Clinical Guidelines (Nursing)

Chemotherapy induced nausea and vomiting

  • Note: This guideline is currently under review.  

      Introduction

      Chemotherapy induced nausea and vomiting (CINV) is a common and extremely unpleasant side effect for children receiving chemotherapy. The goal of antiemetic therapy is to prevent vomiting and minimise nausea during and after the administration of chemotherapy. The severity of nausea and vomiting can, to some degree, be predicted by the chemotherapeutic agents being delivered but there is a degree of variation between patients. Antiemetic treatments should be initiated prior to the first dose of chemotherapy for best control of nausea and vomiting, as it can often become difficult to control nausea once the child is actually vomiting. Non-pharmacological measures are also an important consideration and should be implemented in conjunction with pharmacological regimes to allow for the effective management of CINV.

      Aim

      The aim of this guideline is to provide an overview of the prevention and management of chemotherapy induced nausea and vomiting in the paediatric oncology patient.

      Definition of terms 

      Acute CINV- CINV occurring within 24 hours of chemotherapy administration

      ALL- acute lymphoblastic leukemia

      AML- acute myeloid leukemia

      AUC- area under the curve (pharmacokinetics)

      Anticipatory CINV- CINV occurring within the 24 hour period prior to chemotherapy administration; often provoked by the environment or “thought” of chemotherapy (as example sight of chemotherapy, CVAD being accessed)

      BARF scale- Baxter Animated Retching Faces scale (validated pictorial nausea scale)

      BSA- body surface area

      CINV- chemotherapy induced nausea and vomiting

      CTZ- chemoreceptor trigger zone

      Delayed CINV- CINV occurring 1-5 days after chemotherapy completion with a peak intensity 2-3 days post treatment completion

      Emetogenicity- likelihood of chemotherapy agent inducing nausea, vomiting or retching

      Haematopoietic stem cell transplant- transplantation of the blood forming components/cells of the body

      Nausea- an unpleasant feeling in the throat or stomach that may or may not result in vomiting

      NG- nasogastric

      Vomiting- ejecting part or all of the contents of the stomach through the mouth; emesis

      VAS- visual analogue scale

      Assessment

      All patients receiving chemotherapy for childhood cancer or as pre conditioning for a haemopoietic stem cell transplant (HSCT) require ongoing assessment of the incidence and severity of nausea and vomiting.

      It is the responsibility of nursing staff to regularly assess patients for signs and symptoms of CINV and decide on subsequent methods of management in consultation with the managing clinician.

      The following assessment tools can assist in determining the incidence and severity of CINV;

      Baxter retching faces (BARF) nausea scale

      Suitable for children aged 0-7 years

      BARF Scale

      Visual Analogue Scale (VAS)

      Suitable for children > 7 years 

       

       VAS Scale

      * Baxter Retching Faces Nausea Scale & Visual Analogue Scale- Baxter et al., 2011  

      Each of the scales establishes a score from 0 to 10

      • A score of 0 indicates no nausea
      • A score of 10 indicates worst possible nausea


      The assessment tools should be utilised by health professionals to provide an overview of the child’s condition which will allow for an appropriate plan of care based on these findings.

      Results of the assessment should be clearly documented at least once per shift (more frequently if clinically indicated) in the medical record. The CINV score (0 to 10) and type of scale (BARF or VAS) utilized should be recorded.

      Other indications of children experiencing CINV may include

      • Food refusal
      • Decreased fluid intake
      • Decreased urine output
      • Retching
      • Less interaction with others
      • Sweating

       

      Management

      Emetic potential of chemotherapy agents

      Chemotherapy agents have different emetic potentials that are classified based on their risk of inducing nausea and vomiting

      Low Emetogenic Potential

      • 10 to <30% frequency of emesis in the absence of effective prophylaxis

      Moderate Emetogenic Potential

      • 30-90% frequency of emesis in the absence of effective prophylaxis

      Highly Emetogenic Potential

      • Greater than 90% frequency of emesis in the absence of effective prophylaxis


      Often, combinations of moderately emetogenic agents can yield a course with high emetic potential; for example both ifosfamide and doxorubicin have moderate emetic potential yet when delivered together have high emetic potential. Other combinations of chemotherapy can, as a whole, have low emetic potential but with extra antiemetic cover required at certain times; for example high risk ALL induction is generally low emetic potential but antiemetics are usually required around daunorubicin doses.

