Nausea & Vomiting Brian H. Black D.O.. Review the importance of Nausea & Vomiting in both acute and...
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Nausea & Vomiting Brian H. Black D.O.. Review the importance of Nausea & Vomiting in both acute and palliative settings Discuss and review key anatomic
Review the importance of Nausea & Vomiting in both acute
and palliative settings Discuss and review key anatomic
considerations Discuss receptors important for appropriate
medication selection and treatment Describe a mechanistic
approach
Slide 3
nausea nz,-ZH noun a feeling of sickness with an inclination to
vomit synonyms: sickness, biliousness, queasiness, swimmy, lothing,
gagging, sea/air/car sickness
Slide 4
regurge r grj, r -, -gj, -gij Verb Passive retrograde movement
of ingested material, usually before it has reached the stomach
synonyms: dry heave, retch, drive the bus, puke in my own mouth,
barf a little, boff, or be sick
Slide 5
vomit vmt/ Verb or present participle eject matter from the
stomach through the mouth synonyms: heave, retch, get sick, throw
up, puke, purge, hurl, barf, upchuck, bark, spew, ralph, or be
sick
Slide 6
Progressive Failsafe Measures are plenty in the human body
which help prevent toxic absorption Examples include: Appearance
Smell Taste GI receptor stimulation AND VOMITING
Slide 7
Slide 8
Nausea & Vomiting is common cc in 2% a component in >
20% Only 25% of pts with symptoms visit a physician Thus stats
likely significantly under-represent the problem It is more common
in those 15-24 yo as a single presenting complaint, but nausea is a
major component of morbidity Cost estimates - over 4 billion/yr in
U.S. Complications include hypokalemia and metabolic acidosis which
can lead to serious illness or death
Slide 9
A 46 yo obese female presents with nausea s/p cholecysectomy
three days ago. She has dysuria. She notes worsening symptoms after
she eats at which point she occasionally vomits. She is taking the
IR morphine as prescribed for pain on a regular basis and pain is a
4/10. What pathway is involved this pts nausea? A.) Vagal &
splanchnic mechanoreceptor firing d/t stretch d/t Ileus B.) SE of
Morphine acting on the chemoreceptor trigger zone C.) Urinary
infection s/p unnecessary cath placement D.) Substance P and
histamine release from pain and inflammation E.) Any or all of the
above
Slide 10
A 46 yo obese female presents with nausea s/p cholecysectomy 4
days ago. She has dysuria. She notes worsening symptoms after she
eats at which point she occasionally vomits. She is taking the IR
morphine as prescribed for pain on a regular basis and pain is
tolerable What pathway is involved in her nasuea? A.) Vagal &
splanchnic mechanoreceptor firing d/t stretch caused by Ileus B.)
SE of Morphine acting on the chemoreceptor trigger zone C.) Urinary
infection s/p unnecessary cath placement D.) Substance P and
histamine release from pain and inflammation E.) Any or all of the
above
Slide 11
Nausea is caused by many disease states and is often
multi-factorial. Some medications are more effective than others
for different causes. What are the common pathways? How do we
approach treatment?
The right Rx at the right time Leveraging of S.E. Limitation of
testing Consideration for cost Multi-drug strategies
Non-pharmaceutical options
Slide 19
The Art of War It is said that if you know your enemies and
know yourself, you will not be imperiled in a hundred battles Sun
Tzu
Slide 20
VOMIT(c) Vestibular cOnstipation (and other Enteric
Dysfunction) Metabolic Derangement Infection / Inflammation Toxins
Cortical / Central
Slide 21
An 72 yo WF presents to the Emergency room stating she has
severe nausea of sudden onset. She was reaching down to get the
trash and suddenly noted ringing in her ears and dizziness. She
denies vision changes or difficult swallowing. She has had this
before and has several meds at home. She calls you because she is
now confused which one to take. Which of the following treatments
are likely to act on the main neurotransmitters involved? A.)
