Nausea and Vomiting

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Nausea and Vomiting

• Jo Lenton
• Clare FryerCommunity Specialist Palliative Care
  Nurses

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End of Life Scenario

• 60 year old lady diagnosed with lung cancer 6
  months ago. PMH of ischaemic heart disease.
• Lives with husband.
• Previous radiotherapy, no further treatment
  planned. For palliative care and symptom
  management.
• Back and shoulder pain have been managed fairly
  well on current medication.

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Scenario cont

• Over the past few days her general condition has
  started to deteriorate.
• In the last 24 hours condition has deteriorated
  further with escalating pain across her back and
  shoulder and increased dyspnoea and nausea.
• She is starting to have difficulty swallowing
  medication. Taking no diet and very little fluid.
• How would you manage her symptom control?

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Current medication

• Fentanyl 75mcg/hr patch
• Oramorph 30-40mg prn
• Pregabalin 200mg bd
• Metoclopramide 10mg tds
• Lorazepam SL 0.5mg prn
• Furosemide 40mg daily
• Omeprazole 20mg daily
• Bisoprolol 2.5mg daily
• Sol. Aspirin 75mg daily

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First steps to manage nausea and vomiting

• What is the cause?
• Medical treatment
• 1st line
• Other options
• Non-medical treatment

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Definitions

• Nausea an unpleasant feeling of the need to
  vomit, often accompanied by autonomic symptoms
  (cold sweat, salivation, tachycardia etc)
• Vomiting the forceful expulsion of gastric
  contents through the mouth

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Scale of the problem

• Occurs in 40-70 patients with advanced cancer
• 1/3 will have more than 1 contributing factor
• 1/3 will need more than 1 anti-emetic

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Mechanism of Nausea and Vomiting

• vomiting centre in reticular formation of medulla
• activated by stimuli from
• Chemoreceptor Trigger Zone (CTZ)
• area postrema, floor of the fourth ventricle
• outside blood-brain barrier (fenestrated venules)
• Upper GI tract pharynx
• Vestibular apparatus
• Higher cortical centres

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Cortex
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Stimuli Of Vomiting Pathways
Chemoreceptor Trigger Zone Vestibular Cortical Peripheral
drugs opioids chemoTx etc... biochemical Ca renal failure liver failure sepsis radiotherapy tumor opioids anxiety association ICP radiotherapy chemotherapy GI irritation inflammation obstruction paresis compression
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Assessment of Potential Causes In Scenario

• Assess and treat the cause, if possible and
  appropriate whilst respecting the patients wishes
• Biochemical - Hypercalcaemia, uraemia,
  dehydration
• Raised intracranial pressure - Possible cerebral
  secondaries
• Fear and Anxiety - fear of dying, breathlessness

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Assessment of Potential Causes In Scenario

• Drug Induced - Opioids
• Gastric Stasis Constipation, ascites - due to
  potential liver metastasis
• MDT decision taken that this lady is dying, no
  reversible causes appropriate to treat, place on
  EOL Pathway

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Non-medical treatment

• Calm environment good ventilation
• Frequent small snacks
• Avoid sight smell of food eg cooking

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Algorithm Sheffield EOL Pathway
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If at first you dont succeed

• Review regularly and alter according to
  effect/side effects
• ENSURE DELIVERY po/sc/csci/pr
• Consider adding a second agent
• Different mechanisms of action
• Consider levomepromazine
• broad spectrum antiemetic
• 6.25-12mg (1/4 -1/2 tablet) po
• or 6.25 mg-25 mg sc/sc infusion over 24hrs
• Beware of sedative effect/ Seek Specialist advice
• Dont forget the effect of anxiety pain

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Gastric stasis - causes

• Drugs
• Opioids
• Squashed stomach syndrome
• tumour, enlarged liver, ascites
• Outflow obstruction
• tumour

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Gastric stasis - symptoms

• Epigastric discomfort
• Fullness
• Early satiety
• Exacerbated by eating / relieved by vomiting
• Large volume vomits (undigested food)
• If Bowel Obstruction suspected seek specialist
  advice

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Gastric stasis Drug Management
Cause Drug Dose Comments
Gastric Stasis Ascites GI Tract infiltration 1) Metoclopramide 10-20mg po three times a day or 40-80mg sc infusion/24 hours Parkinsonian side-effects Abdominal cramps may occur
Gastric Stasis Ascites GI Tract infiltration 2) Domperidone 10mg po/30mg PR three times a day Abdominal cramps may occur
Gastric Stasis Ascites GI Tract infiltration 3) Levomepromazine 6.25-12.5mg po at night 6.25-12.5mg sc infusion/24 hours May cause drowsiness, hypotension Parkinsonian side-effects
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Chemically- induced nausea - causes

