恶心和呕吐的姑息性处理目的.ppt.ppt

恶心和呕吐的姑息性处理目的简要地回顾晚期癌症恶心和呕吐的原因描述常用止吐药物的作用部位和机制研究晚期癌症不同类型的恶心和呕吐的识别和处理ManagementofNauseaandVomitinginPalliativeCareDr.CharlieBond,SirmichaelSobellHouse,OxfordAimsTobrieflyreviewthecausesofnauseaandvomitinginadvancedcancerTodescribethesiteandmechanismofactionofthecommonanti-emeticsToconsidertherecognitionandmanagementofthedifferentpatternsofnauseaandvomitinginadvancedcancer,CausesofNauseaandVomitinginAdvancedCancer晚期癌症患者恶心和呕吐的原因,Cancer癌症Visceralneuropathy内脏神经病Bowelobstruction肠梗阻BrainMetastases脑转移RaisedCalcium血钙升高RenalFailure肾功衰Anxiety焦虑Cough咳嗽GeneralDebility全身衰竭Constipation便秘Oral/Oesophagealcandida口/食管念珠菌病Infections感染,Treatment/Drugs治疗/药物Chemotherapy化疗Radiotherapy放疗Opioids阿片类药物NSAIDS/AspirinTNSAIDS/阿司匹林Anti-biotics抗生素Irontablets铁剂ConcurrentConditions合并症Dyspepsia/pepticulcer消化不良/消化性溃疡Alcoholicgastritis酒精性胃炎Renalfailure肾功衰DiabeticKetoacidosis糖尿病性酮症酸中毒,Commoncausesofnauseaandvomitinginadvancedcancer晚期癌症患者恶心和呕吐的常见原因,VomitingCentre,GutMucosa,AreaPostremaCTZ,CerebralCortex,VestibularNuclei,Anti-emeticReceptorProfilesMetoclopromideD2,5HT4agonist5HT3100mgHaloperidolD2+ProchlorperazineD2,H1DomperidoneD2(Nocentralaction)CyclizineACH,HILevomepromazineD2,5HT2,Alpha1,AChGranisetron5HT3,H1,5HT2,AChm,D2,-opioid,5HT3,H1,AChm,D2,GABA,2,5HT3,5HT2,MorphineDigoxinHypercalcaemiaUraemiaChemotherapy,RaisedIntra-cranialpressureFear/Anxiety,Movement/Vertigo,GastricirritantsMorphineRadiotherapyCytotoxicchemotherapy,呕吐中枢,胃粘膜,丘脑后部CTZ,大脑皮层,前庭细胞核,止吐药受体类型灭吐灵D2,5HT4激动剂5HT3100毫克氟哌啶醇D2+丙氯拉嗪D2,H1多潘立酮D2(无中枢作用)赛克利嗪ACH,HI左美丙嗪D2,5HT2,Alpha1,ACh格拉司琼5HT3,H1,5HT2,AChm,D2,-阿片类受体,5HT3,H1,AChm,D2,GABA,2,5HT3,5HT2,吗啡地高辛高钙血症尿毒症化疗,颅内压升高恐惧/焦虑,运动/眩晕,胃刺激物吗啡放射疗法细胞毒素化疗,恶心和呕吐-7种临床原因化学性/代谢性胃停滞/胃排空梗阻反流肠梗阻颅脑疾病/治疗性原因与运动相关的因素原因不明/多种原因Nauseaandvomiting-7clinicalpicturesChemical/metabolicGastricstasis/gastricoutletobstructionRegurgitationBowelobstructionCranialdisease/treatmentMovementrelatedCauseunclear/multiplecauses,恶心和呕吐的处理纠正可逆转的因素非药物治疗药物治疗处理焦虑ManagementofNauseaandVomitingCorrectthecorrectableNon-drugtreatmentDrugtreatmentManageanxiety,化学性/代谢性因素原因药物(包括阿片类药物)尿毒症高钙血症癌病临床表现难治性/持续性恶心呕吐常常不会缓解恶心症状Chemical/MetabolicCausesDrugs(includingopioids)UraemiaHypercalcaemiaCarcinomatosisClinicalPicturePersistent/continuousnauseaVomitingoftendoesnotrelievenausea,化学性/代谢性处理处理治疗高钙血症治疗肾衰(如果可能)停止使用引起恶心的药物(如果可能)避免闻到刺激性食物的味道氟哌啶醇(作用于丘脑后部的多巴胺2拮抗剂)二线药物:左美丙嗪(广谱止吐药)Chemical/metabolic-managementManagementTreatHypercalcaemiaTreatrenalfailure(ifpossible)Stopdrugscausingnausea(ifpossible)KeepawayfromsmelloffoodHaloperidol(D2Antagonistactingatareapostrema)2ndline:Levomepromazine(broadspectrum),胃停滞/胃排空梗阻原因药物阿片类药物抗胆碱能药物自主神经系统障碍肝肿大消化性溃疡/胃炎Gastricstasis/gastricoutletobstructionCausesDrugsOpioidsAnti-CholinergicsAutonomicfailureHepatomegalyPepticulceration/gastritis,胃停滞/胃排出梗阻临床特征间歇性恶心恶心症状常由呕吐缓解进食便感到过早饱胀进食后感到腹胀可能有呃逆现象Gastricstasis/gastricoutletobstructionClinicalpictureIntermittentnauseaNauseaoftenrelievedbyvomitingFeelfullquicklywheneatingFeelbloatedaftereatingMayhaveHiccups,胃停滞/胃排空梗阻治疗胃炎/消化性溃疡停止使用刺激胃的药物(非甾体类抗炎药)避免大量进食动力性止吐药物:灭吐灵(5HT4激动剂,D2拮抗剂)多潘立酮(D2拮抗剂)Gastricstasis/gastricoutletobstructionTreatgastritis/pepticulcerationStopdrugsthatirritatestomach(NSAIDS)AvoidlargemealsPro-kineticanti-emetic:Metoclopromide(5HT4Agonist,D2Antagonist)Domperidone(D2Antagonist）,反流原因食道癌/狭窄纵膈肿瘤/淋巴腺病临床特征吞咽困难偶尔消化不良轻微或无恶心食物反流RegurgitationCausesOesophagealtumour/strictureMediastinaltumour/lymphadenopathyClinicalPictureDysphagiaDyspepsiasometimesLittleornonauseaRegurgitationoffood,反流的处理放射诊疗支架/扩张/激光地塞米松软食/流质食物质子泵抑制剂-奥美拉唑RegurgitationManagementRadiotherapyStents/dilatation/laserDexamethasoneSoft/liquiddietProtonpumpinhibitor-Omeprazole,颅脑疾病/治疗原因颅内压升高放射治疗脑干/脑膜疾病临床表现恶心在上午加重头痛神经病变体征Cranialdisease/treatmentCausesRaisedintracranialpressureRadiotherapyBrainstem/meningealdiseaseClinicalpictureNauseaworseamHeadacheNeurologicalsigns,颅脑疾病/治疗处理地塞米松8-16mg/每天睡觉时盖薄被子赛克利嗪二线药物:左美丙嗪(甲氧异丁嗪)Cranialdisease/treatmentManagementDexamethasone8-16mg/daySleepwithbedtiltCyclizine2ndLine:Levomepromazine,与运动相关的原因原因前庭性疾病颅底的肿瘤临床表现与运动有关的恶心/呕吐治疗赛克利嗪二线药物:左美丙嗪MovementRelatedCausesVestibulardiseaseBaseofskulltumourClinicalpictureNausea/vomitingassociatedwithmovementManagementCyclizine2ndLine:Levomepromazine,原因不明/多种原因一线药物:甲氧氯普胺（灭吐灵）二线药物:使用一种不同受体类型的药物考虑使用广谱的止吐药物,即左美丙嗪或联合应用不同类型的止吐药物即赛克利嗪+氟哌啶醇加用地塞米松处理焦虑Causeunclear/multiplecauses1stline:Metoclopromide2ndline:UseadrugwithadifferentreceptorprofileConsiderabroadspectrumanti-emetice.gLevomepromazineoracombinationwithdifferentprofilese.gCyclizine+HaloperidolAddDexamethasoneManageanxiety,阿片类药物诱发的恶心和呕吐恶心和呕吐的机制:丘脑后部(化学感受器触发带)胃停滞对前庭系统的某种作用?OpioidinducedNauseaandVomitingMechanismsofnauseaandvomiting:Areapostrema(chemoreceptortriggerzone)Gastricstasis?Aneffectonthevestibularsystem,Systematicreviewoftreatmentsforopioidinducednauseaandvomiting.DrIanBack2001,阿片类药物引起的恶心和呕吐治疗的系统回顾.DrIanBack2001,由化疗和放疗引起的呕吐恶心和呕吐的机制:丘脑后部(化学感受器触发带)5-羟色胺(5HT)从肠嗜铬细胞或血小板的大量释放处理氟哌啶醇恩丹西酮/格拉司琼(5HT3拮抗剂)地塞米松ChemotherapyandradiotherapyinducedvomitingMechanismsofnauseaandvomiting:Areapostrema(chemoreceptortriggerzone)Massivereleaseofserotonin(5HT)fromenterochromaffincellsorplateletsManagementHaloperidolOndansetron/granisetron(5HT3antagonist)Dexamethasone,SobellHouseOxford常用的止吐药物灭吐灵占50%处方：10mg-20mgPOqid或40-100mg/24hcsci氟哌啶醇占25%处方：1.5-3mgqn或2.5-5mgsc/24h,或csci赛克利嗪2550mgtid或100-150mgsc/24h,或csci左美丙嗪6.25-12.5mgPOqn或scCommonlyusedanti-emeticsatSirMichaelSobellhouse,OxfordMetoclopromide50%prescriptions10mg-20mgqdsPOor40-100mg/24hrsSCinfusionHaloperidol25%prescriptions1.5-3mgnoctePOor2.5-5mgSC/24hrs-statorinfusionCyclizine25-50mgtdsPOor100-150mgSC/24hrsSCinfusionLevomepromazine6.25-12.5mgnoctePOorSC,Nauseaandvomiting-references,Symptommanagementinadvancedcancer3rded.TwycrossandWilcock,Radcliffemedica