Haldol B.) Gabapentin C.) Benadryl D.) Ondansetron E.) Vitamin
B6
Slide 22
An 72 yo WF presents to the Emergency room stating she has
severe nausea of sudden onset. She was reaching down to get the
trash and suddenly noted ringing in her ears and dizziness. She
denies vision changes or difficult swallowing. She has had this
before and has several meds at home. She calls you because she is
now confused which one to take. Which of the following treatments
are likely to act on the main neurotransmitters involved? A.)
Haldol B.) Gabapentin C.) Benadryl D.) Ondansetron E.) Vitamin
B6
Slide 23
Slide 24
V OMIT(c) Peripheral Vestibular (VIIIth nerve) Sudden onset
Head movement triggers More likely to have auditory symptoms
(ringing) Does not require an extensive workup Central Vestibular
Likely involve posterior circulation brainstem symptoms the Ds
including Diplopia, Dysphagia, Dysarthria Can indicate more serious
disease Often vague symptoms and history Imaging of the brain may
be helpful in these cases
Slide 25
V OMIT(c) Peripheral Vestibular Receptors involved: Cholinergic
& Histaminic Scopolamine patch 1.5mg sq q3 days can also be
given via IV, or SubQ injection Meclizine 25mg po tid Promethzaine
25mg po q4-6 hrs prn
Slide 26
V OMIT(c) Vestibular cautions and considerations:
Cholinergic/Histaminic blockade can lead to: Dry mouth Sedation
Vision changes Fall risks May exacerbate poor gut motility
Non-rational treatment with H1 / M1 blockade leads to these side
effects WITHOUT IMPROVEMENT OF THE NAUSEA! Anti-cholinergic
symptoms are especially concerning in the elderly
Slide 27
A 52 yo male presents with metastatic lung cancer presents to
the clinic with abdominal fullness, nausea, and intermittent
vomiting. His sx previously were managed on Ondansetron (zofran),
but have become refractory to escalating doses What is the next
best step? A.) Stop Ondansetron B.) Change Chemo Regimen C.) Add
Dexamethethasone D.) Do a Rectal Exam E.) Add Haldol
Slide 28
A 52 yo male presents with metastatic lung cancer presents to
the clinic with abdominal fullness, nausea, and intermittent
vomiting. His sx previously were managed on Ondansetron (zofran),
but have become refractory to escalating doses What is the next
best step? A.) Stop Ondansetron B.) Change Chemo Regimen C.) Add
Dexamethethasone D.) Do a Rectal Exam E.) Add Haldol
Slide 29
Slide 30
V O MIT(c) cOnstipation (and other enteric dysfunction) O in
this case does not count for a frank obstruction of the bowel, but
instead obstruction via constipation and also movement problems of
the bowel leading to nausea Cholinergic, Histaminic, and 5-HT3,
5-HT4 receptors helpful targets Stimulation of the myenteric plexus
(senna) can relieve obstruction of the bowel due to constipation
Bowel dysmOtility Loss of bowel movement which impairs food and
waste transit Can occur as a result of DM or other dz Prokinetics
can be helpful (Metoclopramide stimulates 5HT4 receptors)
Slide 31
V O MIT(c) Laxative therapy can be burdensome &
unpredictable Methylnaltrexone Action: selectively inhibits the Mu
receptors of the GI tract Does not affect analgesia 10mg SubQ qod
usually effective Rapidly response when effective May be cost
prohibitive in some settings
Slide 32
V O MIT(c) cOnstipation (& other enteric dysfunction)
cautions and considerations: Stimulant laxative overuse can lead to
Beware of Prokinetic agents (Meta Reglan) for use in frank
obstruction! They are contraindicated To prevent constipation you
should consider starting a stool softener with all Narcotic
prescriptions they go together like peas and carrots
Slide 33
Frank and Complete Obstruction of the Bowel Common in ovarian
