Symptom Management. Thomas McKain, MD, ABFM, ABHPM Medical Director

Transcription

1 Symptom Management Nausea & Vomiting Thomas McKain, MD, ABFM, ABHPM Medical Director

2 Mr. Jones has nausea and vomiting. May I initiate Compazine from the Comfort Pak?

3 Objectives 1. Delineate the Differential Diagnosis for Nausea and Vomiting 2. Describe the Pathophysiology of Nausea and Vomiting 3. Explore the Pharmacologic treatment for Nausea and Vomiting

4 QUESTIONS GOING THROUGH MY MIND: Are there signs of bowel obstruction? Bowel function? Did nausea begin with a new med, such as morphine? Recent chemo or XRT? Anticipatory nausea? Is there early satiety?

5 QUESTIONS GOING THROUGH MY MIND: Is there vomiting? What is produced? Is nausea positional? Associated with anxiety? What works? What doesn't? Brain tumor? (early morning symptoms) Organ system failure?

6 OBSTRUCTED

7 HOW DO WE DIAGNOSE GI OBSTRUCTION? Check the records/ask the patient Do a CT scan, or GI series Examine the Patient!!

8 HIGH OBSTRUCTION (ESOPHAGUS) Abdomen may be flat, and benign on exam Vomiting of undigested food, which "won't go down"

9 GASTRIC OUTLET OBSTRUCTION Cancer of stomach, duodenum, head of pancreas External pressure on stomach from other tumors Food goes down, but won't stay down Food may be partially digested Abdominal exam benign, or perhaps upper mass noted

10 SMALL BOWEL OBSTRUCTION Large volume emesis, colored fluid Distended abdomen, firm, tinkling or absent bowel sounds (Fluids are normally secreted by the stomach and SB, and reabsorbed by the colon.)

11 SMALL BOWEL OBSTRUCTION

12 LOWER COLON OR RECTAL OBSTRUCTION See anorexia, and "constipation" Caused by mass in lower colon, or pelvis (must suspect!) Presents with sudden vomiting of feces Often fatal aspiration Abdomen exam NOT like SBO Rectum probably empty

13 TREATMENT OF BOWEL OBSTRUCTION Decadron, opioid, haldol, IVF Add Robinul and/or Octreotide Surgery: PEG for drainage; colostomy; remove obstruction

14 NON-OBSTRUCTED N/V

15 METABOLIC (toxins, inflammation, etc.) liver, renal failure, cancer Infections low sodium; high calcium

16 MEDS CHEMO XRT OPIOIDS

17 INTRACRANIAL PRESSURE, HEADACHES, VERTIGO

18 CONSTIPATION

19 HOW OPIOIDS CAUSE CONSTIPATION Decrease peristalsis Increase sphincter tone Decrease fluid secretion into bowel Increase fluid reabsorption from bowel

20 ULCERS, GB DISEASE, PANCREATITIS, ETC.

21 GASTROPARESIS (see early satiety) Diabetes, Autonomic dysfunction, Alcoholism, Parkinson's, Chemo, XRT, Drugs (opioids, etc.) Treat with Reglan (lower dose in CKD), Erythromycin, Prilosec, Zantac, et al.

22 TREATMENT OF NAUSEA Assess the cause, and the chemistry involved May need more than one anti-emetic, and may need to be scheduled

23 ANATOMY/PHYSIOLOGY Chemoreceptor Trigger Zone (CTZ): floor of 4th ventricle of brain Vomiting Center (VC): medulla (brainstem)

24 ANATOMY/PHYSIOLOGY

25 ANATOMY/PHYSIOLOGY

26 CHEMICAL MEDIATORS AND (RECEPTORS) Serotonin (5HT3) Dopamine (D2) Acetylcholine (Ach-m) Histamine (H1)

27 MEDICATIONS AND CHEMISTRY INVOLVED

28 SEROTONIN (5HT3) Zofran (ondansetron), et al Remeron (mirtazapine) Reglan (metoclopramide) (high doses)

29 DOPAMINE (D2) Reglan (metoclopramide) Haldol (haloperidol) Compazine (prochlorperazine) Thorazine (chlorpromazine)

30 ACETYLCHOLINE (Ach-m) Phenergan (promethazine) Antivert (meclizine) Benadryl (diphenhydramine) Levsin (hyoscyamine) Robinul (glycopyrrolate) Transderm Scop (scopolamine)

31 HISTAMINE (H1) Phenergan (promethazine) Antivert (meclizine) Benadryl (diphenhydramine) Atarax (hydroxyzine)

32 OPIOID-INDUCED NAUSEA (may resolve with time) Effects on gut (gastroparesis), CTZ, and vestibular system Can try lower dose of opioid, or rotate to another Could try Reglan, Zofran, and meclizine

33 CHEMO-INDUCED NAUSEA Need 3 drugs: -Zofran -Decadron -Emend (aprepitant) Alternatives to Zofran: -Kytril (granisetron) -Anzemet (dolasetron)

34 GASTROINTESTINAL IRRITATION/DISEASE All mediators may be involved, so multiple meds may be needed Steroids, Reglan, Zofran, meclizine, Ativan

35 VESTIBULAR NAUSEA (Positional) Histamine and Acetylcholine Opioids may be the cause meclizine, or Phenergan, or Benadryl

36 ANXIETY "Waves of nausea" Use Benzodiazepines (Also for anticipatory nausea)

37 EMPIRICAL APPROACH 1. Reglan...to block dopamine, and promote gastric motility 2. Try Haldol, OR, Compazine, OR Thorazine 3. Try Phenergan, OR, meclizine 4. Zofran

38 REGLAN AS FIRST LINE Use lower doses in CKD Avoid in pts with seizure disorders Avoid in pts with abdominal pain Can cause dystonias, akathisia, etc.

39 RESISTANT CASES Zyprexa/olanzapine, 2.5 to 5 mg qhs, as single agent Non-formulary, needs override Zyprexa can antagonize all 4 receptors: dopamine, serotonin, acetylcholine, and histamine Can improve appetite, mood, sleep

40 QUESTIONS?