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RC Study > Nausea and Vomiting > Flashcards

Nausea and Vomiting Flashcards

1
Q

Causes of nausea and vomiting

A
  • Pharyngeal irrtatation
    • oral/esophageal candidiasis
    • tenacious sputum
  • Gastric irritation
    • PUD
    • Gastritis
  • Gastric stasis
    • OPioids
    • ACH
    • hepatomegaly
    • gastric outlet obstruction
    • autonomic dysfunction (anorexia-cachexia)
  • Stretching of GI tract
    • constipation
    • MBO
    • mesenteric metastases
  • Infection
    • bacterial, viral, fungal infxn in AIDS/HIV
  • Medications
    • opioids (30% of patients)
    • cytotoxic drugs
    • SSRI
    • antivirals
    • antibiotics
    • any drug
  • Metabolic causes
    • hyerpcalcemia
    • renal failure
    • liver failure
    • DM
  • Raised intracranial pressure
    • primary tumour/mets
    • cerebral infections (HIV AIDS)
  • Movement induced
    • vestibular disorders
    • traction on tumor in mesentery/viscera
  • Psychosomatic causes
    • anxiety
    • pain
    • Anticipatory nausea
  • Tumour induced
    • Autonomic dysfunction
    • cytokines
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2
Q

Assessment of nausea and vomiting (History)

A
  • Medications
  • full review of systems
  • past medical hx (PUD, gastritis)
  • meaning of nausea and vomiting
  • Triggers or alleviating factors
  • frequency (can lead to dehydration, OIN)
  • Nature of vomitus (feculent, hematemesis)
  • Vomiting without nausea = proximal bowel obstruction or raised ICP
  • Neuro or cognitive changes
  • numerical analog scale rating
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3
Q

Physical exam for Nausea and vomiting

A
  • dehydration / volume status
  • abnormalities of the GI tract
  • constipation
  • hepatomegaly
  • obstruction
  • signs of raised ICP or CNS infection
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4
Q

Laboratory investigations for nausea and vomiting

A
  • Cr, urea
  • hypercalcemia
  • Hyponatremia
  • Hypomagnesemia
  • liver failure
  • Blood glucose
  • Abdominal Xray
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5
Q

Nausea defintion

A
  • Subjective sensation
  • Unpleasant expression of autonomic stimulation
  • pallor, diaphoresis
  • salivation
  • signals imminent vomiting
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6
Q

Chemoreceptor Trigger Zone

A
  • functional entity in area postrema on floor of fourth ventricle
    • area postrema : medulla oblongata
    • circumventricular organ with permeable capillaries and sensory neurons that enable dual role to detect circulating chemical messengers in blood and transduce them into neural signals
    • transmits to VC
  • Outside BBB
  • bathed by systemic circulation
  • D2 receptors in area postrema stimulated by high concentrations of emetogenic substances
  • medications or metabolic disturbances
  • 5Ht3
  • cannabinoids
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7
Q

Receptor pathways and neurotransmitters chart

A
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8
Q

Vomiting centre

A
  • Not a specific anatomical entity
  • diffuse network in medulla oblongata that gathers input and acts as a central pattern generator for the vomiting reflex
  • H1, AchM, 5HT2
  • receives input from
    • CRTZ (D2, 5HT3)
    • Vagal and sympathetic afferents (D2, 5HT4)
      • liver, gut, pharynx
    • vestibular nuclei (H1, M)
    • Cortex (H1)
  • Stimulation causes parasympathetic and sympathetic output as well as neurotransmitter cascade to induce vomiting
  • Nausea without vomiting may be stimulation of VC without sufficient amplification to trigger vx.
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9
Q

Antiemetic medications and side effects : Vomiting Centre

A
  • Antihistamine/Anticholingeric
    • cyclizine, dimenhydrinate, diphenhydramine (drowsy, dry mouth, constipation)
  • Anticholingergic
    • Hyoscine hydrobromide (scopolamine) : EPS, dry mouth, constipation, sedation, hypotension
  • Serotonin antagonists
    • ondanstron, granisetron, tropistetron : expensive, HA, constipation
    • metoclopramide high doses : drowsiness, EPS
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10
Q

Antiemetic medications and side effects: CRTZ

A
  • Dopamine antagonists (D2)
    • haldol : EPS
    • butyrophenones : EPS
    • phenothiazines (methotrimpeprazine, prochlorperazine) : EPS, sedation
    • Prokinetics metoclopramide : EPS
    • Domperidone (Does not cross BBB) : less EPS
  • Serotonin antagonists
    • ondansetron
    • metoclopramide at high doses
  • Cannabinoids
    • Dronabinol
    • Nabilone : euphoria, dysphoria, anxiety, mania, tachycardia, dry mouth, appetite
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11
Q

