Post on 26-Mar-2015
HYDRATION & NUTRITION
And
NAUSEA & VOMITING
IN
PALLIATIVE CARE OF CHILDREN
Mike Harlos MD, CCFP
Medical Director, WRHA Palliative Care and St. Boniface General Hospital Palliative Care
Section Head, Palliative Care, University of Manitoba Dept. of Family Medicine
TREATMENT / INTERVENTION CONSIDERATIONS
• What are the goals of the treatment?
• Whose goals are they, and are they consistent with those of the patient?
• Is it possible to achieve the goals?
• What are the:
– Positive effects vs. Side effects (clinical assessment by health care team)
– Benefits vs. Burdens (experiential interpretation of positive and side effects by patient / family)
• Is there enough reserve to tolerate the treatment?
The “Path of Least Regret”
• How will families look back on the decisions for care?
• When family uncertain or ambivalent about “doing something” vs. “not doing something”, consider leaning toward “doing” if it is reasonable (eg. hydration)
• Power imbalance between health care professionals and patient / family… be perceptive about when this might be influencing the dynamic of decision-making
• Controversial topic; there is no consensus among the palliative care community
Hydration in the Terminal Phase
1. Morita T, Tei Y, Tsunoda J, Inoue S, Chihara S.Determinants of the sensation of thirst in terminally ill cancer patients.Support.Care Cancer 2001;9:177-86
2. Burge FI. Dehydration symptoms of palliative care cancer patients. J.Pain Symptom.Manage. 1993;8:454-64.
• Conflicting literature regarding whether there is1 or is not2 a correlation between dehydration and thirst in the dying
• There are specific circumstances where rehydration can be very helpful:
Opioid-induced neurotoxicity Hypercalcemia Reversible bowel obstruction
• In severe hypoalbuminemia, may aggravate peripheral edema
• No evidence for hydration causing ↑ terminal secretions
•Each circumstance is approached individually with regards to goals
Hydration ctd
Hypodermoclysis• Effective, simple route for hydration when venous access
compromised
• In adults usually give 30 - 50 ml/hr NS; there are reports of adding KCL
• Adverse reactions include local edema, cellulitis, discomfort at insertion site
• Use indwelling small gauge cathalon rather than butterfly needle
• Very little literature regarding pediatrics:
1. Steffey JM Hypodermoclysis in infants and children.J Iowa State Med Soc. 1963 Jul;53:393-6
2. Vyskocil JJ, Kruse JA, Wilson RF. Techniques for vascular access when venous entry is impossible. Route depends on urgency and the agent to be administered. J Crit Illn. 1993 Apr;8(4):539-45
NUTRITION
IN THE
DYING CHILD
Proposed NomenclatureBechard L.J., et al Nutritional Supportive CarePrinciples & Practice of Pediatric Oncology 4th Ed; Edited by Pizzo & Poplack
Wasting: • Involuntary weight loss
• Seen in anorexia nervosa, cancer, HIV, and others
• First see decline in body fat, then in body protein stores (fat-free mass; lean body mass)
• Energy repletion usually successful in restoring nutritional status
Cachexia: • Involuntary loss of fat-free mass in the setting of minimal or no overall weight loss
• Seen in cancer, critical illness, HIV, other metabolic stress
• Patients may be of normal weight yet malnourished
• Loss of lean body mass is associated with decreases in strength, immune function, pulmonary function, as well as increased disability and death
• Nutritional support may not reverse catabolic effects of underlying condition
“The cancer anorexia-cachexia syndrome is extremely
common in children with advanced cancer and is
frequently associated with a patient’s decline and death.
