NAUSEA &VOMITING

Anky Tri Rini Kusumaning Edhy

 CASE

A, 15 yo high school, diagnosed stage IV Osteosarcoma with multiple

lung nodules. He got chemotherapy and higher dose opioids and it’s
creating significant side effect.
He has already got adequate anti vomiting.
He has significant vomiting and nausea, so it leads to difficulty in
staying hydrated.
The team is talking with A and his parents about the options
What is your opinion about the case?
 Cause : medis ? Non medis ?
 Treatment ?
 EVALUATION AND ASSESSMENT

History and Physical examination

Onset
Quality
Associations
Does vomiting provide relief?
Medications
Associated symptoms
NAUSEA/ VOMITING MECHANISMS
MANAGEMENT

Treat underlying cause : ileus, drug adverse effects, anxiety

Integrative approaches :
Provide small meals chosen by child
Provision of favourite drinks
Hypnosis, breathing techniques
Good oral care
Avoid discomforting smells
Aromatherapy
Acupressure
ANTI EMETICS
- 5 HT3 Receptor antagonists :
 Ondansetron / Granisetron
- D2 Receptor antagonists :
 Metoclopramide/ Haloperidol  extrapyramidal reactions
- Domperidone  no extrapyramidal reactions, does not cross the blood
brain barrier
- H1 and Achm receptor antagonist :
 Diphenhydramine, promethazine
OPIOIDS  NAUSEA AND VOMITING

- Induces activation of the chemoreceptor trigger zone

- Peripheral pathway activation
- Sensitization of the labyrinth and activation of the vestibular system

Treatment :
1. Opioid rotation
2. low dose naloxone : 0,5-2 mcg/kg/hour
3. D2 receptor antagonist and or antihistamine/ anticholinergic
CHEMOTHERAPY  NAUSEA AND VOMITING

Types : Treatment :
- 5 HT3 receptor
1. Acute Emesis
antagonists
2. Delayed Emesis - NK1 receptor antagonist
3. Anticipatory Emesis - Glucocorticoids
- Benzodiazepines
ASCO GUIDELINES
EMPIRIC MULTIMODAL ANTI EMETICS

First line :
5HT3 receptor antagonist and/ or
D2 receptor antagonist and/ or
H1 & Achm receptor antagonist
Second line :
Consider adding corticosteroid
Adding low dose benzodiazepine
Consider substituting phenothiazine for both antihistamine and
dopamine antagonist
Third line :
Consider adding cannabis
Consider aprepitant
Consider low dose propofol