Nausea and Vomiting
Katherina M. Violette
I. Definition:
Nausea and vomiting are two of the most common side effects of chemotherapy. They are also among the top concerns and fears for any patient who is about to receive chemotherapy.
A. Nausea is an uncomfortable wavelike feeling of distress in the epigastrium, abdomen, or in the back of the throat. It results in diminished gastric tone and reduced peristalsis. It is often associated with parasympathetic symptoms such as sweating or hypersalivation. It can be experienced alone or in combination with vomiting.
B. Vomiting is the forceful expulsion of the contents of the stomach, duodenum, or proximal jejunum through the mouth and nose.
C. Patterns of Nausea and Vomiting
1. Anticipatory nausea or vomiting is a conditioned or learned response to the previous emetogenic effects of therapy and their associated environmental stimuli. It is characterized by the onset of nausea or vomiting triggered by a sensory stimulus that reminds the person of circumstances in which they experienced nausea or vomiting from true physiologic causes. Anticipatory nausea and vomiting have been associated with all types of cancer therapy. This type of nausea can be significantly reduced if acute and delayed nausea and vomiting are minimized from the onset of therapy.
2. Acute nausea or vomiting occurs within the first 24 hours after therapy. The most common treatment-related cause is chemotherapy.
3. Delayed nausea or vomiting develops at least 24 hours after the administration of therapy. This is most common in patients receiving cisplatin, carboplatin, cyclophosphamide, anthracyclines, high doses of chemotherapy, and radiation therapy. The pathophysiology of delayed nausea and vomiting is poorly understood and research is ongoing.
II. Etiology:
Vomiting is a complex process that must involve coordination of input from both the brain and the gastrointestinal (GI) tract. The vomiting center (VC) is located in the lateral reticular formation of the medulla. The VC is stimulated by one of five different afferent pathways or by stimulation from the chemoreceptor trigger zone (CTZ), which is located anterior to the medulla in the fourth ventricle. Several factors may contribute to nausea and vomiting in the cancer patient.
A. Afferent pathway stimulation from any mechanism causes stimulation of the vomiting center.
1. Vagal visceral afferents are associated with irritation of the GI tract.
2. Sympathetic visceral afferents are stimulated when organs of the chest and abdomen are irritated, obstructed, or ischemic.
3. Vestibulocerebellar afferents involve the labyrinth of the inner ear. This is generally not of concern in chemotherapy-related nausea and vomiting.
4. Midbrain afferents respond during increased intracranial pressure.
5. Cerebral cortex and limbic system afferents respond to stimulation of the senses, including sights, tastes, and odors. This is where classical conditioning is manifested as anticipatory nausea and vomiting.
B. CTZ Stimulation
1. It is believed that chemotherapy-related vomiting is primarily the result of stimulation of the CTZ. It is thought that metabolites of chemotherapy irritate the CTZ by way of direct blood supply or the exposure to cerebrospinal fluid. Vomiting results when the CTZ stimulates the VC.
2. Several neurotransmitters have been identified as being present or affecting this area. They include dopamine, serotonin (5-HT), gamma-aminobutyric acid (GABA), histamine, acetylcholine, norepinephrine, prostaglandin, glutamate, corticosteroid, cannabinoid, opiate, and neurokinin-1 (NK1).
3. Chemotherapy stimulates enterocromaffin cells in the GI tract to release serotonin.
C. Other Factors
1. Radiation therapy involving the brain, chest, abdomen, or back will cause stimulation of sympathetic visceral afferents and possibly vagal visceral afferents. Total body irradiation often causes nausea and vomiting.
2. Constipation, GI obstruction, renal dysfunction, or biliary obstruction can all cause nausea and vomiting because of sympathetic and vagal visceral afferents.
3. Brain metastases can directly or indirectly stimulate midbrain afferents.
4. Severe anxiety or pain causes stimulation of cerebral cortex afferents that result in nausea or vomiting.
5. Electrolyte abnormalities, especially hypercalcemia and hyponatremia, can cause nausea and vomiting. The suspected mechanisms are stimulation of vagal visceral afferents or direct effects on the CTZ.
6. Other medications (eg, opioids, nonsteroidal antiinflammatory agents, salicylate-containing medications).
III. Patient Management
A. Assessment
1. Nausea
a. Dizziness is thought to occur in conjunction with nausea because of vagally induced bradycardia and hypotension.
b. Pallor usually occurs in conjunction with hypotension.
c. Diaphoresis, abdominal cramping, and hypersalivation coincide with parasympathetic afferent vagal stimulation.
d. Tachycardia occurs due to the sympathetic stimulation of the stress response when a person is nauseated.
