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Define Nausea
Vomiting?
Retching?
- Nausea is the unpleasant feeling or sensation that may be immediately followed by vomiting
- Vomiting is the expulsion of gastric content. This is NOT voluntarily controlled
- Retching is the movement of abdominal and thoracic muscles before vomiting.
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Which 4 areas provide input to vomiting center?
Involves Brain and GI.
- Chemoreceptor trigger zone, with neurotransmitters dopamine and serotonin.
- Vestibular apparatus
- Cerebral cortex
- Visceral GI tract afferent nerves
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Of the 4 areas that provide input to the vomiting center, which is the most important with regards to where drugs will act/affect?
Chemoreceptor trigger zone (CTZ)
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True/False:
Hypercalcemia can cause nausea and vomiting.
True
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What are the 2 main etiologies for nausea and vomiting?
Drug Induced : Opioid family, narcotics (Primary reason), cardiac glycosides, Broncodilators (digoxin, theophylline), antibiotics
Medical conditions: Fluid & electrolyte disorders, pregnancy, GI obstruction, Increase Intracranial pressure, Surgery, peritonitis, dysfunctional bowel syndrome, metastasis, etc.
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What are some possible acute complications from N&V?
- 1) Dehydration
- 2) Aspiration
- 3) Malnutrition
- 4) Electrolyte or acid/base abnormalities
- 5) Esophageal tears
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What is the ultimate goal of therapy for N&V?
To determine the cause and use of the most appropriate agent(drug)
- Example: Gastroenteritis is due to food eaten. Usually short lived, can use compazine.
- CINV: can be severe. Always pre-treat, continue for 24-72 hrs after therapy
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True/False: Post operative nausea and vomitting (PONV) is more common in adults than children.
- False.
- 2x higher in children than adults.
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List risk factors for PONV in adults (5):
- 1.) Female
- 2.) Non-smoker
- 3.) Family Hx of motion sickness/PONV
- 4.) Long surgeries (2-3 hrs) OR use of nitrous oxide
- 5.) Post-operative use of opioids
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True/False: Prophylaxis vs. treatment therapies are different for N&V.
True.
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What are the three broad categories to examine as causes of N&V?
- 1.) Dietary
- 2.) Physical
- 3.) Pscyhological
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List the seven non-pharmacological therapies for N&V.
- 1.) Relaxation
- 2.) Biofeedback (?)
- 3.) Self hypnosis
- 4.) Cognitive distraction
- 5.) Guided imagery
- 6.) Systematic desensitization
- 7.) Accupressure therapy
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What are the 4 categories of drugs that treat N&V?
- 1.) 5 HT3 receptor antagonists (serotonin antagonists)
- 2.) Anticholinergics (including antihistamines)
- 3.) Antidopaminergics (including phenothiazines)
- 4.) Misc.
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What drugs are included in the class of phenothiazines?
- 1.) prochlorperazine (Compazine)*
- 2.) chlorpromazine (Thorazine)
- 3.) thiethylperazine (Torecan)
- 4.) promethazine (Phenergan)
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What is the PO dosing for prochlorperazine (Compazine)?
5-10 mg PO q 4-6 hrs
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What is the IM dose for prochlorperazine (Compazine)?
5-10 mg IM q 3-4 hrs
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What is the IV dose of prochlorperazine (Compazine)?
2.5 - 10 mg IV q 3-4 hrs
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What is the rectal dose of prochlorperazine (Compazine)?
25 mg rectally q 6 hrs
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List adverse effects of the phenothiazines (dopamine blockers):
- - Sedation (most common)
- - anticholingeric effects
- - alpha adrenergic blocking effects
- - EPS
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What is the black box warning for promethazine (Phenergan)?
Do not use in children under 2 years of age.
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True/False: Phenergan can be administered IV.
True.
Use caution --> very caustic to tissues, must be diluted, and administered only into a large vein or central venous site.
Start with a low dose = 6.25 - 12 mg over 10 -15 mins.
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Which phenothiazine may be used for PONV?
promethazine (Phenergan).
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What classes of drugs are categorized as anti-dopaminergics (dopamine blockers)?
- 1.) phenothiazines
- 2.) butyrophenones
- 3.) benzamides
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What are symptoms of EPS?
Who is at highest risk?
- - muscle spasms
- - restlessness
- - gait disturbances
*Children and elderly patients*
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What 2 drugs are classified as butyrophenones?
- 1.) haloperidol (Haldol)
- 2.) droperidol (Inapsine)
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True/False: haloperidol is a common drug used to treat N&V.
- False.
- Used only when other treatments fail.
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List the adverse effects for the butyrophenones:
- - sedation
- - somnolence (drowsiness/sedation)
- - dystonic reactions (movement disorder)
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What is the black box warning associated with the butyrophenones?
QT prolongation or Torsades de pointes may occur.
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What is the only use for droperidol?