• Drugs (10-30 on initiation of opioid)
• antibiotics, anticonvulsants, antidepressants,
  cytotoxics, steroids, digoxin, NSAIDs
• Metabolic
• renal or hepatic failure, hypercalcaemia,
  hyponatraemia, ketoacidosis
• Toxins
• ischaemic/obstructed bowel, tumour effect,
  infection

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Chemically- induced nausea - symptoms

• Constant nausea
• Vomiting is variable in volume timing
• May be other features of drug toxicity

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Chemically induced nausea Drug Management
Cause Drug Dose Comments
Biochemical/drug e.g. Hypercalcaemia, uraemia, opioids 1) Haloperidol 0.5-5mg po/sc at night 5-10mg sc infusion/24 hours Sedative and anxiolytic Parkinsonian side-effects
Biochemical/drug e.g. Hypercalcaemia, uraemia, opioids 2) Metoclopramide 10-20mg po three times a day/ 40-80mg sc infusion/24 hours Abdominal cramps may occur Parkinsonian side-effects
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Raised intracranial pressure causes

• Intracranial tumour
• Cerebral oedema
• Intracranial bleed
• Meningeal infiltration by tumour
• Skull metastases
• Cerebral infection

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Raised intracranial pressure symptoms

• Nausea worse in the morning
• Headache
• Nausea and/or vomiting provoked by head movement

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Raised intracranial pressure Drug Management
Cause Drug Dose Comments
Raised intracranial pressure 1) Dexamethasone 4-16mg taken once a day or in two divided doses, morning and lunchtime Dry mouth, blurred vision, sedation, confusion, constipation
Raised intracranial pressure 2) Cyclizine? 25-50mg po three times a day or 50-150mg sc infusion/24 hours
Raised intracranial pressure 3) Prochlorperazine 5-10mg po/12.5mg im three times a day Parkinsonian side-effects, may cause drowsiness
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Fear and Anxiety Drug Management
Cause Drug Dose Comments
Fear and Anxiety 1) Haloperidol 0.5-5mg po/sc at night 5-10mg sc infusion/24 hours Sedative and anxiolytic Parkinsonian side-effects
Fear and Anxiety 2) Lorazepam? 0.5-1mg po prn May cause drowsiness
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Symptoms Of Bowel Obstruction

• Colicky abdominal pain
• Nausea and vomiting
• Constipation
• Distended abdomen

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Management Of Bowel Obstruction

• Establish if bowels sounds are present
• If colicky pain present stop prokinetic ie
  metroclopramide and replace with Hyoscine
  Hydrobromide and Haloperidol
• If no pain manage with prokinetic
• Alterative route for administration needs to be
  considered, possible sub-cutaneous and rectal.

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Bowel Obstruction
According to response Treatment
If no colicky pain Trial of prokinetic agent Metoclopramide 30-80mg by sc infusion over 24hours
If colicky pain Stop prokinetic agents. Start Hyoscine butylbromide? 30mg Haloperidol 5mg /- Diamorphine? for pain by sc infusion over 24hours
Review the patient within 24 hours Optimize the dose of Hyoscine butylbromide? (for colicky pain up to120 mg/24 hours) and Haloperidol (for nausea up to 10mg/24hours) by sc infusion over 24hours
Review the patient within 24 hours. Consider substituting Cyclizine? 150mg by sc infusion over 24hours for haloperidol (note compatibilities in syringe driver)
If patient still vomiting at next review Consider change of hyoscine butylbromide to Octreotide?? 600mcg by sc infusion over 24hours
If patient still vomiting Increase Octreotide?? by increments of 300mcg per 24 hours to a maximum of 1200mcg/24 hours.
If nausea still a problem Change cyclizine to Levomepromazine? 6.25 mg sc infusion over 24hours. This may be increased as tolerated (may cause drowsiness and hypotension)
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References

• http//www.sheffield.nhs.uk/palliativecare/resourc
  es/palliativecareformulary.pdf
• http//www.sheffield.nhs.uk/palliativecare/resourc
  es/communityeolcpathway.pdf
• http//www.sheffield.nhs.uk/palliativecare/resourc
  es/eolcp_hospital.pdf