Its cause is multifactorial, and it is most often
irreversible, even in the face of hyperalimentation or
vigorous nutritional support”
Wolfe J., Grier H.E., Care of the Dying Childin Principles and Practice of Pediatric Oncology4th Edition; Philip A. Pizzo and David G. Poplack, Editors
Feeding Options
Oral • May require soft diet if mucositis present
• Caloric supplementation if required
• “Normal”
Enteral (Tube)
• Nasogastric or percutaneous gastrostomy
• Demonstrated improved weight gain in newly Dx pediatric cancer patients and in BMT settings
• Cost savings over TPN
Parenteral (TPN)
• Of demonstrated benefit in BMT patients
• Uncertain / unproven benefit in other cancer settings
• Risks include infection, hepatic toxicity, metabolic abnormalities;
• Careful patient selection and close monitoring required
Loss of AppetiteLook for Reversible Causes
• Pain
• Anxiety
• Nausea / Vomiting
• Thrush in the mouth or esophagus
• Constipation
• Drugs
• Depression
Goals of Nutrition and Fluid Management in the Dying Child
• Alleviate any hunger and thirst
• Reduce anxiety about intake
• Preserve the social aspects of mealtimes
Strategies Around Feeding
• Frequent small meals
• Favourite foods, cravings
• If not hungry, don’t force intake
• Help find other ways than feeding for family to nurture
Management Of Nausea And
Vomiting In
Palliative Care Of Children
0
10
20
30
40
50
60
70
80
90
100
% P
reva
len
ce
Hongo T. et al, Pediatrics International Feb 2003 p.60
Symptoms At The End of Life in Children With Cancer
Managing Nausea & Vomiting in Palliative CareSome Differences in Children vs. Adults
• Assessment, communication challenges
• Higher risk of extrapyramidal reactions, akathisia, and somnolence with dopamine antagonists in children
– Metoclopramide (Maxeran®)
– Prochlorperazine (Stemetil®)
– Haloperidol (Haldol®)
– Chlorpromazine
• If using dopamine antagonists, consider slow administration (45-60 min.), as well as concomitant use of diphenhydramine (Benadryl®) 0.5 – 1 mg/kg q4-6h po/IV continued for additional 24hrs after dopamine antagonist stopped.
N & V Management – Differences in Children vs. Adults ctd
• Route of administration
– Oral may be compromised by developmental, psychological, or practical reasons (eg. too nauseated)
– IV may be upsetting if no pre-existing line
– Very limited data on SQ dosing
– Tolerating SQ dosing?
• Ongoing chemotherapy and feeding even in terminal phase
• Available oral or transdermal doses may be inappropriately high
MECHANISM OF NAUSEA AND VOMITING
• vomiting centre in reticular formation of medulla
• activated by stimuli from:– Chemoreceptor Trigger Zone (CTZ)
• area postrema, floor of the fourth ventricle• outside blood-brain barrier (fenestrated venules)
– Upper GI tract & pharynx– Vestibular apparatus– Higher cortical centres
CortexCortex
CTZCTZ
VestibularVestibular
GIGI
VOMITING VOMITING CENTRECENTRE
Chemoreceptor Trigger Zone
Vestibular Cortical Peripheral
drugs• opioids• chemoTx• etc...
biochemical• Ca++
• renal failure• liver failure
sepsis
radiotherapy
tumor
opioids
anxiety
association
ICP
radiotherapy
chemotherapy
GI irritation• inflammation• obstruction• paresis• compression
CAUSES OF NAUSEA & VOMITING
PRINCIPLES OF TREATING NAUSEA & VOMITING
• Treat the cause, if possible and appropriate
• Environmental measures
• Antiemetic use:
– anticipate need if possible
(NB: Children do not usually require prophylactic antiemetics
when opioids started Ref: Beardsmore et al 2002 Palliative Care
in Paediatric Oncology; European J Cancer 38 p1900-1907)
– use adequate, regular doses
– aim at presumed receptor involved
– combinations if necessary