Only used in cases pre-operative anaesthesia.
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What is the only drug classified as a Benzamide?
metoclopramide (Reglan)
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True/False: metoclopramide is both a dopamine and serotonin blocker
- True.
- Its a serotonin blocker at higher doses
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What are the main side effects of metoclopramide (Reglan)?
- -sedation
- -diarrhea
- -restlessness
- -anxiety
- -EPS
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With what population is metoclopramide never used and why not?
Children. Due to the risk of EPS
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What corticosteroid can be used for N&V?
dexamethasone (Decadron) - used on a short-term basis
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When is dexamethasone (Decadron) used for N&V?
Its used as a last resort, but routinely used in CINV.
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Serotonin antagonists block what kind of receptors?
5-HT3
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What are the 4 Serotonin antagonists used for N&V?
- 1.) ondansetron (Zofran) **Need to know dosing
- 2.) granisetron (Kytril)
- 3.) dolasetron (Anzemet)
- 4.) palonosetron (Aloxi)
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True/False. Ondansetron has no clinical advantage over other SSRI's.
True
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What are the dosage forms and strengths for ondansetron (Zofran)?
- Tablet - 4, 8 and 24 mg
- Oral disintegrating - 4 and 8 mg
- Solution - 4mg/5ml
- Injection - 2 mg/ml and 32 mg/50 ml
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When is ondansetron used for N&V?
- 1.) IV 4 mg usually given for pre-op (1 dose)
- 2.) PONV: 4 mg IV/IM before induction of anesthesia or at onset of N/V
- 3.) Chemo-induced
- a) by mouth 8-32 mg BID-TID
- b) IV: three 0.15 mg/kg doses (1/2 pre, then 4 & 8 hrs post) or single 32 mg dose
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True/False. Headache is the most common side effect for ondansetron.
True.
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What are the rare side effects of ondansetron?
Elevation in liver transaminases, constipation, diarrhea or QT interval prolongation
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Name the drug that is a neurokinin receptor antagonist (selective antagonist of substance P).
aprepitant (Emend)
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What are the indications for metoclopramide (Reglan)?
- - CINV
- - PONV
- - Post-operative gastric motility
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What is/are the indications for aprepitant (Emend)?
aprepitant is ONLY used for CINV.
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Why must women taking aprepitant (Emend) use a another form of birth control pills use another form of contraception?
aprepitant (Emend) inhibits CYP3A4, reducing the efficacy of oral birth control pills.
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What drugs fall under the class of antihistamines used for N&V?
- - diphenhydramine (Benadryl)
- - dymenhydrinate (Dramamine)
- - meclizine (Antivert)
- - trimethobenzamide (Tigan)
- - scopolamine (Transderm Scop)
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True/False: the antihistamine class of drugs are generally ineffective at treating N&V, unless it is associated with motion sickness.
True.
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What are common side effects of the antihistamines used for N&V?
- - Drowsiness/sedation
- - Dry mouth
- - Blurred vision
- - Children have a paradoxical experience (insomnia)
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Which antihistamine is the exception to the rest, as it causes less sedation than compazine and may be used as an alternative to compazine should the drowsiness become a problem?
trimethobenzamide (Tigan)
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What drug is classified as a benzodiazepine?
lorazepam (Ativan)
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What is/are the indications for lorazepam (Ativan)?
- Treatment for anticipated N&V.
- For example, as pre-chemotherapy treatment.
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What is a common side effect of the benzodiazepines?
Sedation
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True/False: The cannabinoids are scheduled drugs.
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What drugs are classified as cannabinoids?
- - dronabinol (Marinol)
- - nabilone (Cesamet)
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What is the only indication for the cannabinoids?
CINV
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What are the common side effects for the cannabinoids?
- - CNS effects
- - dizziness
- - dysphoria
- - mood & sensory changes
- - paranoid ideation
- - blurred vision
- - hypotension
- - tachycardia
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What medications may be given as treatment for EPS / acute dystonic reactions?
*First ensure the patient has stable airway and respiratory activity
- - diphenhydramine
- 0.7-1 mg/kg/dose IV/PO q 4-6 hrs PRN
- - benztropine (Cogentin)
- 1-2 mg IV/PO q 4-6 hrs PRN (works faster)
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True/False: Whenever possible, administer anti-emetics before N&V occur.
True.
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True/False: first-line treatment of N&V in pregnant women is compazine.
- False.
- Most cases are due to a deficiency in pyridoxine (Vit B6). Give this first. If N&V does not subside, consider anti-emetics.
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What are some recommended medications for the treatment of CINV?
- - aprepitant (Emend)
- - dexamethasone (Decadron)
- - Serotonin 5 HT3 receptor antagonists
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What are some recommended medications for the treatment of Gastroenteritis?
Gastroenteritis is short lived and self limiting, but can be treated with prochlorperazine (Compazine)
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