& colon CA Hernias or post-op adhesions can cause partial or
complete obstruction too Definitive treatment is not
pharmaceutical, but surgical Options include: IV fluids and NG
tubes, surgical correction, venting gastrostomy tube, and placing
stents across the obstruction Poor surgical candidates can be
approached with endoscopic methods
Slide 34
Frank and Complete Obstruction of the Bowel Opiates and
Dopamine antagonists are key Somatostatin analogues like Octreotide
(Sandostatin) used to inhibit secretion of GH, TSH, ACTH,
prolactin, and decrease the release of gastrin, CCK, insulin,
glucagon, gastric acid and pancreatic enzymes. All leading to
decreased peristalsis & splanchnic blood flow
Slide 35
Slide 36
VO M IT(c) Metabolic Derangement Correction of the abnormality
is key Not all cases of nausea need lab testing Consider a
metabolic profile in refractory cases Check a metabolic profile:
Ca/Na/K. Cause & Effect Adrenal disorders Parathyroid disorders
Uremia Many others exist. These causes should be considered in
resistant cases and in patients who exhibit signs and symptoms of
disease
Slide 37
Slide 38
VOM I T(c) Receptors involved: Cholinergic, Histaminic, 5HT-3,
& Neurokinin 1 Infection Tx of infection (Sepsis,
Pyleonephritis, Pneumonia) Inflammation Of the Gut stimulation of
NK1 receptors Corticosteroids may have a role but the evidence is
limited Useful Medications Promethazine (eg. Labrinthitis)
Prochlorperazine (Sepsis) Coating Agents like Bismuth or
Sulcralfate
Slide 39
Slide 40
A 69yo diabetic pt with hx of heart failure is seen at the ECF.
On review of symptoms she has complaints of nausea. You note she is
on 12 medications, and recently started a new anti-depressant.
Which of the following is true regarding medication induced Nausea?
A.) Nausea is an uncommon SE of medication B.) The mechanism
involved in most causes of nausea are poorly defined C.) Medication
induced nausea is typically associated with brief periods of
symptoms immediately after administration D.) Medication induced
nausea occurs early in use and exhibits a consistent course over
time
Slide 41
A 69yo diabetic pt with hx of heart failure is seen at the ECF.
On review of symptoms she has complaints of nausea. You note she is
on 12 medications, and has recently started a new anti-depressant.
Which of the following is true regarding medication induced Nausea?
A.) Nausea is an uncommon SE of medication B.) The mechanism
involved in most causes of nausea are poorly defined C.) Medication
induced nausea is typically associated with brief periods of
symptoms immediately after administration D.) Medication induced
nausea occurs early in use and exhibits a consistent course over
time
Slide 42
Slide 43
Toxins Receptors involved usually include Dopamine and 5-HT3
Useful classes: Anti-dopaminergic & 5-HT3 antagonists Many
toxins cause nausea due to stimulation of the chemreceptor
trigger-zone Chemotherapy Medications Opiates (Morphine) Digoxin
Clonadine Polypharmacy NSAIDs local irritation
Slide 44
Chemotherapy Risk Factors Multi-day Dose-dense IV (vs po) Short
infusion time Chemotherapy induced nausea and vomiting can be
limited by judicious use of treatment Medication rotation may be
helpful
Slide 45
VOMIT( C ) Cortical / Central CNS disease (brain mets)
Dexamethasone 40mg daily PO, IV, or SubQ Decrease swelling Anxiety
Tx c Benzos can be helpful Ativan 1mg po q4 hrs
Slide 46
Cortical / Central / Chemo cautions considerations and other
cs: Anxiolytics Can cause over-sedation Not helpful for the tx of
nausea Can help decrease anxiety associated with poor sx control
5HT3 drugs expensive & not always needed Corticosteroids can
cause S.E.