      Anti emetic treatments should be decided based on the emetic potential of the prescribed course of chemotherapy, although there may be some instances where a specific child requires deviations from the guidelines. These decisions should be discussed with the child’s fellow or consultant. Once an effective antiemetic regimen has been determined for an individual child, this regimen should be used for future courses of chemotherapy as appropriate.

      Pharmacological prevention and management of CINV

      Full list of emetic potential of individual agents here.

      Antiemetic Prophylaxis guideline

      Minimal emetic potential Low emetic potential  Moderate emetic potential High emetic potential
      •  nil
      •  Consider Ondansetron stat dose pre chemotherapy
      •  Ondansetron 6-8/24
      • Aprepitant on day 1 of chemotherapy cycle
      • Ondansetron 6/24
      • Dexamethasone if appropriate (see table below)

      Antiemetics should be continued throughout the period of administration of chemotherapy and for at least 24 hours following completion of chemotherapy.

      Breakthrough CINV guideline 

      Breakthrough nausea and vomiting (defined as a failure to attain the goal of nil nausea and vomiting and a reasonable oral intake) should be treated promptly. It is wise to have antiemetics charted on the prn chart so that nursing staff can initiate breakthrough medication promptly. A suggested order of escalation in the face of breakthrough nausea and vomiting is tabulated below but this should be adjusted for individual situations. Consideration should be given to the contribution of anticipatory nausea and vomiting which is likely to respond better to benzodiazepines and non-pharmacologic management.
      Recommended order of escalation for breakthrough nausea and vomiting;

      Minimal emetic potential
      Low emetic potential  Moderate emetic potential  High emetic potential
      1. Ondansetron 6-8/24
      2. Metoclopramide
      1. Ondansetron 6-8/24
      2. Metoclopramide
      3. Dexamethasone if appropriate (see table below)
      1. Metoclopramide
      2. Dexamethasone if appropriate (see table below)
      3. Aprepitant if appropriate (see table below)
      1.  Metoclopramide
      2. Cyclizine/ Chlorpromazine

      Delayed CINV

      This is defined as CINV occurring 1-5 days after chemotherapy and is most commonly seen after cisplatin. Regular antiemetics should be continued for at least 48 hours after completion of cisplatin and in any other course of chemotherapy where delayed CINV has occurred in the past. Consideration can be given to a second dose of aprepitant on day 3-4 of chemotherapy if this is appropriate. Ongoing dexamethasone and ondansetron may be sufficient.

      Antiemetic medications table

      Drug
      Drug Class
      Route Dose
      Considerations
       Ondansetron 5HTз (serotonin) receptor antagonist.
      Works both centrally on the CTZ and peripherally on the vagus by blocking the 5HTз receptors
      IV/PO/SL 0.15 mg/kg to a
      maximum 8mg.
      8/24

      Can be given 6/24 with highly emotogenic chemotherapy
      Administer 15 minutes prior to first dose of chemotherapy, then 6-8/24 as required.

      Efficacy is enhanced with Dexamethasone administration.
       Metoclopramide Dopamine receptor antagonist.
      Acts on dopaminergic receptors in the CTZ & on peripheral vagal receptors to accelerate gastric emptying.
      In high dose may act on 5HTз receptors in the CTZ.
      IV/PO 0.15mg/kg to a maximum of 10mg
      6-8/24
      Dystonic reactions including oculogyric crises are rare but caution is advised for first exposure to drug.
       Dexamethasone Corticosteroid.
      Mechanism of action as an antiemetic is unclear 
      IV/PO  <0.6m²-2mg BD (pre chemotherapy loading dose 4mg)

      0.6-1.5m²-4mg BD (pre chemotherapy loading dose 8mg)

      >1.5m²-6mg BD (pre chemotherapy loading dose 12mg)

      Can consider increasing to 8/24 if breakthrough vomiting occurs

      Maximum of 12 doses per course of chemotherapy
      Caution in patients with AML- increases risk of infection.
      Consultant approval required).

      Not for use in patients where corticosteroids are part of their chemotherapy regime (B & T Cell ALL, NHL).

      Not for use in children having chemotherapy for CNS tumours without direct fellow or consultant approval- may impair CNS penetration of chemotherapy.

      If using aprepitant, halve the dose of dexamethasone (aprepitant doubles the AUC of dexamethasone).
       Cyclizine Antihistamine  IV/PO 0.5-1mg/kg to a maximum of 50mg
      8/24.
      Not for use in infants <1 year.

      Not a powerful antiemetic but may be used if vomiting persists despite recommended regimes.

      Rapid IV administration can cause drowsiness and dizziness.

