Nausea and vomiting at the end of life: Difference between revisions

Latest revision as of 11:28, 30 November 2022

Differential Diagnosis

Head
- Increased ICP
- Meningeal irritation
- Anxiety
- Vestibular disorders
Gastrointestinal
- Esophageal: GERD, thrush
- Gastric
  - Gastric irritation
  - Gastric stasis
- Obstruction
- Infection
Organ failure
- Renal failure
- Liver failure
Other causes
- Medications
- Hypercalcemia
- Tumour-induced
- Sepsis

Pathophysiology

Four pathways
- Vestibular system
  - Causes: motion, labyrinth disorders
  - Receptors: muscarinic acetylcholinergic and H1 histamine receptors
- Chemoreceptor trigger zone (area outside blood-brain barrier)
  - Causes: drugs, metabolic products, bacterial toxins
  - Receptors: central D2 dopamine receptors (most important), 5HT3 serotonin receptors, and NK1 receptors
- Cortex
  - Causes: sensory input, anxiety, meningeal irritation, increased ICP
- Peripheral pathways
  - Causes: mechanical stretch, chemotherapy, radiotherapy, GERD, Candida, metastases, local drugs or toxins
  - Receptors: 5HT3 serotonin receptors (GI tract), mechanoreceptors and chemoreceptors in GI tract

Management

Metabolic: D2 antagonist (e.g. haloperidol, metoclopramide)
Chemotherapy: D2 antagonist (e.g. haloperidol, metoclopramide)
Increased ICP: dexamethasone
Obstruction: general surgery consult or medical management (AAAH)
- Anti-emetic
  - Neuroleptics: haloperidol 0.5-2mg po/sc up to q1h prn
  - If partial: metoclopramide 5-10mg po/sc QID
- Analgesic
  - Opioids
  - Anti-spasmodics: buscopan 10mg po/sc q6h (antikinetic)
- Anti-secretory
  - Somatostatin analogues: octreotide 100-500 mcg sc TID
  - Anticholinergics: scopolamine, buscopan
- Anti-inflammatory
  - Dexamethasone 4mg po/sc daily to QID
  - Decreases edema around obstruction to allow passage of some stool
- Hydration

@@ Line 4: / Line 4: @@
 ** Increased ICP
 ** Meningeal irritation
-** Anxiety
+** [[Anxiety]]
 ** Vestibular disorders
 * Gastrointestinal
-** Esophageal: GERD, thrush
+** Esophageal: [[GERD]], [[thrush]]
 ** Gastric
 *** Gastric irritation
@@ Line 18: / Line 18: @@
 * Other causes
 ** Medications
-** Hypercalcemia
+** [[Hypercalcemia]]
 ** Tumour-induced
-** Sepsis
+** [[Sepsis]]
 == Pathophysiology ==
@@ Line 34: / Line 34: @@
 *** Causes: sensory input, anxiety, meningeal irritation, increased ICP
 ** Peripheral pathways
-*** Causes: mechanical stretch, chemotherapy, radiotherapy, GERD, candida, metastases, local drugs or toxins
+*** Causes: mechanical stretch, chemotherapy, radiotherapy, [[GERD]], [[Candida]], metastases, local drugs or toxins
 *** Receptors: 5HT3 serotonin receptors (GI tract), mechanoreceptors and chemoreceptors in GI tract
 == Management ==
-* Metabolic: D2 antagonist (e.g. haldol, metoclopramide)
+* Metabolic: D2 antagonist (e.g. [[haloperidol]], [[metoclopramide]])
-* Chemotherapy: D2 antagonist (e.g. haldol, metoclopramide)
+* Chemotherapy: D2 antagonist (e.g. [[haloperidol]], [[metoclopramide]])
-* Increased ICP: dexamethasone
+* Increased ICP: [[dexamethasone]]
 * Obstruction: general surgery consult or medical management (AAAH)
 ** Anti-emetic
-*** Neuroleptics: haloperidol 0.5-2mg po/sc up to q1h prn
+*** Neuroleptics: [[haloperidol]] 0.5-2mg po/sc up to q1h prn
-*** If partial: metoclopramide 5-10mg po/sc QID
+*** If partial: [[metoclopramide]] 5-10mg po/sc QID
 ** Analgesic
 *** Opioids
-*** Anti-spasmodics: buscopan 10mg po/sc q6h (antikinetic)
+*** Anti-spasmodics: [[buscopan]] 10mg po/sc q6h (antikinetic)
 ** Anti-secretory
-*** Somatostatin analogues: octreotide 100-500 mcg sc TID
+*** Somatostatin analogues: [[octreotide]] 100-500 mcg sc TID
-*** Anticholinergics: scopolamine, buscopan
+*** Anticholinergics: [[scopolamine]], [[buscopan]]
 ** Anti-inflammatory
-*** Dexamethasone 4mg po/sc daily to QID
+*** [[Dexamethasone]] 4mg po/sc daily to QID
 *** Decreases edema around obstruction to allow passage of some stool
 ** Hydration