Slide 47
Special Cases: Carcinomatosis Prokinetics Agents are usually
agents of choice Steroids as anti-inflammatories can be very useful
as well Examples include Metoclopramide & Decadron combos
Treatment resistant cases D2 Blockage can be very effective via
central action Haloperidol 1mg q4 hours (po, IV, or SubQ)
Prochlorperazine 5mg po q6 hrs or 25mg PR BID
Slide 48
A 15 year old with recent mood swings pt presents with
complaint of vague symptoms of nausea. She is also complaining of
some mild dysuria & fatigue. Which of the following is true:
A.) Empiric antibiotics and sx recheck is adequate B.) Lab testing
is essential for the dx C.) A med acting at the serotonin receptor
(5-HT3) will be the best anti-emetic for treatment D.) These cases
are generally self limited, but NSAIDs or corticosteroids can be
helpful E.) The diagnosis is likely to be psychogenic
Slide 49
A 15 year old with recent mood swings pt presents with
complaint of vague symptoms of nausea. She is also complaining of
some mild dysuria & fatigue. Which of the following is true:
A.) Empiric antibiotics and sx recheck is adequate B.) Lab testing
is essential for the dx C.) A med acting at the serotonin receptor
(5-HT3) will be the best anti-emetic for treatment D.) These cases
are generally self limited, but NSAIDs or corticosteroids can be
helpful E.) The diagnosis is likely to be psychogenic
Slide 50
Nausea Gravidarum ( aka morning sickness) Affects more than
half of all pregnant patients. Usually worse in the early AM hours,
but can occur anytime of day Usually abates on its own around the
12 th week of pregnancy Felt to be multi-factoral and related to
increased estrogen & progesterone levels, increase in
salivation, low blood sugar, as well as the hormone BHCGs effects.
Women with uncomplicated morning sickness have a LOWER risk of
miscarriage, preterm delivery, low birth wt, & mortality
Consider alternative causes in a pregnant women if worsening sx or
if onset AFTER 9 weeks gestation
Slide 51
Timing? New Medications could be the culprit Lifestyle changes
could lead to anxiety & psychosocial distress Vomiting occurs
earlier and in larger amounts in proximal obstructions (as compared
to colorectal obstruction) Location? Sometimes asking Where is the
nausea can be helpful to elucidate symptoms of dizziness, pain, or
infection Others with same illness? Travel? Cases of food poisoning
or infection can be shared with others, but this is not always
volunteered by the patient in a nurses intake
Nausea + dental /parotid gland changes Bulemia Nausea + the Ds
Neurogenic vomiting Nausea + THC use daily Cannabinoid Hyperemesis
Nausea + Bilious Vomiting Small bowel obstruction Abd pain, then
nausea Appendicitis Symptoms > 1 months Chronic Nausea &
Vomiting
Slide 54
Vitals & Volume Dehydration (tachycardia & skin tenting
with dry mm) Abdominal exam (including rectal) Nausea, Pain, and
Distension Obstruction Hypo or Hyperactive bowel sounds? Masses?
Ascites? Tenderness? Hard stool in rectal vault? Neuro exam
Nystagmus
Slide 55
CMP (Comprehensive Metabolic Profile) To review: Renal
Function, Liver Function, e- levels (Ca / Na) Urine: UA & BHCG
Other testing is done as suggested by Hx & PE CBC TSH Stool
Guiac Amylase/Lipase H Pylori testing Stool cultures *** Labs and
testing should only be done as needed to dx problem & assist
identification of appropriate management strategy. If it wont
change your treatment, then dont do it!
Slide 56
MRI / CT of brain (CT if acute Ultrasound Obstruction series
Other GI studies For pts with significant dysphasia or sx of GERD
with failure to resolve with tx trial EGD Manometry can be done to
eval LES pressure and mm contractions if EGD normal Gastric
emptying study is recommended if gastroparesis is suspected.