      May antagonize the prokinetic effect of metoclopramide.
       Aprepitant  Neurokinin-1
      (NK-1) receptor antagonist
      PO  Single dose administered on day 1 of chemotherapy

      Based on BSA

      0.5-0.8m²=55mg

      0.8-1.2m²=110mg

      >1.2m² BSA= 165mg
      Potent antiemetic reserved for highly emotogenic chemotherapy regimes or where breakthrough vomiting has occurred in past courses.

      Course can be extended in some cases if required- discuss with fellow or consultant.

      Administer dose 1 hour prior to chemotherapy

      Aprepitant increases steroid AUC. Avoid with regimens including steroid medications. Check with consultant.
       Lorazepam Benzodiazepine SL/PO  12-16 kg= 0.25mg BD

      16-20 kg= 0.5mg BD

      20-30 kg= 1mg BD

      > 30 kg = 2mg BD 
      Little efficacy as anti emetic alone- not to be administered without additional antiemetics.

      Useful for anticipatory nausea and vomiting.

      Should only be administered for short courses- usually charted PRN.
       Domperidone Dopamine antagonist PO  0.1-0.2mg/kg to
      a maximum of 10mg QID 
      Similar action to Metoclopramide but less of a central antiemetic effect.

      Consider use if nausea is associated with delayed gastric emptying.
       Chlorpromazine Phenothiazine antipsychotic.

      Has antidopaminergic, antiadrenergic, antiserotonergic, anticholingeric and antihistaminergic effects.
      IV  0.3-0.5mg/kg
      6-8/24

      Minimum infusion rate- 30 minutes
      Can have sedative and extrapyramidal effects.

      Rapid administration can cause hypotension and dysphoria.

      Not for use in infants <1 year.

       

      Antiemetic guideline for common chemotherapy combinations

      Antiemetic Traffic Light Regimen.

      Further considerations

      • Anticipatory CINV, is common in adolescents and rarely responds to standard antiemetic regimes. Benzodiazepines can be useful in this patient population but do not have direct antiemetic effects. The best treatment for anticipatory CINV is prevention- if patients do not associate chemotherapy with nausea, anticipatory nausea will not develop
      • Dexamethasone should be charted regular (not PRN) if included in antiemetic regimes as the efficacy is enhanced with prophylactic administration
      • Delayed emesis is common after chemotherapy courses containing cisplatin. Antiemetics should be continued regularly for at least 48 hours after completing chemotherapy
      • Ondansetron is as effective as granisetron and is the 5HTз (serotonin) antagonist of choice for CINV 

      Non-pharmacological management of CINV

      Despite the advances in pharmacological management, standard pharmacological regimes may not fully alleviate symptoms of CINV in paediatric oncology patients. Investigating the adjuvant role of non-pharmacological interventions is an important consideration of antiemetic therapy. Non-pharmacological measures should be implemented in conjunction with pharmacological regimes to allow for the effective management of CINV. The use of non-pharmacological measures may not be appropriate for each patient, interventions should be implemented according to the individual patient’s needs and circumstances.
      Some suggested non- pharmacological interventions may include;

      Music therapy / relaxation

      Music therapy and relaxation are beneficial interventions in managing CINV with minimal negative side effects. Music therapy may include a) active music engagement, and b) individual (recorded) music listening. These interventions are suitable for all ages, are cost effective and can be implemented in the inpatient, outpatient and home environments. The music therapist is available to assess and advise on the most suitable plan.
      Music listening/relaxation during chemotherapy:

      • Where possible advise families to bring familiar music and music playing device for the first period of chemotherapy. 
      • Involve a music therapist to assess the capability of children receiving chemotherapy to use music independently 
      • Encourage patients to listen to recorded music they find comforting and relaxing during periods of chemotherapy. Familiar music is the best option; music which is liked is also useful if familiar music is not available. 
      • Commence music listening prior to chemotherapy administration or during experiences of anticipatory nausea and vomiting. 
      • Contact Educational Play Therapy or Comfort First Clinicians to assess if patient may benefit from focused breathing exercises to assist relaxation
      • Encourage periods in a quiet environment
      • Cluster medical and nursing care to allow for periods of rest 

      For children aged under 7 years, active music engagement may be more effective than passive music listening. The music therapist can advise/ plan for this. See also section on Cognitive Distraction.

        Guided imagery

        Encouraging patients to focus on thoughts and images they find pleasing and relaxing will divert attention from nausea and vomiting to desirable thoughts and images.

