Need help with vomiting patient

[Kerry45]

I have 70 yr old cancer gallbladder and liver. She is vomiting bile huge amounts 24/7. We have tried compound our pharmacy makes zofran 4 mg , promethazine 50 mg dexamethasone 1 mg, raglan 1 mg , haldol 2 mg and Ativan 1 mg all in one topically dose she takes every 2 hours. She refuses suppossitoy we have discussed IV but she refuses that too. She vomiting all the time nothing is working. She's been like this for 3 weeks and sips of water only intake. We keep adjusting the compound nothing is working. I am lost

[goosecreekgirl]

is it possible to drop an NG tube and hook it up to suction? When I worked on Digestive Disease floor it was pretty much standard for care of pts. with same issues.

[Kerry45]

She doesn't want anything like that. She's so so weak that she sits in recliner 24/7. She has bed sores now her sisters are taking care of her and giving her the compound every 2 hrs around the clock. I have seen her vomit it's awful

[goosecreekgirl]

Poor thing. I wish you both the best.

[nutella, MSN, RN]

If she is vomiting all the time she might not get enough medication that way.

Since she is refusing sups and iv - how about gel?

[heron, ASN, RN]

We once had a patient with refractory vomiting who did well with continuous haldol via clysis. She might accept clysis with its tiny sq needle as opposed to the hassle of an iv.

[NutmeggeRN, BSN]

Poor thing, does she want to die? Would a Palliative Care consult be in order? Maybe a psych consult? (not if she wants to do die, note I said palliative care first), but if she is unable to comprehend the ramifications of her decisions?

[toomuchbaloney]

Are you in a state which allows medicinal cannabis? I have seen hospice patients with intractable N/V add an oral concentrate (Lozenges and hard candy sort of things) which they suck on as adjuvant therapy with good results.

Marinol will likely be useless, IMO.

[vampiregirl, BSN, RN]

The data I've read on topical administration of these meds is conflicting. I've had a couple of patients in the past that it was very effective for, but some that didn't seem to get much relief. The hospice I work for doesn't currently use the topic compounds.

Your options are a little limited w/ the patient currently declining IV and rectal administration. Have you considered the zofran ODT or ativan SL. It also may seem counterproductive, but can she swallow any of the antiemetics with sips of water? Or does your facility allow IM administration of meds and/or will the patient allow it. Maybe if you can get the nausea under control w/ IM, you would be able to transition to a routine PO.

It's so hard for the patient, caregivers and the hospice staff when symptoms are hard to manage! Good luck:)

[dkpfeil69]

What about an anticholinergic?

[Tenebrae, BSN, RN]

Would she be ok with a sub cut line? We use those alot in community palliative care and while they are not as quick acting as IV, they are effective with a continuous infusion and can also be used for bolus doses

[annie.rn]

This is probably a long shot b/c of the stage of illness and her lack of desire to do anything too invasive (I don't blame her) but do you think she would ever consider having a gastric tube inserted percutaneously? It could then be left to gravity or to suction to keep the stomach emptied. The emptying of the stomach may help to keep the nausea under control.