Slide 57
Slide 58
Nausea/Vomiting >48 hours Hematochezia or Melena Sustained
High Fever Weakness or Altered (focal neuro change) No urination in
> 8hrs / or other dehydration signs Diarrhea or severe abd pain
Lack of charting return if worsening or new symptoms Rick
Bukata
Slide 59
Aprepitant (NK-1 blocker mainly for use in CINV) Decadron 10mg
po/IV (Anti-inflammatory Corticosteroid) Haldol 1mg po, im, subq q4
hrs prn (D2 Blockade) Lorazepam 1mg po q4hrs prn (Benzodiazepine
Anxiolytic) Meclizine 25mg po tid (Antihistamine) Methylnaltrexone
10mg SQ qod (Mu Receptor Antagonist)
Frequent small meals Removal of all unpleasant and strong
scents AVOID ALL PERFUMES LIMIT HARSH CLEANERS Removal triggering
visual stimuli Coke syrup, B12, Ginger, Cinnamon, Marijuana
(dronabaniol) Accupressure / Accupuncture (Sea Bands on anterior
wrist)
Slide 62
Slide 63
Accupuncture Accupressure Sea Bands Herbs Clove Cinnamon Cumin
Ginger Mint Cold Compress Avoiding Spicy Foods and offending foods
Alka-Seltzer Avoid due to the fact it contains ASA and can irritate
stomach lining
Slide 64
Slide 65
Promethazine & Prochlorperazine Sound similar but are very
different drugs Promethazine (Phenergan) MOA: Strong Antihistamine
with weak anti-dopaminergic effects most useful for vertigo and
gastroenteritis due to infections and inflammation Prochlorperazine
(Compazine) MOA: Antidopaminergic preferred agent for opioid
related nausea Can be given 5-10mg po qid Very helpful PR at 25mg
PR BID!!! Both meds: Are commonly used to treat nausea and
especially OINV (Opiate induced Nasusea & Vomiting), but no
trials (that I know) have compared them head-to-head
Slide 66
There is NO EVIDENCE for the use of anxiolytics as isolated
agents in the treatment of nausea Anxiolytics ARE useful for tx of
anxiety as associated with severe nausea & vomiting. SE can
include sedation, fall risk, and aspiration Constipation is a
frequent SE of narcotics (and multiple other meds) Consider
starting laxatives when starting opiates and other meds that are
associated with constipation
Slide 67
Nausea & Vomiting is common Control can dramatically
improve quality of life A rational symptomatic approach can yield
improved control & minimize side effects All approaches should:
Identify the etiology of disease Correct the complications Target
the receptor for therapy
Slide 68
Several animals do not vomit: Rats Horses Rabbits Guiena pigs
Japanese quail But Pandas apparently do vomit and there is an
entire subculture of artists capturing the thought and vision in
rainbows
Slide 69
Slide 70
Glare P, et al. Systemic review of the efficacy of antiemetics
in the treatment of nausea in patients with far-advanced cancer.
Support Care Cancer. 2004; 12:432-440 Hallenbeck J. Palliative Care
Perspectives. New York, NY: Oxford University Press; 2003: pp75-86
Vol. 8, No. 1, January/February 2009 issue of ASHA's Access
Audiology. Clark K, Smith JM, Currow DC. The prevalence of bowel
problems reported in a palliative care population. J Pain Symptom
Manage 2012;43:993-1000. Basch E, Prestrud AA, Hesketh PJ, et al.
American Society of Clinical Oncology. Antiemetics: American
Society of Clinical Oncology clinical practice guideline update. J
Clin Oncol 2011;29:4189-98. Maceira E, Lesar TS, Smith H.
Medication related nausea and vomiting in palliative medicine. Ann
Palliat Med 2012;1(2):161-176. DOI: 10.3978/
j.issn.2224-5820.2012.07.11 Keith Scorza, MD, et al., Dewitt Army
Community Hospital Family Medicine Residency, Fort Belvoir,
Virginia. Am Fam Physician. 2007 Jul 1;76(1):76-84 William D.
Anderson, MD, et al, University of South Carolina School of
Medicine, Columbia, South Carolina, Am Fam Physician. 2013 Sept 15;
99(6): 371-379