Page 187 Guide to Pain Management in Low-Resource Settings

Hematologic Cancer with Nausea and Vomiting 175

Pearls of wisdom

Treatment algorithms (adapted from Policzer and Sobel
[3]) are shown in Table 5.

Table 5
Treatment algorithms
Cause Symptoms Treatment Alternatives
Cortical
CNS tumor/meningeal irritation Focal neurological signs or mental status Corticosteroids
changes Consider palliative radiation
Increased intracranial pressure Projectile vomiting and headache Corticosteroids
Anxiety or psychogenic symp- Anticipatory nausea, conditioned responses Counseling
toms Relaxation techniques
Benzodiazepines
Uncontrolled pain Pain and nausea Increase pain medications
Use adjuvants
Vestibular
Vestibular disease Vertigo or vomiting after head motion Antihistamines (meclizine)
Middle-ear infections Ear pain or bulging tympanic membrane Antibiotic therapy and other supportive
care
Motion sickness Travel-related nausea Anticholinergics (scopolamine)
Chemoreceptor Trigger Zone
Medications Nausea worse after medication dosage or exac- Decrease dose or discontinue medication
erbated after increasing dose
Metabolic (renal or liver failure) Increased blood urea nitrogen (BUN), creati- Dopamine antagonist
nine, bilirubin, etc.
Hypercalcemia Somnolence, delirium, high calcium Hydration
Corticosteroids
Bisphosphonates
Gastrointestinal Tract
Irritation from medications Use of nonsteroidal anti-infl ammatory drugs Discontinue drug if possible
(NSAIDs), iron, alcohol, antibiotics Add histamine (H ) blocker, proton pump
2
inhibitor, or misoprostol
Tumor infi ltration or infection Evidence of abdominal tumor, candida esopha- Antihistamines
gitis, colitis Treat infection
Anticholinergics
Constipation or impaction Abdominal distension, no bowel movement for Laxatives
many days Manual disimpaction
Enema
Obstruction by tumor or poor Constipation unrelieved by treatment Prokinetic agents
motility
Malignant bowel obstruction Severe pain, abdominal distension, visible Analgesics (opioids)
peristalsis Anticholinergics
Dopamine antagonists
Corticosteroids
Consider octreotides

References [2] Naeim A, Dy SM, Lorenz KA, Sanati H, Walling A, Asch SM. Evidence-
based recommendations for cancer nausea and vomiting. J Clin Oncol
2008;26:3903–10.
[1] Dalal S, Palat G, Bruera E. Chronic nausea and vomiting. In: Berger [3] Policzer JS, Sobel J. Management of selected nonpain symptoms of life-
AM, Shuster JL, Von Roenn, Jamie H, editors. Principles and practice limiting illness. Hospice and palliative care training for physicians—a
of palliative care and supportive oncology, 3rd edition. New York: Lip- self-study program, 3rd edition, vol. 4. Glenview, IL: American Acad-
pincott Williams & Wilkins; 2007. emy of Hospice and Palliative Medicine; 2008.