2. Vomiting
a. Excessive salivation occurs with vagal visceral afferent stimulation. This often precedes actual vomiting.
b. Increased heart rate before vomiting and decreased heart rate during vomiting. The stressor of impending vomiting causes tachycardia, but, as vagal stimulation occurs with vomiting, the heart rate decreases.
c. Decreased blood pressure occurs with bradycardia.
d. Increased rate and depth of respiration.
e. Generalized feeling of weakness.
3. Nausea and vomiting assessment scales and standards
a. Nausea is a subjective symptom; vomiting is objective.
b. There are variable and subjective degrees of distress associated with these symptoms.
c. Self-report is the most important and reliable method of collecting information about nausea and vomiting because it is the amount of distress it induces that may dictate interventions for persistent symptoms.
d. Nausea and vomiting should be assessed for about 3 days after acute emetogenic therapy and indefinitely in therapies known to cause delayed nausea and vomiting.
e. The Nausea and Vomiting Symptom Distress Adaptation Scale originally developed by Rhodes, Watson and Johnson is one of the most common instruments used to assess nausea and vomiting (Rhodes, Watson & Johnson, 1984).
f. Other multisymptom assessment tools may include questions addressing the presence or severity of nausea and vomiting.
4. Assessment of nausea and vomiting should include evaluation for potential complications.
a. Electrolyte abnormalities
b. Dehydration
c. Anorexia/cachexia
d. Mallory-Weis tear (esophagus-stomach junction tears with forceful vomiting and causes sudden and severe upper GI bleeding)
e. Aspiration pneumonia
f. Pathologic fractures
g. Dental carries
B. Diagnostic Parameters
1. There are no specific tests used to diagnose nausea and vomiting.
2. A general assessment and history of the patient may indicate the occurrence of nausea and vomiting.
a. Patient’s response to nausea or vomiting in other situations, such as pregnancy, flu, car-sickness, or nervousness, may give an indication as to the response to nausea and vomiting during the cancer experience. The presence of four or more of the following specific characteristics with the first chemotherapy treatment has been found to significantly predict subsequent anticipatory nausea development. This anticipatory nausea typically will occur by the fourth cycle of chemotherapy (Morrow, Lindke & Black, 1991).
(1) Actual presence of nausea or vomiting with first cycle
(2) Patient report that nausea/vomiting was “moderate, severe, or intolerable”
(3) <50 years old
(4) Susceptibility to motion sickness
(5) Feeling warm or hot all over and/or sweating with first treatment
(6) Feelings of generalized weakness after first treatment
b. History of chronic or high alcohol intake has been associated with a lesser occurrence of nausea or vomiting (Markman, 2002).
c. Females are more likely to experience nausea or vomiting than males (Markman, 2002).
d. Elderly patients are less likely to experience nausea and vomiting than younger patients (Markman, 2002).
e. Previous strategies or medications used to treat nausea or vomiting and their success are important to note and incorporate into the patient’s treatment plan.
f. Patient’s expectations or anxiety regarding treatment may be related to previous personal and anecdotal experiences, and may include misconceptions regarding the symptom or its management.
g. The emetogenic potential of the chemotherapeutic agent, at least in part, predicts the risk of its occurrence (Table 27-1). Some chemotherapeutic agents have a higher incidence of nausea and vomiting as a side effect, which would make them more emetogenic.
h. Concomitant radiation therapy also increases the risk of nausea and vomiting in patients.
C. Treatment: General Guidelines
1. Nonpharmacologic interventions
a. Provide a calm, reassuring environment.
b. Minimize distinctive odors or sights, including perfumes, room deodorizers, and disinfectants. Strong smells can trigger nausea. Smells can also produce a conditional response.
c. Provide adequate ventilation in the room.
d. Use distractions, including music or television.
e. Use relaxation techniques, such as progressive muscle relaxation and guided imagery.
f. Use hypnosis and systematic desensitization.
g. Consider aromatherapies thought to help alleviate nausea and vomiting, such as peppermint.
h. Consider ginger, which has been reported by patients as helpful.
i. Acupuncture and acupressure may be tried. Mild pressure applied to the inner aspect of the wrist (P-6 acupressure point) can be applied by using acupressure bands.
j. Encourage light aerobic exercise, as patient tolerates.
k. Have an emesis basin close at hand, but not in sight.
l. Offer frequent mouth care.
m. Plan dietary interventions (see Chapter 28).
(1) Offer mints or sour candy during chemotherapy administration to help decrease metallic or drug taste.
(2) Serve foods that are room temperature or colder to minimize the odors that can often make a patient nauseous.
(3) Avoid fatty or spicy foods.
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