Antiemetic medications and side effects: Gut receptors and vagus nerve

A
  • Dopamine antagonists
    • butyrophenones HALDOL : eps
    • Phenothiazines (prochlorperazine, methotrimeprazine) : EPS, sedation
    • Prokinetics (domperidone, metoclopramide) : EPS
  • Serotonin antagonists
    • ondanstron
    • metoclopramide at high doses
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12
Q

Antiemetic medications and side effects: vestibular nuclei

A
  • Anticholingeric
    • scopolamine (hyoscine hydrobromide) : sedation, dry mouth, constipation, delirium, IOP, urinary retention)
  • Antihistamines / anticholinergics
    • Cyclizine, diphenhydramine, dimenhydrinate
    • Phenothiazine (methotrimep, prochlorperazine)
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13
Q

Antiemetic medications and side effects: Cortex

A
  • Antihistamines/ anticholingerics
  • Anxiolytics
    • benzos
  • Cannabinoids
    • nabilone, dronabinol
  • Corticosteroids
    • dex
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14
Q

Dosages and routes of administration of anti-emetics

A
  • Metoclopramide
    • 30-60 mg / day up to 120 mg/day
    • q4-6 h ATC and hourly if needed
    • oral, SC, IV
  • Haldol
    • 0.5-5 mg/day div bid
    • QHS, BID, q1h prn
    • oral, sc, IV
  • Prochlorperazine
    • 5-10 mg po, 10-20 mg rectally
    • q4h ATC and q1h prn
    • oral, rectal
  • Domperidone
    • 10 mg
    • q4h -q6h ATC and q1h prn
    • oral
  • Cyclizine
    • 25-50 mg
    • q8h
    • oral, sc, rectal
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15
Q

Non pharmacological approaches to nausea and vomiting

A
  • avoid sight or smell of triggering food / odours
  • small frequent bland meals
  • good oral hygiene
  • fresh air, calm environment
  • distractions
  • sitting upright after a meal
  • acupuncture
  • acupressure (pericardium P6 or Neiguan acupoint on anterior surface of forearm 3cm proximal to wrist crease)
  • Psychological techniques not studied
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16
Q

Hypercalcemia of malignancy

A
  • 10-40% cancer patients, myeloma, breast, lung, renal cancers
  • Bone mets 20% of hypercalcemia
  • PTH protein secretion 80% hypercalcemia
  • nausea, vomiting, constipation, weakness, polydipsia, polyuria, somnolence, confusion, agitation, anorexia
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17
Q

Corrected Serum Calcium level (mmol/L)

A

Corrected serum calcium level (mmol/L) =

serum calcium (mmol/L) + [(40-albumin g/L) x 0.02]

Normal < 2.65

Ionized calcium best in myeloma (paraproteins have calcium binding effects)

18
Q

Hypercalcemia of malignancy treatment

A
  • Rehydration + bisphosphonate
  • worsens renal failure
  • symptomatic hypocalcemia rare
  • Calcitonin temporary relief 100u sc tid for 1-2 days
19
Q

Bisphosphonates

A
  • Clodronate
    • 1500 mg, 900 mg if Cr > 150 mmol/L
    • sc, iv over 4 hours
    • works within 2-3 days
    • duration 2 weeks
  • Pamidronate
    • 60-90 mg
    • IV over 4 hours
    • works within 3-7 days
    • duration 3-4 weeks
  • Zoledronic acid
    • 4 mg
    • IV over 15 minutes
    • works withint 3-7 days
    • 4-6 weeks duration
20
Q

Tips for management of nausea and vomiting : CBM

A
  • nausea is very distressing
  • multifactorial, aim to treat receptor
  • D2 antagonists: metoclopramide, haldol, prochloperazine
  • Antihistamine : cyclizine, limiting side effects
  • SC routes
  • interprofessional team
  • always check for constipation
21
Q

Other medications options

A
  • atypical antipsychotics (olanzapine)
  • benzos: anticipatory nausea,
  • Octreotide:
    • Somatostatin analogue
    • inhibits endocrine and exocrine gut secretions, reabsorption of electrolytes in gut
    • restore GI transit
  • Propofol
    • antiemetic, CRTZ
  • Opioids: not useful
  • Mirtazapine :
    • 5Ht3 antagonism
    • anecdotal reports
22
Q

