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Therapeutics > Ex: 6 - Nausea/Vomiting (68) > Flashcards

Ex: 6 - Nausea/Vomiting (68) Flashcards

1
Q

Nausea

A

Sickness at the stomach; an inclination to vomit

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2
Q

Vomiting

A

The ejection of matter forcibly from the stomach through the esophagus and mouth

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3
Q

Retching (arcadas)

A

Making movements of vomiting w/o effect

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4
Q

What are other symptoms associated with nausea and vomiting

A

Pallor
Tachycardia
Diaphoresis

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5
Q

Etiology of nausea and vomiting: GI disorders

A

Influenza
-Intestinal pathogen
-food poisoning
Ulcers; GERD
Pancreatitis
Cholecystitis
Obstruction
Tumors
DM gasteoparesis

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6
Q

Etiology of nausea and vomiting: CNS disorders

A

Anxiety tumors HA

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7
Q

Etiology of nausea and vomiting: Pain

A

Acute or chronic

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8
Q

Etiology of nausea and vomiting: Excessive intake of just about anything… pregnancy

A

Intake:
Man vs Food
Alcohol

Pregnancy
-80% of pregnant women

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8
Q

Treatment-induced causes of nausea and vomiting

A

Cancer chemotherapy
-Varies with agent and dose
Radiation therapy
-CNS and abdominal
Anesthesia (~30%)
-Varies greatly with type

NV associated w/procedures
-Especially abdominal

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9
Q

Drug-induced causes of NC cont: Anti-neoplastic agents

A

Opioids
Aspirin, NSAIDs, etc
Iron
Some antibiotics
-Tetracycline; erythromycin
Estrogens
-High doses
Anti-parkinson meds
SSRIs

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10
Q

Complications of NV

A

Patient discomfort
Dehydration (K+, Na+, Cl-)
Malnutrition
Aspiration Pneumonia
Anxiety; anticipatory NV
Compromise therapy
Decreased QOL

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11
Q

Assessment of NV

A

Number of episodes
Onset
Duration of symptoms
Evidence of dehydration
Severity of nausea
-Visual analog scale
0-10

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12
Q

Questions to ask patients:

A

How long have you had NV?
What color
How often
Is the vomiting related to eating?
-If so, what foods/ and how soon after eating
-Do you have nausea w/o vomiting?

Is the NV associated with…
-Abdominal pain
-Constipation
-Diarrhea
-A loss of appetite
-A change in color of your stool
-A change in color of your urine
-Fever
-Chest pain
-HA
-Hearing loss

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13
Q

Pathophysiology of NV

A

Cortex
-Sensory input
-Anxiety and memory
-Meningeal irritation
-Increased ICP

CTZ
-Drugs, metabolic
Dorsal vagal complex
Multiple receptors

GI
-Serotonin release from mucosal enterochromaffin cells
-obstruction
-stasis
-inflammation

Vestibular
-Motion
-CNS lesions
-Opioids
-aggravates most nausea

when we have agents that impact receptors at multiple places, tend to be more efficacious

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14
Q

Patho of NV cont: Site of drug action

A

Dopamine receptors [D2]
Histamine receptors [H1 and H2]
Muscarinic - cholinergic receptors [M1]
Serotonin receptors [5-HT3]
Neurokinin receptors [NK-1]

Often use antihistamines/antimuscarinics to treat NV

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15
Q

Non-pcol management of NV

A

First steps
-Determine the cause
-Put the gut to rest
-clear liquid diet
-IV hydration

Dietary
-Avoid fatty, fried, sweet and spicy foods
-eat food that is cold or at room temp

16
Q

Non-pharmacologic therapy

A

Physical
-Avoid unpleasant sights, sounds, and odors that may aggravate NV
-Fresh air
-Avoid sudden movements
-Dim lights
-acupressure
-3 fingers above the wrist
-Pregnancy
-Chemotherapy

17
Q

Nerve stimulation therapy

A

ReliefBand
-helps the stomach return to a normal rhythm of 3 cycles/min
-Adjustable settings on 2 day and 5 day devices

18
Q

Drug therapy: Antihistamines - Anticholinergics

A

Meclizine; Dimenhydramine; Scopolamine
MOA:
-Block histamine and or muscarinic receptors in the CTZ and NTS centers
-Interrupt visceral afferent pathways
Side effects: drowsiness, sedation, dry mouth, constipation, blurred vision

Overall, role is limited for moderate to severe NV

19
Q

Drug therapy - Phenothiazines

A

-Prochlorperazine
-Promethazine
-Chlorpromazine

MOA
-Dopamine inhibition at CTZ
-Comparison of phenothiazines
-Std of care prior to 5-HT3 antagonists

SE
-Dizziness, sedation, dry mouth, hypotension, EPS (abnormal movements that occur when dopamine receptors stimulated)

