7
Q

What metabolic disturbances can cause N&V?

A 
Renal impairment 
Hepatic impairment
Hyponatraemia 
Hypercalcaemia 
Sepsis
Hyperglycaemia
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8
Q

What drugs can cause nausea and vomiting?

A 
Opioids
Chemotherapy 
RT
Antibiotics
NSAIDS
Diuretics 
Digoxin 
SSRIs
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9
Q

What can cause gastric stasis?

A 
Pyloric tumour/nodes
Ascites
Hepatomegaly 
Opioids
Anticholinergics
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10
Q

What GI disturbances can cause N&V?

A

Constipation
Gastritis
Ulceration
Obstruction

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11
Q

What neurological factors can cause N&V?

A

Raised ICP (usually in context of cerebral mets)
Motion sickness
Meningeal disease
Vestibular - related to activation of acetylcholine and histamine (H1) receptors

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12
Q

What psychological factors can cause N&V?

A

Anxiety
Fear
Pain
Anticipatory nausea

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13
Q

What percentage will have more than 1 cause ?

A

25%

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14
Q

How is choice of anti emetic decided upon?

A

The probable cause and the mechanism by which the drug acts

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15
Q

What neurotransmitters are implicated in the control of nausea and vomiting?

A 
Acetylcholine (AChm receptor)
Dopamine (D2 receptor)
Histamine (H1 receptor)
Substance P (NK-1 receptor)
Serotonin (5HT3 or 2 receptors)
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16
Q

What can vomiting also be referred to as?

A

Emesis

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17
Q

What symptoms are associated with emesis?

A 
Profuse salivation
Sweating
Tachycardia 
Pallor 
Nausea 
Retching movements
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18
Q

How are the contents of the stomach expelled?

A

The stomach, oesophagus and their sphincters are relaxed during vomiting. Most of the expulsion force arises from the contraction of the diaphragm and the abdominal muscles .

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19
Q

Where is the chemoreceptor trigger zone located in the brain?

A

Medulla - specifically the area postrema (on the floor of the fourth ventricle)

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20
Q

Is the CTZ in or outside the BBB?

A

Outside - so emetic toxins in blood can reach it

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21
Q

What is the role of the chemoreceptor trigger zone?

A

Respond to various stimuli - toxins and drugs in the blood

Communicate with the vomiting centre, which initiates emesis

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22
Q

Where is the vomiting centre found?

A

Within medulla (has a BBB)

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23
Q

Which cancer chemotherapy agents are highly emetic?

A

Cisplatin
Cyclophosphamide
Adriamycin

24
Q

What receptors are located at the CTZ?

25
What receptors are located at the vomiting centre?
AChm H1 5HT2 NK1 Also mu receptors
26
How does CNVIII interact?
It has AChm and H1 receptors | Communicates with CTZ and vomiting centre
27
How does Haloperidol work?
A potent D2 antagonist | Widely used in context of chemical causes of nausea and vomiting
28
What are the features of chemical associate nausea and vomiting?
Persistent, often severe nausea Unrelieved by vomiting Aggravated by sight/smell of food, drowsiness/ confusion
29
What anti emetics are best for chemical causes?
Haloperidol Metoclopramide Ondansetron
30
Metaclopramide acts on what receptors?
D2 and 5HT3 Helps in those with delayed stomach emptying and GORD
31
What anti emetics are best for gastric stasis?
Pro kinetics - they are often D2 antagonists E.g metaclopramide or domperidone
32
Domperidone acts at what receptor ?
D2
33
What are the features of gastric status nausea and vomiting?
``` Fullness and regurgitation Reduced appetite Vomiting large volumes relives nausea Epigastric discomfort Hiccups ```
34
How does cyclizine work?
H1 antagonist | ACh antagonist
35
What antiemetics are good for bowel obstruction?
Cyclizine - slows peristalsis | Dexamethasone - reduces oedema
36
What does NICE suggest to use for raised intracranial pressure induced N&V?
Cyclizine Dexamethasone also used
37
What features are associated with raised ICP associated N&V?
Nausea worse in morning Projectile vomiting Worse on head movement Headache
38
What anti emetic is best for vestibular causes?
Cyclizine Refractory cases: prochlorperazine
39
What can be used if anticipatory nausea is the clear cause?
Short acting benzodiazepine e.g lorazepam If benzodiazepines not ideal - cyclizine
40
What is Aprepitant?
An anti emetic that works by blocking substance P from acting at NK1 receptors Acts mainly centrally
41
What is aprepitant used for?
Emetogenic chemotherapy
42
What is frequently cited as the most distressing side effects of chemotherapy?
Nausea and vomiting
43
CINV has increased risk associated with what?
Specific chemo agents Female gender Age less than 50 Past history of nausea and vomiting - pregnancy, motion sickness, prior chemotherapy use
44
What types of CINV are there?
Acute Delayed Anticipatory
45
What side effects of aprepitant are there?
Constipation | Headache
46
CINV consists of an acute and delayed phase. Acute phases emesis responds well to ...
5HT3 antagonists e.g ondansetron Delayed phase remains difficult to control (but the discovery of NK1 antagonists helped as they elicit anti emetic effects in acute and delayed)
47
When is ondansetron used?
Chemotherapy, radiotherapy or surgery No effect on vomiting caused by motion sickness Only 5HT3 effect
48
How does hyoscine work?
Anticholinergic | Very sedating
49
When is hyoscine used?
Motion sickness Post op nausea and vomiting May be used pre surgery to reduce saliva Bowel obstruction
50
Control of symptoms using one anti emetic is possible in what percentage of patients?
60% 1/3 required second antiemetic - combine antiemetics with different mechanisms of action
51
What route is generally preferred?
Oral absorption likely to be poor, so consider SC for at least 24 hours Switch to oral if improving
52
What non pharmacological measures can be tried?
Smells that patient likes Small, appropriate meals Acupuncture ?
53
What is levomepromazine typically used for?
Low potency antipsychotic Analgesic, antiemetic and hypnotic properties Primarily used in palliative care “Dirty drug” - blocks a variety of receptors: D2, 5HT2, H1, ACH
54
Why is dexamethasone useful?
Reduces permeability of BBB to emetogenic substances | Improves effects of other anti emetics including NK1 antagonists, 5HT3 and metaclopramide
55
Why are seratonin antagonists useful in CINV?
Following chemotherapy there is a huge release of serotonin from enterochromaffin cells in bowel wall
56
What would be the first choice in pregnancy associated nausea and vomiting?
Cyclizine - greater experience with them and not thought to be teratogenic
57
What are the side effects of cyclizine?
Sedation | Dry mouth, blurry vision, urinary retention

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