– anticipate need for alternate routes
Stimulus Area Receptors
Drugs,
MetabolicChemoreceptor
trigger zone
Motion,
PositionVestibular
VisceralAbdominal
organs
↑ ICP Cerebral cortex
DD22 5HT
MM HH11
DD22 5HT
HH11
VOMITING VOMITING CENTRECENTRE
5HTMM
HH11
5HT MMHH11DD22
EffectorEffectorOrgansOrgans
DopamineDopamine SerotoninSerotonin HistamineHistamine MuscarinicMuscarinic
Safety and Tolerability of 5HT3 Antagonists
Goodin S., Cunningham R. The Oncologist 2002 p424-436
• High specificity for 5HT3 receptors; extrapyramidal
reactions unlikely
• It has been suggested that the combination of a 5HT3
antagonist with dexamethasone should be the standard
antiemetic prophylaxis in all pediatric patients
• Granisetron well tolerated; fever and headache most
common adverse events
Safety and Tolerability of 5HT3 Antagonists ctd
Goodin S., Cunningham R. The Oncologist 2002 p424-436
• May prolong QT interval
– 19% of patients given ondansetron in one study
– Seems less with granisetron
– risk of torsades de pointes
– use with caution when high dose methadone used, or
in patients with arrhythmias or on other meds that
might prolong QT
0
10
20
30
40
50
60
70
80
Any AdverseHeadache
Asthenia
ConstipationDiarrhea
Dizziness
Insomnia
DyspepsiaAnorexia
Visual
Granisetron
Ondansetron
Comparative Incidence of Adverse Effects: Granisetron (n=542) vs. Ondansetron (n=543)
Perez et al; J Clin Oncol 1998;16:754-760
0 50 100 150 200 250 300 350
Scopolamine
Haloperidol
Prochlorperazine
CPZ
Promethazine
Metoclopramide
Dopamine
Muscarinic
Histamine
1250
RELATIVE ANTIEMETIC RECEPTOR AFFINITIES
DrugClass
Examples for Breakthrough Nausea (Not necessarily the same as for Chemotherapy Protocols)
SerotoninAntag.
• Granisetron1 : ≥ 4 yo: 20-40 mcg/kg/day divided once or twice daily single dose po/IV
• Ondansetron2: 0.15 mg/kg /dose given tid
H1 Antag.• Dimenhydrinate (Gravol®): 5 mg/kg/day divided q6-8h,
max 300 mg/dayChildren > 12 yo: 50 – 100 mg q 4-6h; max 400 mg/day
Anti-musc.: Transderm-V® (scopolamine patch) 3
2 – 3 yo ¼ Patch
3 – 9 yo ½ Patch
10+ 1 Patch
Antinauseants / Antiemetics
1 Komada Y et al. A randomised dose-comparison trial of granisetron in preventing emesis in children with leukaemia receiving emetogenic chemotherapy. Eur J Cancer 1999; 35(7):1095-1101.2 Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack 3 The Rainbows Children’s Hospice Guidelines 2002
DrugClass
Examples for Breakthrough Nausea (Not necessarily the same as for Chemotherapy Protocols)
DopamineAntagonists *
• Prochlorperazine1 (Stemetil®) for children >10kg – po/pr: 0.4 mg/kg/day in 3-4 divided doses– IM: 0.13 mg/kg/dose– IV: not recommended
• Metoclopramide1 0.1 – 0.2 mg/kg/dose q6h prn **
Prokinetics *• Metoclopramide1 0.1 – 0.2 mg/kg/dose q6h prn **• Domperidone2 0.2 – 0.4 mg/kg/dose up to qid; max. 1.6
mg/kg/day
* Consider using prophylactic Benadryl® concomitantly** Much lower than for established chemotherapy protocols
Antinauseants / Antiemetics ctd.
1 Pediatric Lexi-Drugs Sept. 20032 The Rainbows Children’s Hospice Guidelines 2002
DrugClass
Examples for Breakthrough Nausea (Not necessarily the same as for Chemotherapy Protocols)
Cannabinoids• Dronabinol: has been effective in children with doses
of 2.5 – 7.5 mg/m2 q2-4h prn up to 6 doses/day
• Not first line; dysphoria common
Dexamethasone
• limited data on dosing
• One reference*: 10 mg/m2 to a maximum of 10 mg, given once/day
Misc.• Lorazepam**: 0.02 - 0.04 mg/kg/dose, (max.1 or 2
mg/dose, depending on reference) po/IV q4-8h
Antinauseants / Antiemetics ctd.
* Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack
** Cancer Pain Relief and Palliative Care in Children, W.H.O. 1998