C.I.N.V

Nausea & vomiting: Nausea is usually defined as the inclination

to vomit or as a feeling in the throat or epigastric region alerting an individual that vomiting is imminent ( subjective ).

Vomiting is defined as the ejection or expulsion of gastric contents through the mouth, often requiring a forceful event (reflexive )

Retching is the contraction of the abdominal wall,diaphragm &thoracic muscle wihtout expulsion

Nausea Autonom

ic sympto

ms

Retching

Contraction

Vomiting Contraction + forced

expel of Gicontent

Pathophysiology

Nausea & vomiting are complex interaction from different systems

Central vomiting

center (medulla)

CTZ(5-

HT3 ,D2,NK1

Gastrointestinal(vi

sceral afferents(

5-HT3,D2,N

K1

Cerebral cortex

(sensory)

Vestibular system

(H!, muscarini

c )

•Types & causes :

GI or intraperitonealCardiac Neurologic Therapy induced Endocrine/metabolic Others ( CINV , PONV , NVP , motionskiness )

•How are we manage ?!

DESIRED OUTCOME The overall goal of antiemetic therapy

is to prevent or eliminate nausea and vomiting; this should be accomplished without adverse effects or with clinically acceptable adverse effects.

Pharmacological

Non pharmacological

•General treatment approach :

Removal or treatment of the under lying cause

Correction of dehydration & electrolyte disturbances (oral hydration preferred if possible )

When we choose Drug treatment we use drugs that target receptors involved (may use combination )& also we need alternative forms of medication wit different route of administration (IM ,IV ,SC ,Suppository….etc)

•Non pharmacological ttt:

It is including :1. Dietary approaches (small meal ,

high protein , avoid spicy or fatty food eat dry blended food, using herbal remedy , multivitamins intake )

2. Psychotherapy & hypnosis 3. Acupressure & electric-acupoint

stimulation by wearing briclet affecting this area

•Pharmacological Anti emetic classes :

• cyclazine• Diphenhydramine

Antihistaminic

• Phenothiazine(chloropromazine)• Butyrophenone(haloperidol)

•Benzamides(metaclopromide , domperdione )

antidopaminergic

• Granisetron• ondansetron• Palonosetrone

Serotonin antagonists

Neurokinin 1 antagonist

•Aprepitant •Fosaprepitant

•Cont,.:

•Dexamethasone Corticosteroides

• Aloprozolam • Lorazepam

Benzodiazipens

• nabilone• Dronabinol

Cannabinoids

1 • Types of CINV

2 • Risk stratification

3 • How to manage (guidelines )

CINV

•Types :1. Acute onset : 0-24hrs after chemo

administration .2. Delayed onset : occurs more than 24hrs

after chemo administration 3. Anticipatory vomiting : is triggered by

sights ,smells , sounds & is a conditioned response & mainly after uncontrolled N&V by chemo

4. Breakthrough emesis occurs despite prophylactic ttt

5. Refractory emesis refers to emesis that occurs during cycles when antiemetic prophylaxis have failed in pervious cycles

•Risk stratification :

Patient related

risk factors

Emetogenicity of chemotherapy

agents

Radiation exposure

•Patients related risk :Patient’s age (younger or those

younger than 50 years Female sexHX of motion skiness or NVP Poor control of N&V in pervious

chemo cycles HX of chornic alcoholism (+ve

risk ↓incidence)

Chemo related:

Radiation: Radiation can also cause N&V , the

incidence & severity vary according the site & size of the radiation field :

a. Mildly emetogenic (radiation to head , neck or extremities )

b. Moderate (radiation to upper abdomen ,pelvis or craniospinal )

c. High (total body ,total nodal & upper half body irradiation )

How to manage: