Nausea

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Nausea Vomiting in Palliative Care

• Chris Higgs
• Dorothy House Hospice

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Case 1

• Male 58 years old
• MND for 1 year
• PMH hypertension
• Joint aches and pains. Stiffness.
• Diclofenac stopped because rectal bleed
• Other drugs Riluzole, Baclofen, Bendrofluazide,
  Losartan, Lactulose, Simvastatin, Paracetamol.
• Increasing pain and stiffness
• Oramorph produced constipation but Butrans
  (Buprenorphine weekly patch) 20mcg/hr is
  successful

3

• Persistent retching and early morning nausea
• Burning sensation in lower chest on eating
• Omeprazole and Gaviscon
• Still persistent nausea
• Cyclizine dry mouth and little benefit
• Next steps for Case 1?

4
Case 2

• Woman of 76 years
• 1999 carcinoma of breast
• PMH hysterectomy, cholecystectomy,
  pyelonephritis, diverticulitis, hiatus hernia,
  scoliosis.
• 2005 hemicolectomy for secondary tumour in
  bowel
• Chemotherapy drugs always make her sick, despite
  Domperidone, Ondansetron and Dexamethasone
• 2006 husband dies in Dorothy House Hospice
• 2007 bone metastases. Pamidronate reaction with
  diarrhoea and vomiting.

5

• 2008 background nausea and constipation
• Normal calcium and bowel sounds
• Reduced opioid dose no effect
• oral Cyclizine initial benefit then vomiting
• csci Cyclizine skin reaction
• csci Levomepromazine (via Sofset) drowsy, still
  occasional vomiting
• CT scan abdo multiple areas bowel wall
  infiltration, no bowel obstruction
• Next steps for Case 2?

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Case 3

• Female 75 years old
• 2007 - Carcinoma of stomach and omental mass
• Elects to have no treatment
• Background nausea and early satiety
• Cyclizine makes her tired
• Vomiting and abdominal distension with absent
  bowel sounds.
• Ascites drained
• csci Metoclopramide and Dexamethasone -
  successful

7

• One month later
• Persistent vomiting, some blood
• Ascites drained again
• Still persistent vomiting, almost immediate after
  intake
• Next step for Case 3?

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Case 4

• Female 58 years old
• 2005 Carcinoma of the ovary
• Surgery and chemotherapy
• Pulmonary emboli Warfarin
• Chemotherapy produces persistent vomiting despite
  drugs
• Ascites drained on 2 occasions
• Feb 08 admitted RUH
• Nausea and persistent vomiting
• Constipated, quiet bowel sounds
• Responds to oral Metoclopramide and
  Dexamethasone, with csci Levomepromazine for
  nausea

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• April 08 admitted RUH
• Persistent nausea and vomiting
• Investigations calcium and liver function are
  normal, tumour markers increased, bowel sounds
  normal, CT abdo shows no obstruction.
• Naso-gastric tube inserted, still vomiting
• Appears depressed and panicky
• Drugs tried Dexamethasone, Metoclopramide,
  Ondansetron, Cyclizine, Levomepromazine,
  Prochlorperazine, Octreotide, Buscopan, Midazolam
• All fail
• Next step for Case 4?

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Why has this patient nausea or vomiting?
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Possible causes

• Drugs e.g. opioids, chemotherapy
• Radiotherapy gut area
• Hypercalcaemia, uraemia
• Liver failure
• Gastric stasis
• Gastric and intestinal obstruction
• ? Constipation
• Raised intracranial pressure
• Cerebellar metastases
• Anxiety, fear

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Other causes

• Hiatus hernia
• Gastritis
• Gastroenteritis
• Vestibular disturbance
• Cough
• Pharyngeal irritation
• Conditioning/association

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(No Transcript)
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Nausea or Vomiting?
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5HT3
AChm/H1
5HT2
NK1
D2
AChm
D
Receptors AChm muscarinic H1
histamine 5HT2,3,4 serotonin D dopamine NK1
neurokinin
5HT3
AChm
5HT3,4
16
Drugs used for Nausea Vomiting
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(No Transcript)
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Essential oils to help nausea vomiting

• Lavender
• Chamomile
• Bergamot
• Orange
• Ginger

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Csci route / 24hrs

• Combination if uncertain
• Metoclopramide 30mg
• Levomepromazine 6.25mg
• /- Dexamethasone 4mg
• Cyclizine or levomepromazine
• Cyclizine and dexamethasone often do not mix

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Bowel obstruction

• ? Gastric outflow
• Small bowel
• Large bowel
• Hyoscine butylbromide (Buscopan)
• 60-120mg / 24hrs csci
• /- Dexamethasone 2-4mg

Octreotide300-800mcg / 24hrs (If small bowel
obn)
Nasogastric tube
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• Persistent retching and early morning nausea
• Burning sensation in lower chest on eating
• Omeprazole and Gaviscon
• Still persistent nausea
• Cyclizine dry mouth and little benefit
• Next steps for Case 1?
• Oral levomepromazine

22

• 2008 background nausea and constipation
• Normal calcium and bowel sounds
• Reduced opioid dose no effect
• oral Cyclizine initial benefit then vomiting
• csci Cyclizine skin reaction
• csci Levomepromazine (via Sofset) drowsy, still
  occasional vomiting
• CT scan abdo multiple areas bowel wall
  infiltration, no bowel obstruction
• Next steps for Case 2?
• csci then oral metoclopramide dexamethasone

23

• One month later
• Persistent vomiting, some blood
• Ascites drained again
• Still persistent vomiting, almost immediate after
  intake
• Next step for Case 3?
• Nasogastric tube

24

• April 08 admitted RUH
• Persistent nausea and vomiting
• Investigations calcium and liver function are
  normal, tumour markers increased, bowel sounds
  normal, CT abdo shows no obstruction.
• Naso-gastric tube inserted, still vomiting
• Appears depressed and panicky
• Drugs tried Dexamethasone, Metoclopramide,
  Ondansetron, Cyclizine, Levomepromazine,
  Prochlorperazine, Octreotide, Buscopan, Midazolam
• All fail
• Next step for Case 4?
• CT brain cerebella metastases. Radiotherapy.