20
Q

Drug therapy - Serotonin Antagonists

A

Ondansetron
Granisetron
Palonosetron
Dolasetron

MOA
-Serotonin inhibition at CTZ, VC, and GI tract

Side effects:
-Mild HA; Dizziness; fatigue; constipation
-Recent concern about QT prolongation

21
Q

Advantages/Disadvantages of various Serotonin antagonists

A

Ondansetron
-Multiple dosage forms; including ODT
-Generic/lower cost <$10 tx course

Granisteron
-Multiple dosage forms: patch; LA injection
-Generic/lower cost <$10 tx course

Dolasetron
-PO only
-$$$

Palonsetron
-Longest DOA - t 1/2 = 40hrs
Brand only, $$$
No PO dosage form

No suppository dosage forms

22
Q

Drug therapt: Neuokinin-1 antagonists

A

Will not see as much, primarily used for chemotherapy induced NV (CINV)

Aprepitant; Fosaprepitant; Rolapitant

MOA
-Neurokinin receptor inhibition at CTZ, VC, and GI tract

Side effects
-Fatigue; hiccups; constipation; decreased appetite

23
Q

Drug therapy - others

A

Butyrophenones:
Haloperidol; Droperidol
MOA: Dopamine inhibition at CTZ
Black box Warning: risk of EKG abnormalities - Rarely used

Metoclopramide
-MOA: Dopamine inhibition at CTZ
-Serotonin inhibition at CTZ, VC and Gi tract (high dose)
EPS at high dose (Give with benadryl)

Corticosteroids (Dexamethasone)
MOA: inhibition of cortical input into vomiting center?
Enhances the efficacy of any other antiemetics

Cannabinoids
-MOA: Binds with cannabinoid or CB1 receptors in the brain
Side effects: sedation, dry mouth, euphoria, dysphoria; facial flushing, visual changes

24
Q

Importance of Route of Admin in the Tx of NV

A

Route of admin:
-Po tablet
-ODT tablet
-PR
-IV
-IM

25
Q

Tx of motion sickness

A

Very common
-1/3 of population very susceptible
1/3 susceptible with rough conditions
1/3 susceptible with extreme conditions
-Peak age 12-21 years
Prevention

26
Q

Treatment of Motion sickness:

A

Scopolamine (Transderm-Scop)
-Apply patch before needed
-Duration = 72 hours

Dimenhydrinate 50mg
-Dramamine
-Oral (30-60 min before needed)

Meclizine 25 mg
-Bonine; Dramamine less drowsy
-zentrip
-Oral (30-60 min before needed)

27
Q

Tx of NV secondary gastroenteritis or pain

A

VERY COMMON
-Treat symptoms while treating the Cause
-Ondansetron 4-8mg IV/ODT/PO q8-12 hours prn
-Promethazine 12.5 -25mg IV/IM/PO q4-6 hrs prn

28
Q

Post Operative NV

A

Very common with older inhaled agents
-Patients with multiple risk factors are at highest risk for PONV
Most common complication associated w/ambulatory surgery (30-50%)
Prevention

29
Q

Risk factors for PONV

A

Patient-specific factors
-F > M
-Non-smoking status
-HX of PONV
-hx of motion sickness

Anesthetic risk factors
-Intra-operative use of volatile anesthetics
-less with propofol
-Use of nitrous oxide
-Type of surgery
-Laparoscopy
-Craniotomy
-ENT

30
Q

Tx of PONV chart

A

Risk:
Low
-1-2 risk factors
Prophylaxis:
-No tx necessary

Risk: Moderate to high
2+ risk factors
Prophylaxis:
-Tx with 1 or 2 agents
-Only1 agent if propofol is used
-5-HT3 antagonists are DOC
-All classes can be used
Drugs administered at end of procedure

Risk: Highest
-3 or more esp. if prior hx of PONV
-Always use 2 agents
-5-HT3 + metoclopramide or aprepitant

Risk: Breakthrough
Prophylaxis:
-Use an agent from a different class if within 6 hours of original dose
-Amisulpride (Barhemsys)

31
Q

Treatment of PONV

A

Aprepitant (Emend)
-40 mg orally 1 to 3 hours prior to induction of anesthesia
-May be superior to ondansetron 4mg at both 24 and 48 hrs post-op
-Data in trials was not statistically significant

Amisulpride (Barhemysys)
-5-10 mg IV infused over 1-2 minutes
-Selective dopamine-2 and dopamine -3 antagonist
-Not indicated for prophylaxis

-has been associated with QT prolongation

32
Q

Monitoring antiemtic therapy

A

Efficacy
-Volume
-Frequency and duration
-Nausea rating
-Ability to eat
-PRN doses of anti-emetic agents
-QOL ratings

Toxicity
-Sedation/drowsiness
-Dizziness
-Diarrhea
-HA
-Anticholinergic SE
-EPS

Therapeutics (49 decks)

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