Nausea and vomiting
Questions
- Frequency and nature of nausea with or without vomiting
- Assess bowel movements; any suggestions of constipation? Diarrhoea? Bowel Obstruction?
- Are they able to eat and/or drink?
- Any signs of dehydration e.g. decreased urine output? dry mucous membranes? thirst?
- Any evidence of reflux?
- Extent of known disease? E.g. known brain, bone, liver metastases
- What medication are they taking?
- Are they currently receiving chemotherapy or radiotherapy?
- Do they have increasing abdominal pain?
Check if patient is neutropenic. If evidence of neutropenic sepsis, treat according to guidelines.
Grade 1 (Green)
Loss of appetite without alteration in eating habits.
Vomiting < 2 episodes in 24 hrs
Advice
- Review prescribed antiemetics and make sure route and frequency are appropriate.
- Assess patient compliance
- Identify cause and change antiemetics if needed in line with policy.
- Offer AOCU review if unable to take oral medications
- Give self-help advice
- Phone/review patient after 24 hours to ensure settling
Grade 2 (Amber)
Oral intake decreased, dehydration.
Vomiting 3-5 episodes in 24 hrs
Advice
- Review prescribed antiemetics and make sure route and frequency are appropriate.
- Assess patient compliance
- Identify cause and change antiemetics if needed in line with policy.
- Offer AOCU review if unable to take oral medications
- Give self-help advice
- Phone/review patient after 24 hours to ensure settling
Grade 3 (Red)
Inadequate fluid intake; tube feeding or TPN.
Vomiting >6 episodes in 24 hrs
Advice
Admit for assessment, IV fluids and electrolyte replacement as appropriate.
Fully investigate cause;
- Disease related e.g. brain or liver mets, hypercalcaemia, obstruction.
- Medication related e.g. chemotherapy, opiates etc.
Prescribe antiemetics as appropriate to the cause
Grade 4 (Red)
No Oral intake. Life Threatening
Advice
Admit for assessment, IV fluids and electrolyte replacement as appropriate.
Fully investigate cause;
- Disease related e.g. brain or liver mets, hypercalcaemia, obstruction.
- Medication related e.g. chemotherapy, opiates etc.
Prescribe antiemetics as appropriate to the cause
Handover management with patient’s team, discuss all interruptions of treatment with team +/- AOS prior to proceeding.
Arrange follow up review as necessary.
Initial assessment – patient seen in AOCU
- History of complaint – Include other toxicities associated with the complaint.
- If on chemotherapy ascertain when last dose given.
- Check all prescribed medication
- Examination of mucous membranes – Check for signs of dehydration
- Assessment of fluid balance status (BP, pulse etc..) and signs of systemic infection
- Check bloods- Renal function, FBC, CRP. Do blood cultures if any signs of systemic infection
Treatments
General Antiemetic Advice
- Antiemetics are best given regularly, not PRN
- Ensure that courses are completed
- Consider if there is a failure to absorb medication, and change route of antiemetics accordingly
- If on chemotherapy and had 1st line anti emetic failure consider adding apprepitant for future cycles
- Cyclizine blocks the prokinetic effects of domperidone/metoclopromide so they should not be used together
- Drugs acting on the same receptor (e.g. domperidone and metoclopramide) should not be used together.
- For patients < 20 years old the dose of metoclopramide should be 10mg, or consider using domperidone (risk of oculogyric crisis with metoclopramide).
| Cause | Treatment Options |
|---|---|
| Anxiety/anticipatory nausea | Lorazepam Antidepressants in longer term: seek advice from patient’s GP or oncology team |
| Bowel Obstruction | Levomepromazine, haloperidol or Cylizine |
| Constipation | Treat cause/Metoclopromide |
| Dealyed gastric opening | Metoclopromide |
| Drugs * (non chemotherapy) | Stop drug if possible. Haloperidol or Levomepromazine |
| Gastric irritation | Treat cause ( e.g. proton pump inhibitors). Haloperidol or Levomepromazine |
| Hypercalcaemia | Treat Cause Haloperidol or Levomepromazine |
| Metabolic causes (e.g. hyperglycemia, hyponatraemia | Haloperidol or Levomepromazine |
| Raised intracranial pressure (e.g. brain metastases) | Treat cause Dexamethasone and cyclizine |
Chemotherapy and Emesis
Chemotherapy induced nausea and vomiting (CINV) is one of the most common side effects of chemotherapy; however with the use of modern antiemetic regimes persistent CINV is now relatively rare.
CINV can be grouped into 3 phases:
- Acute: Within 24 hours of receiving chemotherapy, commonly resolves within 24 hrs.
- Delayed: From 24 hours after chemotherapy. Seldom persists beyond 1 week
- Anticipatory: Occurs prior to any chemotherapy and is a learned response to previous chemotherapy.
In addition CINV can be classified as:
Breakthrough: development of nausea and vomiting despite standard prophylactic antiemetic therapy, which requires treatment with additional pharmacological agents (rescue antiemetics).
Refractory: emesis that occurs during subsequent treatment cycles despite standard and rescue antiemetic therapy.
| Step | Anti-emetic | Comments |
|---|---|---|
| Step 1 | REGULAR Domperidone or metoclopramide or cyclizine +/- Dexamethasone 4-8mg BD (if platinum chemo) AND PRN Anti emetics (see comments) | Do not use domperidone and metoclopramide together Consider IV and PR routes Options for PRN anti emtics: PRN Haloperodol 0.5- 2mg 4° PO or 0.5-1mg 4°SC or PRN levomepromazine 6.25mg 4°PO or 3.125-6.25 4°SC Or PRN Ondansetron 8mg BD IV/PO ( if 1-3 days post chemo) |
| Step 2 | Add regular dose of the PRN anti emetic from step 1 | Consider PRN lorazepam 0.5-1mg 6° PO if element of anticipatory nausea is suspected |
| Step 3 | Escalate doses if applicable, providing no toxicity observed | Obtain palliative care review Consider syringe driver for SC administration of anti emetics, especially in cases with impaired absorbance, e.g. bowel obstruction. |
