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MANAGEMENT OF NAUSEA AND VOMITING IN PALLIATIVE CARE

MANAGEMENT OF NAUSEA AND VOMITING IN PALLIATIVE CARE. INCIDENCE OF NAUSEA AND VOMITING IN TERMINAL CANCER PATIENTS. Nausea: 50 - 60 % Vomiting: 30 %. MECHANISM OF NAUSEA AND VOMITING. vomiting centre in reticular formation of medulla activated by stimuli from:

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MANAGEMENT OF NAUSEA AND VOMITING IN PALLIATIVE CARE

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  1. MANAGEMENT OF NAUSEA AND VOMITING IN PALLIATIVE CARE

  2. INCIDENCE OF NAUSEA AND VOMITING IN TERMINAL CANCER PATIENTS Nausea: 50 - 60 % Vomiting: 30 %

  3. MECHANISM OF NAUSEA AND VOMITING • vomiting centre in reticular formation of medulla • activated by stimuli from: • Chemoreceptor Trigger Zone (CTZ) • area postrema, floor of the fourth ventricle • outside blood-brain barrier (fenestrated venules) • Upper GI tract & pharynx • Vestibular apparatus • Higher cortical centres

  4. VOMITING CENTRE Cortex CTZ GI Vestibular

  5. CAUSES OF NAUSEA & VOMITING CHEMORECEPTOR TRIGGER ZONE VESTIBULAR CORTICAL PERIPHERAL • drugs • opioids • chemo • etc... • biochemical • ­Ca++ • renal failure • liver failure • sepsis tumor opioids anxiety association ­ICP • radiotherapy • chemotherapy • GI irritation • inflammation • obstruction • paresis • compression

  6. PRINCIPLES OF TREATING NAUSEA & VOMITING • Treat the cause, if possible and appropriate • Environmental measures • Antiemetic use: • anticipate need if possible • use adequate, regular doses • aim at presumed receptor involved • combinations if necessary • anticipate need for alternate routes

  7. 5HT 5HT 5HT AREA STIMULUS RECEPTORS Chemoreceptor trigger zone Drugs, Metabolic D 2 M H 1 Motion/ Position Vestibular H1 M VOMITING CENTRE Visceral Abdominal organs D 2 ­ ICP H Cortex 1 EFFECTOR ORGANS (usually use decadron) 5HT H1 M D2 Dopamine Serotonin Histamine Muscarinic

  8. RELATIVE ANTIEMETIC RECEPTOR AFFINITIES 1250

  9. EXAMPLES OF ANTIEMETIC USE • haloperidol 0.5 - 1 mg po/sq/iv q6-12h • prochlorperazine 5 - 20 mg po/pr/iv q4-8h • CPZ 25 - 50 mg po/pr/iv q6-8h • methotrimeprazine 5 - 10 mg po/sl/sq q4-8h • metoclopramide 10 - 20 mg po/sq/pr q4-8h • domperidone 10 mg po q4-8h • scopolamine patch (Transderm-Vâ) • metoclopramide 10 - 20 mg po/sq/pr q4-8h • domperidone 10 mg po q4-8h • cisapride 10 mg po tid-qid DOPAMINE ANTAGONISTS ANTIMUSCARINIC PROKINETIC

  10. EXAMPLES OF ANTIEMETIC USE • dimenhydrinate 25 - 100 mg po/pr/[sq] q4-8h • promethazine 25 mg po/iv q4-6h (Not sq) • meclizine 25 mg po q6-12h • ondansetron 4 - 8 mg bid-tid po/sq/iv • granisetron 0.5 –1 mg po/sq OD - bid • dexamethasone 2 - 4 mg po/sq/iv OD-qid • lorazepam 0.5 - 1 mg po/sl q4-12h H1 ANTAGONISTS SEROTONIN ANTAGONISTS MISCELLANEOUS

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