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Nausea and Vomiting in Palliative Care

Nausea is an unpleasant feeling of needing to vomit and is often accompanied by autonomic symptoms as pallor and salivation Vomiting is the forceful expulsion of gastric contents through the mouth Regurgitation is the passive expulsion of material from the pharynx or oesophagus through the mouth Retching -is rhythmic , labored , spasmodic movements of the diaphragm and abdominal muscles usually occurring in the presence of N/V and often resulting in vomiting N+V affects up to 70 % of patients with advanced cancer Many involved mechanisms , patterns and treatments More common in certain groups ie < 65 yrs age , females and certain malignancies as gastric and breast cancer

History-When did it start and how ? triggers , volume , pattern any relation to recent treatment ? aggravating & relieving factors ? colour , nature and frequency constipation ? bowel habit medications try and distinguish between vomiting , expectoration and regurgitation

Examination –eye ? jaundice oral cavity ? candida fundi ? papilloedema abdomen bowel sounds hepatomegaly rectal examination – if constipation / obstruction is suspected signs of dehydration , sepsis , toxicity pulse , temp , respiration

Causes –drugs biochemical constipation radiotherapy liver failure gastric stasis bowel obstruction raised ICP cerebellar metastases anxiety , fear conditioned check biochemical profile

Non-pharmacological measures –Good oral hygiene- regular mouth care Regular bowel habit Small portions of food -regular and palatable A calm and reassuring environment Accupressure bands ( Seabands ) ginger Avoid food preparation and cooking smells Psychological approach TENS Nurse in upright position

Chemical / Metabolic -Drugs ( eg opiates , diuretics NSAIDs or antibiotics ) Tumour toxins Renal failure Hypercalcaemia ( Admit of Calcium > 2.8 mmol/L )-Often severe persistent nausea- little relief from vomiting/ retching, Haloperidol ( first ) Levopromazine 
( can cause sedation above 6.25 mg bd) Ondansetron 3rd line.
Haloperidol Pure dopamine D2 antagonist ( centrally acting ) Useful with cyclizine in bowel obstruction Often used for opioid induced nausea may cause extrapyramidal SEs ( also restlessness and inability to keep still ) PO eg 1.5 mg BD or 3 mg nocte SC 1.2- 5mg 4 Hrly PRN Syringe driver 2.5 to 10 mg / 24 hrs Start with a lower dose in renal failure and elderly frail patients )
Procyclidine – antimuscarinic can be used to counter SEs

Motility disorders –
Haloperidol Pure dopamine D2 antagonist ( centrally acting ) Useful with cyclizine in bowel obstruction Often used for opioid induced nausea may cause extrapyramidal SEs ( also restlessness and inability to keep still ) PO eg 1.5 mg BD or 3 mg nocte SC 1.2- 5mg 4 Hrly PRN Syringe driver 2.5 to 10 mg / 24 hrs Start with a lower dose in renal failure and elderly frail patients )
Procyclidine – antimuscarinic can be used to counter SEs.

Gastric stasis- large vol vomitus , infrequent vomiting , relief of symptoms after vomiting , oesophageal reflux , epigastric fullness , early satiation , hiccups.Gastric stasis ( metaclopramide ) Gastric outlet obstruction-symptoms similar to gastric stasis but also forceful vomiting and rapid dehydration.Metoclopramide Domperidone ( If extrapyramide SEs a problem) Dexamethasone.
Metoclopramide Dopamine D2 antagonist and prokinetic Extrapyramidal SEs reversible with procyclidine Avoid – GI Perf , complete obstruction , GI haemorrhage or after GI surgery , Parkinson’s dis PO 10-20 mg qds SC 10-20 mg qds Syringe driver 30-120 mg/ 24 hrs Usually not combined with cyclizine 
( anticholinergic’s block prokinetic action ) or Hyoscine

Radiotherapy/ chemotherapy related –Radiotherapy
 Ondanseteron 8 mg stat then 8mg bd up to 5 days Haloperidol 1.5 to 3 mg nocte// bd.Dexamethasone 1 mg = 7 mg Prednisolone Corticosteroid Reduces intracerebral swelling – other mechanisms uncertain Standard in chemotherapy induced N&V Consider PPI prophylaxis (risk peptic ulceration ) Best given in morning Often used for N/V of unknown mechanism @ 4mg/ day

Bowel obstruction –Abdominal carcinomatosis Autonomic neuropathy Severe constipation ↑ likely with Ca of ovary or bowel.May be high low or multiple levels Partial intermittent intially Nausea often improved after vomiting Nausea ↑↑ , colic +/- , faeculent vomiting in advanced complete obstruction Abdominal distension.Stop any drug contributing to ↓ peristalsis ( eg Cyclizine , Tricyclic anti depressants or Opioids ) Meoclopramide if no colic via infusion If colic develops- stop Metoclopramide and treat as bowel obstruction.Cyclizine 150 mg / 24 hr Hyoscine butylbromide 
( if colic ) 40-100 mg/ 24 hr sc Levomepromazine 6.25 to 25 mg / 24 hr s/c Cyclizine + Haloperidol (combination ) Ondansetron 8-24 mg/ 24 hr po /IV/SC Octreotide ( faster acting and higher efficacy than anticholinergics ) Dexamethasone → bowel wall oedema reduction (8-16 mg sc )

Cranial –↑ ICP Brainstem / meningeal disease Bleed Infarction Meningeal infiltration Radiotherapy.Cyclizine Dexamethasone 8-16 mg/ day for 7 days
▬ If has been given for longer than 5 days or risk of recurrent symptoms or repeated courses have been given -reduce by 2 mg daily every 5-7 days
▬ Stop if no benefit after 3-7 days

movement related –Vestibular disease Base of skull tumour Motion sickness.Cyclizine Levomepromazine Prochlorperazine or Hyoscine hydrobromide.Domperidone Similar to metoclopramide Does not cross blood brain barrier
( less extrapyamidal SEs ) Beware intestinal obstruction as may cause colic pain Safe in Parkinson’s dis.

LINKS AND RESOURCES

FOR CLINICIANS

Marie Curie Org on nausea and vomiting in palliative care https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/symptom-control/nausea-vomiting#useful-resources

An invaluable resource for dosing and any medication, syringe driver related questions https://book.pallcare.info/

Scottish Palliative Care Guideline https://www.palliativecareguidelines.scot.nhs.uk/

 

 

References

  1. CKS NHS http://cks.nice.org.uk/palliative-care-nausea-and-vomiting#!scenario
  2. Nausea and vomiting in palliative care Emily Collins BMJ 2015;351:h6249
  3. Palliative Care Adult Network Guidelines – http://book.pallcare.info/
  4. North of England Cancer Network Palliative Care guideline assessed via http://www.twca.org.uk/documents/Generic%20Documents/End%20of%20Life/
NECNPalliativeCareGuidelinesBooklet2009[1].pdf
  5. Scottish Palliative Care Guidelines via https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/bowel-obstruction.aspx

 

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