        • Encourage patients to visualise images related to the external environment (nature, landscape images) prior to and during chemotherapy administration
        • Place appealing images/paintings in patients’ rooms during chemotherapy administration
        • Encourage patients to reside in areas where they are able to enjoy the outside view (e.g. by windows) during periods of nausea, vomiting and anxiety
        • Implement music listening in combination with guided imagery for optimal management of nausea and vomiting

          Cognitive distraction

          Cognitive distraction acts to counteract CINV by drawing a patient’s attention away from feelings of nausea and vomiting and focusing attention on more pleasant activities. Patients should be encouraged to participate in;

          • Computer games
          • Movies/Television
          • Arts and crafts
          • Developmental / Group play sessions
          • Active Music Engagement 
          • Education sessions (kinder and school)
          • Socialisation with family, friends and other patients 
          • Discussions about life outside of the hospital setting (pets, siblings, school, hobbies)
          • Organising visits from volunteer services and ward grandparents available at the RCH

          The Educational Play Therapy, Art Therapy and Music Therapy teams can assist in providing activities that promote cognitive distraction

            Massage

            Educating families to perform massage during periods of chemotherapy has a positive impact on reducing levels of stress, anxiety, nausea and vomiting.
            It is not recommended to use massage for the paediatric oncology patient with a low platelet count (platelets ≤ 20-30 x 10e9/L)

            • Commence massage therapy 24 hours prior to chemotherapy administration and continue during and 24 hours after completion of the treatment cycle
            • Consider 20 minute massage therapy cycles at these time points
            • Use non scented oils to reduce nausea associated with oil scents
            • Caution must be taken in patients with solid tumours- Avoid massaging areas where tumour is present to reduce associated pain and anxiety
            • Care must be taken in patients with accessed port-a-cath devices

            Acupressure

            The acupressure technique involves the pressure applied to and then released from acupoints. Acupressure may be performed manually or with wrist pressure bands (also used for motion/travel sickness).

            It is not recommended to use acupressure for the paediatric oncology patient with a low platelet count (platelets ≤ 20-30 x 10e9/L)

            • Acupressure wrist bands may be applied to children prior to and during chemotherapy administration where tolerated

            Manual acupressure

            • Perform daily during chemotherapy administration in the absence of acupressure wrist bands
            • Pressure should be applied to acupoints for 1-3 minutes and then released
            • Acupressure should commence prior to administration of chemotherapy and continue for the duration of the chemotherapy cycle
            • Health professionals should familiarise themselves with the Pericardium 6 (P6) acupressure technique as this is the most successful point for targeting nausea and vomiting
            • Encourage patients and families to familiarise themselves with the P6 acupressure point technique so they are able to independently perform this technique during treatment periods

            Refer to the acupressure points website under ‘useful links’ for a detailed description of acupressure points.

            Dietary considerations

            The following suggestions may be useful to help manage nausea and vomiting;

            • Avoid fried, spicy and rich foods
            • Offer bland, dry foods such as toast and dry biscuits
            • Offer smaller serves of food more frequently
            • Offer cold foods that have little smell
            • Eat meals in a well ventilated room to clear the smell of foods away
            • Rinse the mouth thoroughly after vomiting with water (stomach acid left in contact with the teeth and the mouth lining will cause tooth decay and irritate an already tender mouth)

            Nasogastric feeds

            • Consider withholding or reducing the rates of NG feeds during highly emetogenic chemotherapy and for 3 days post completing 

            Other considerations

            • A multidisciplinary approach to managing CINV will assist in providing appropriate supportive care and effective anti emetic regimes to the paediatric oncology patient
            • Current literature supports the use of ginger supplementation to manage general nausea and vomiting, however ginger is not recommended for use in the paediatric oncology population due to unknown effects on coagulation
            • Poorly controlled CINV can result in dehydration, electrolyte imbalance, anorexia and, fatigue
            • Anti emetic therapies should be routinely administered during chemotherapy administration known to induce nausea and vomiting, not just PRN when patients develop symptoms of nausea
            • If a patient is being discharged with anti emetic medications, the patient and/or caregivers should be given instructions on management of anti emetic regimes at home, prior to discharge

            Companion documents

            Evidence table

            See attached document.

            References

             

            Please remember to read the disclaimer

             

            The development of this nursing guideline was coordinated by Andrew Dodgshun, Oncology Fellow and Lisa Barrow, Clinical Nurse Educator, of Children’s Cancer Centre, and approved by the Nursing Clinical Effectiveness Committee. First published December 2014.