brief discuss about nausea & vomiting generally & go through management of CINV

2. Nausea & vomiting :
 Nausea is usually defined as the inclination to
vomit or as a feeling in the throat or epigastric
region alerting an individual that vomiting is
imminent ( subjective ).
 Vomiting is defined as the ejection or expulsion
of gastric contents through the mouth, often
requiring a forceful event (reflexive )
 Retching is the contraction of the abdominal
wall,diaphragm &thoracic muscle wihtout
expulsion
Nausea
Autonomic
symptoms
Retching
Contraction
Vomiting
Contraction +
forced expel of
Gicontent

3. Pathophysiology
Nausea & vomiting are complex
interaction from different systems
Central
vomiting center
(medulla)
CTZ
(5-HT3
,D2,NK1
Gastrointestin
al(visceral
afferents(5-
HT3,D2,NK1
Cerebral
cortex
(sensory)
Vestibular
system
(H!,
muscarinic )

4. •Types & causes :
 GI or intraperitoneal
 Cardiac
 Neurologic
 Therapy induced
 Endocrine/metabolic
 Others
( CINV , PONV , NVP , motionskiness )

5. •How are we manage ?!
DESIRED OUTCOME
 The overall goal of antiemetic therapy is
to prevent or eliminate nausea and
vomiting; this should be accomplished
without adverse effects or with clinically
acceptable adverse effects.
PharmacologicalNon
pharmacological

6. •General treatment approach :
 Removal or treatment of the under lying
cause
 Correction of dehydration & electrolyte
disturbances (oral hydration preferred if
possible )
 When we choose Drug treatment we use
drugs that target receptors involved (may
use combination )& also we need
alternative forms of medication wit
different route of administration (IM ,IV
,SC ,Suppository….etc)

7. •Non pharmacological ttt:
 It is including :
1. Dietary approaches (small meal ,
high protein , avoid spicy or fatty food
eat dry blended food, using herbal
remedy , multivitamins intake )
2. Psychotherapy & hypnosis
3. Acupressure & electric-acupoint
stimulation by wearing briclet
affecting this area

8. •Pharmacological Anti emetic
classes :
• cyclazine
• DiphenhydramineAntihistaminic
• Phenothiazine(chloropromazine)
• Butyrophenone(haloperidol)
• Benzamides(metaclopromide , domperdione )
antidopaminergic
• Granisetron
• ondansetron
• Palonosetrone
Serotonin
antagonists
Neurokinin 1
antagonist
•Aprepitant
•Fosaprepitant

9. •Cont,.:
• DexamethasoneCorticosteroides
• Aloprozolam
• Lorazepam
Benzodiazipens
• nabilone
• Dronabinol
Cannabinoids

10. 1
• Types of CINV
2
• Risk stratification
3
• How to manage (guidelines )
CINV

11. •Types :
1. Acute onset : 0-24hrs after chemo
administration .
2. Delayed onset : occurs more than 24hrs
after chemo administration
3. Anticipatory vomiting : is triggered by
sights ,smells , sounds & is a conditioned
response & mainly after uncontrolled N&V
by chemo
4. Breakthrough emesis occurs despite
prophylactic ttt
5. Refractory emesis refers to emesis that
occurs during cycles when antiemetic
prophylaxis have failed in pervious cycles

12. •Risk stratification :
Patient
related risk
factors
Emetogenicity of
chemotherapy
agents
Radiation
exposure

13. •Patients related risk :
 Patient’s age (younger or those
younger than 50 years
 Female sex
 HX of motion skiness or NVP
 Poor control of N&V in pervious
chemo cycles
 HX of chornic alcoholism (+ve risk
↓incidence)

14. Chemo related :

15. Radiation :
 Radiation can also cause N&V , the
incidence & severity vary according
the site & size of the radiation field :
a. Mildly emetogenic (radiation to head ,
neck or extremities )
b. Moderate (radiation to upper
abdomen ,pelvis or craniospinal )
c. High (total body ,total nodal & upper
half body irradiation )

16. How to manage :