Vomiting definition

A
  • objective patient experience involving forcefaul elmination of the contents of the stomach by the sustained action of abdominal muscles and opening of gastric cardia
23
Q

Diagram of CRTZ, VC and afferent inputs

A
24
Q

Afferent pathways to vomiting centre

A
  • VAGUS
  • splanchnic nerves
  • sympathetic ganglia
  • glossopharyngeal nerve
  • Vagus stimulated by mechanoreceptors and chemoreceptors in GI tract and vscera
  • “Higher centres”
25
Q

Approach to Nausea and Vomiting Management

A
  1. Identify likely causes
  2. Identify pathway
  3. Identify neurotransmitter receptor
  4. Choose most potent antagonist
  5. Choose route of administration (SC/IV > oral)
  6. Titrate dose carefully
  7. GIVE ANTIEMETIC REGULARLY
  8. If symptoms persist, review likely cause
  9. If combining antiemetics, look at potential drug interactions. (Eg. antihistamines counteract prokinetics)
26
Q

Dopamine antagonists

A
  • Butyrophenones
    • Haldol most potent at CRTZ
    • Opioid induced Nausea
    • Chemical/metabolic Nausea
    • SE: Qtc, EPS, somnolence
  • Prokinetics
    • Metoclopramide
      • D2, 5Ht4,
      • 5Ht3 in high doses
      • CRTZ, GI tract,
      • gastric stasis, ileus
      • SE: Qtc, EPS, Colic
    • Domperidone
      • D2
      • CRTZ, GIT
      • Does not cross BBB, few EPS
      • no parenteral route (cardiac toxicity)
27
Q

Phenothiazines (Methotrimeprazine, prochlorperazine, chlorpromazine)

A
  • D2, H1, Ach, a adrenergic
  • Less potent D2 antagonists
  • Moderate antihistaminergic, anticholingeric action
  • CRTZ, GIT, VC, CNS, CVS
  • Prochlorperazine 5-10 mg po q6-8h
  • SE: Qtc, sedation, parkinsonism
  • use for MBO, peritoneal irritation, nausea NYD, vestibular causes, raised ICP
  • Chlorpromazine: lower seizure threshold
28
Q

Antihistamines

Cyclizine

Diphenyhydramine

Diphenylhydramine

A
  • Cyclizine H1 : less sedating
  • Diphenylhydramine H1
  • Promethazine H1
  • Diphenylhydramine AchM
  • CRTZ, GIT, CNS, VC, vestibular centre
  • SE: dry mouth, blurred vision, constipation, urinary retention, sedation, EPS
  • useful for vestibular disorders
29
Q

Anticholinergics

A
  • Hyoscine Hydrobromide (scopolamine)
  • Hyoscine Butylbromide (buscopan)
  • AchM
  • VC, GIT
  • Intestinal obstruction, peritoneal irritation, raised ICP, excess secretions, esophageal spasm
  • Scopolamine 200-400 ug q4-8 h prn sc
  • SE: dry mouth, sedaton, ileus, urinary retention, blurred vision, agitation, confusion
  • Useful if nausea and colic
  • Do not use with prokinetic : doesn’t make sense as anticholingerics can cause ileus
  • Buscopan does not cross BBB
30
Q

5HT3 antagonists

granisetron

ondansetron

tropisitron

A
  • 5HT3
  • GIT, VC, CRTZ
  • chemotherapy, radiotherapy, post op NV
  • SE: Headache, constipation, diarrhea, Qtc, dizziness, transient elevation of serum aminotransferases
  • Effectiveness increased when combined with dexamethasone
31
Q

NK1 Antagonist

Aprepitant

A
  • NK1 receptors
  • widespread in body
  • Late onset chemotherapy related NV
  • 125 mg po 1 hour prior to chemo, then 80 mg po od x 2 days
  • SE: hiccups, asthenia, fatigue, somnolence, anxiety, anorexia, Gi upset
  • PO only
32
Q

Corticosteroids

A
  • unclear mechanism
  • enhance antiemetic tone in medulla
    • reduce permeability of BBB to emetogenic chemicals
    • depleting GABA in medulla
    • reducing leu-encephalin release in brainstem
  • reducing inflammationg and edema
    • tumour edema
    • reduces stretch on peripheral nerves
    • ICP
33
Q

Cannabinoids : dronabinol, nabilone

A
  • act on peripheral CB1 receptors
  • decrease intestinal motility
  • may act centrally, may act on opioid receptors
  • SE: psychomimetic effects,
34
Q

