1. Nausea & Vomiting
‘made easy’

2. First steps What is the cause? Non-medical treatment Medical treatment
1st line
Other options

3. Scale of the problem Occurs in 40-70% patients with advanced cancer
1/3 will have more than 1 contributing factor
1/3 will need more than 1 anti-emetic

4. Non-medical treatment
Calm environment & good ventilation
Frequent small snacks
Avoid sight & smell of food eg cooking

5. Gastric stasis - causes
Drugs
Opioids
‘Squashed stomach syndrome’
tumour, enlarged liver, ascites
Outflow obstruction
tumour

6. Gastric stasis - symptoms
Epigastic discomfort
Fullness
Early satiety
Exacerbated by eating / relieved by vomiting
Large volume vomits (undigested food)

7. Gastric stasis - management
Prokinetic agent
metoclopramide 10-20mg tds (oral)
40-80/24hrs sc infusion
Also consider
Domperidone (less side effects but not sc)
PPI to reduce acidity
Steroids 8-12mg dexamethasone for 7 days
2nd line
Cyclizine 50mg tds po/sc (150mg/24hrs sc infusion)
bowel distension

8. Chemically-induced nausea - causes
Drugs (10-30% on inititation of opioid)
antibiotics, anticonvulsants, antidepressants, cytotoxics, steroids, digoxin, NSAID’s
Metabolic
renal or hepatic failure, hypercalcaemia, hyponatraemia, ketoacidosis
Toxins
ischaemic/obstructed bowel, tumour effect, infection

9. Chemically-induced nausea - symptoms
Constant nausea
Vomiting is variable in volume & timing
May be other features of drug toxicity

10. Chemically-induced nausea - management
Haloperidol po/sc 1.5-3mg od/bd
mg/24hrs sc infusion
Also consider
Correct the correctable
Metoclopramide (gastric stasis) 10mg tds

11. Raised intracranial pressure – causes
Intracranial tumour
Cerebral oedema
Intracranial bleed
Meningeal infiltration by tumour
Skull metastases
Cerebral infection

12. Raised intracranial pressure – symptoms
Nausea worse in the morning
Headache
Nausea and/or vomiting provoked by head movement

13. Raised intracranial pressure – management
Cyclizine 50mg tds (oral)
150mg/24hr sc infusion
Also consider
High dose steroid: dexamethasone 16mg od
Hyoscine hydrobromide
Kwells 300mcg qds
mg/24hr sc infusion

14. If at first you don’t succeed…
Consider adding a second agent
Different mechanisms of action
eg haloperidol with cyclizine
Avoid antagonistic action
cyclizine counteracts the prokinetic affect of metoclopramide
Consider levomepromazine
‘broad spectrum’ antiemetic
mg (1/4 -1/2 tablet)po
or 5-25 mg sc/sc infusion over 24hrs

15. Summary Gastric stasis Chemically-induced Raised intracranial pressure
metoclopramide
Chemically-induced
haloperidol
Raised intracranial pressure
cyclizine
Consider additional or 2nd line treatment
Don’t forget the effect of anxiety & pain