nausea and vomitingThis information is sourced from NICE, PANG, Sottish Palliative Guidelines, the BMJ and North West London ICS:
Nausea and vomiting are really important symptoms to control. Without effective treatment people can rapidly decline; through an inability to eat resulting in weakness, fatigue and often depression.
Trying to elucidate the cause leads to better success in controlling symptoms. Often there are multiple minor causes that tip the threshold into feeling sick.
Red flags
Exclude bowel obstructionKey clinical features to assess in the community
- Review underlying diagnosis and recent treatment (e.g. site of tumours, organ failure, recent chemo)
- Medication review (see table below)
- Severity eg inability to take usual oral medication
- Overall condition: signs of dehydration or infection (UTI, chest infection, oral candida)
- Abdominal and rectal exam for constipation, masses, bowel sounds, tender epigastrium
- Assessment of anxiety levels as this can be a cause of nausea
- Associated symptoms eg headache suggesting a cerebral cause
An initial approach to treatment
- Stop or reduce dose of offending drugs
- Blood tests for a metabolic cause
- Urinalysis to exclude infection
- Antiemetics (metoclopramide is a good first antiemetic to try)
- Consider more specific treatments according to cause - see table below
- Nutritional and hydration advice can be very effective
Top tips
- Beware worsening colic (or vomiting) with prokinetics - suggests bowel obstruction
- Levomepromazine has a broad spectrum of action but is sedating at doses > 12.5mg/24h
- Ondansetron can cause constipation
- Metoclopramide can cause neurological side effects e.g. akathisia/restlessness
- 25% cases may need 2 anti-emetics
- Olanzapine is an alternative broad-spectrum antiemetic starting in doses of 2.5mg OD
- Prochlorperazine (in buccal form Buccastem) is useful at home if no injections are available
- Bland food, avoid cooking smells, and some complementary approaches eg Sea Bands may help
Specialist care
- Advice on combination antiemetics
- Abdominal CT scan and ultrasound are useful if symptoms persist
Specific treatments according to cause:
|
Cause |
Clinical Features |
Initial approach to treatment |
|
Drugs e.g. opioids*, antibiotics, SSRIs, NSAIDs, steroids, chemotherapy
*If dose of opioid is stable, it is unlikely to be the cause of nausea |
Constant background nausea |
Stop/reduce dose of offending drugs Consider gastroprotection with PPI Haloperidol Oral/subcutaneous dose: 1.5 mg once or twice daily, up to 5 mg daily (lower starting dose 0.5 mg for frail people). Syringe pump:2.5mg–5 mg/24 hrs Metoclopramide Oral/subcutaneous dose: 10 mg 3-4 x/24 hrs. Syringe pump : 30–50 mg /24 hours Ondansetron for chemo nausea. Oral/subcutaneous dose 4mg-8mg tds
|
|
Metabolic causes renal failure, liver failure, hypercalcaemia, hyponatraemia |
Co-existent delirium may suggest metabolic cause |
Haloperidol as above Hypercalcaemia will need IV hydration and bisphosphonates if appropriate to admit
|
|
Gastric stasis, and severe constipation |
Large volume vomit, relief of symptoms after vomiting, oesophageal reflux, hiccups. |
Stop/reduce anticholinergic drugs such as Buscopan, tricycyclic antidepressants, Oxybutinin Use prokinetic antiemetics: e.g. Domperidone 10mg tds orally or Metoclopramide as above Treat constipation Erythromycin 250mg bd may help
|
|
Physical obstruction (from tumour or external compression) |
Vomiting pattern depends on level of obstruction |
If possibility of reversal – use prokinetic Metoclopramide in a syringe pump as above. Dexamethasone e.g. 8mg subcutaneously may help nausea and reduce compression. If likely irreversible – a combination of Cyclizine +/- Haloperidol in a syringe pump CT may help to identify level/reversibility of blockage
|
|
Toxins e.g. ischaemic bowel, tumour products, infection |
|
Levomepromazine Oral or subcutaneous dose: 6.25 mg 8 hourly. Syringe pump dose: 12.5 mg-25mg /24 hrs
|
|
Raised intracranial pressure |
Effortless vomiting, often in the morning, associated with headache and papilloedema |
Cyclizine Oral dose: 25–50 mg up to 150mg/24hrs Subcutaneous dose: 25mg up to 100mg/24 hrs Syringe pump dose: Up to 100mg /24 hrs CT head plus Dexamethasone /oncology review
|
|
Motion-associated nausea |
Nausea or sudden vomiting on movement (eg turning in bed) |
For vestibular disturbance (eg diseases of the inner ear and motion sickness): Cyclizine as above |
|
Anxiety-related nausea |
Nausea may be triggered by a previous stimulus |
CBT may help Lorazepam 0.5mg orally can be tried |