Common syndromes that cause N/V : Chemically induced

A
  • Causes
    • Drugs (opioids, digoxin, anticonvulsants, antibiotics, cytoxics)
    • Toxins (MBO, food poisoning)
    • Metabolic organ failure
    • Hypercalcemic
  • Key features:
    • Drug toxicity
    • Constant nausea, variable vomiting
  • Pathways and receptors:
    • D2 in CRTZ
    • Acute CINV Chemotherapy –> 5Ht3 in vagus, VC, CRTZ
    • Delayed CINV Chemotherapy –> substance P –> NK1 in brain
  • Treatment:
    • stop drug
    • treat underlying causes
    • haldol
    • 5HT3 antagonists
    • NK1 for delayed emesis from chemo
35
Q

Common syndromes of N/V : Gastric stasis

A
  • Causes:
    • Ach drugs
    • Opioids
    • ascites, hepatomegaly
    • peptic ulcer
    • gastritis
  • Key features:
    • epigastric pain
    • fullness, early satiety
    • nausea
    • GERD
    • hiccup
    • ascites
  • Pathway and receptors:
    • gastric mechanoreceptors –> vagal afferents –> VC (H1, AchM)
  • Treatment
    • treat underlying cause
    • prokinetic agents
    • reduce gastric secretions (H2 blocker, PPI, octreotide)
36
Q

Common syndromes N/V: Stretch of GI tract

A
  • Causes
    • Constipation
    • MBO
    • mesenteric mets
  • Key features:
    • altered bowels
    • nausea, vx
    • colic
  • Pathways and receptors
    • Gut mechanoreceptors —> vagal afferents —> VC
  • Treatment
    • treat cause
    • bowel management
    • corticosteroids
37
Q

Common syndromes N/V : Serosal stretch/irritation

A
  • Causes:
    • liver mets, ureteric obstruction, mesenteric mets
  • Key features:
    • of underlying condition, nausea, occ vx
  • Pathways and receptors:
    • H1, AchM
  • Treatment
    • Cyclizine
    • hyoscine butylbromide if bowel paralysis acceptable
38
Q

Common syndromes in N/V: Raised ICP

A
  • Causes:
    • cerebral edema
    • hemorrhage
    • tumour
    • LMD
    • Skull mets
    • Cerebral infections (AIDS)
  • Key features:
    • Headaches
    • papilledema
    • nausea (diurnal)
  • Pathway and receptor
    • Cerebral H1 meningeal mechanoreceptors –> VC (H1, ACH)
  • Treatment:
    • underlying causes
    • high dose steroids
    • cyclizine
    • levopromazine
39
Q

Common syndromes N/V: movement associated emesis / Vestibular

A
  • Causes:
    • Opioids
    • Gut distortion
    • Gastroparesis
    • vestibular disorders
  • Key features:
    • nausea or sudden emesis with movement/turning head
  • Pathway and receptor:
    • Vestibular afferents H1, AchM
    • Gut mechanoreceptors —> vagal afferents —> VC H1, Ach1
  • Treatment:
    • underlying cause
    • NG aspiration in terminal gastoparesis
    • cyclizine
    • hyoscine hydrobromide
    • prochlorperazine
40
Q

Common syndromes N/V: anxiety

A
  • Causes:
    • anxiety
    • anticipatory emesis (classical conditioning)
  • Key features:
    • waves of nausea and vomiting
    • reminders trigger nausea
    • relieved by distraction
  • Pathways and receptors
    • Cortex –> VC H1, ACHM
  • Treatment
    • Address the anxiety
    • psychological techniques
    • benzos
    • Amitriptyline
41
Q

Common syndromes N/V: Upper GI tract causes

A
  • Causes:
    • Glossopharyngeal nerve and vagus nerve irritation
    • Pharyngeal irritation
    • tenacious sputum
    • candida infection
    • AIDS: CMV/herpes simplex
  • Key features:
    • cough, gag, sputum
    • mucositis, sores
  • Pathways and receptors:
    • vagal afferents –> VC
  • Treatments
    • treat infection
    • cough–> PPI, local anesthetic
    • sputum : nac or saline nebs
42
Q

Causes of drug induced nausea

A
  • CRTZ:
    • Opioids
    • Digoxin
    • Anitcoagulants
    • cytotoxics
    • imidazoles
    • antibiotics
  • GI irritation
    • NSAIDS
    • Iron
    • antibiotics
    • cytotoxics
  • Gastric stasis
    • tricyclics
    • phenothiazines
    • opioids
    • anticholingerics

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