Pancreatic Ca and Nausea

  1. Help! I have a 63 year old male pt. with pancreatic CA who has undergone a jejunostomy in the past. He is chronically nauseated and is having trouble keeping even fluids down. Currently he's on Haldol 3 times daily, Ativan prn, Phenergan suppositories and tablets prn , Reglan, Baclofen and is still having continuous nausea and vomits two to three times daily. I feel that the nausea is from outlet flow obstruction and he is not a candidate for anymore surgery or radiation. Does anyone have any other ideas about how to help this poor guy or other meds to try? He had Zofran in the past and that didn't even help. I feel so helpless in caring for him - nothing seems to be working!
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  2. 15 Comments

  3. by   doodlemom
    My experience with zofran is that it only works if the patient's nausea is from taking some other medication (chemo, anesthesia, narcotics.) We have used sandostatin for this problem but it is extremely expensive. It will stop his digestive system from producing the gastric secretions it normally makes so there should be less or a decreased amount of stuff for him to vomit up (I'm assuming he is not eating.) Of course, another option is to place a g-tube or ng-tube to intermittent suction. Most patients don't like something stuck down their nose, but if it's the only thing that stops the vomiting...
    good luck
  4. by   leslie :-D
    have you tried a combination of anti-emetics, using ones that act at different receptor sites?
    i've had pts using 2 or 3 different ones.
    also, high-dose steroids have been helpful for those w/intractible nausea.
    sometimes a pt needs sc continuous infusions.
    and finally, one time i had a pt who had a celiac plexus block...(i think it's contraindicated in bowel obstxn however). this would be the absolute last resort.
    but a palliative g-tube would also be a consideration.

    best of luck to you and your pt.

    leslie
    Last edit by leslie :-D on Jan 31, '07
  5. by   introspectiveRN
    Isn't that one of the worst aspects of pancreatic CA? Because it is so hard to overcome nausea once it has started, we usually do scheduled dosing of ativan, phenergan, compazine and reglan along c a scopalamine patch. I have also used a PLO mixture of Haldol, Benadryl etc. I have an older palliative care book that has something else listed that I cannot remember the name of....grrrr . When I get back to my apartment I will post it.

    Isn't it Thorazine that interrupts all three vomitus receptors in the brain? Can't remember and it has been a looooong day. (IDT today and then too many inservices ).

    I will writecha back as soon as i find it...
  6. by   leslie :-D
    we've used thorazine also, with excellent effect.

    leslie
  7. by   jerseyRN
    I would try a TD gel.... ativan 0.5mg, benadryl 12.5 mg, haldol 0.5 mg reglan 10 mg (unless completely obstructed), dexamethasone 2 mg.... and give it every 4-6 hours around the clock for 24 hours to see if that helps.
    I might give compazine supps 25 mg along with it, every 6-8 hrs.
    I agree... persistent vomiting like this is one of the most miserable and tough to treat symptoms there is (if not the most)
  8. by   river1951
    I agree with the gel, here we use a BDR gel with 25 of benadryl, 10 of reglan and 4 of dexamethasone. It must be used 3 times daily till the nausea and vomiting stops, then 2 times faithfully.
    Hope this helps.
  9. by   abbieRnChpn
    Quote from SCgirl1962
    Help! I have a 63 year old male pt. with pancreatic CA who has undergone a jejunostomy in the past. He is chronically nauseated and is having trouble keeping even fluids down. Currently he's on Haldol 3 times daily, Ativan prn, Phenergan suppositories and tablets prn , Reglan, Baclofen and is still having continuous nausea and vomits two to three times daily. I feel that the nausea is from outlet flow obstruction and he is not a candidate for anymore surgery or radiation. Does anyone have any other ideas about how to help this poor guy or other meds to try? He had Zofran in the past and that didn't even help. I feel so helpless in caring for him - nothing seems to be working!
    We usually try Haldol 5mg sub q every 2 hours prn and every 4 hours routinely. Ativan sometimes helps as well. Good luck..
  10. by   jerseyRN
    Right now we are using ativan 0.5 mg, benadryl 25 mg, haldol 1 mg, reglan 10 mg, dexameth 4 mg TD on a pt with intractable vomiting due to widely metastasized ovarian CA. She is using the gel every four hours in addition to morphine supps 40 mg q3h prn.... you would expect her to be totally snowed, but instead she is alert and talking, comfortable, pain free, vomiting less volume and less often, and even sleeping better at night.

    Whatever it takes!
  11. by   river1951
    Great job! Now she can enjoy her time.
  12. by   SCgirl1962
    This patient is already on Phenergan, Haldol, Compazine, Reglan, Protonix, and Ativan. Felt that it was due to a mechanical obstruction, so I did get his permission to put in an NG tube. This has helped, and we are trying to get him scheduled to have a G-tube put in so he doesn't have the aggravation and discomfort from a long term NG. Thanks for all of your suggestions. I'll be printing these off and referring to them for future references when I have other patients with intractable nausea.
  13. by   Allow Mystery
    Leslie,
    You mention sc continuous infusion; what medication
    do you use for the infusion?
    Thanks

    Quote from earle58
    have you tried a combination of anti-emetics, using ones that act at different receptor sites?
    i've had pts using 2 or 3 different ones.
    also, high-dose steroids have been helpful for those w/intractible nausea.
    sometimes a pt needs sc continuous infusions.
    and finally, one time i had a pt who had a celiac plexus block...(i think it's contraindicated in bowel obstxn however). this would be the absolute last resort.
    but a palliative g-tube would also be a consideration.

    best of luck to you and your pt.

    leslie
  14. by   leslie :-D
    Quote from Allow Mystery
    Leslie,
    You mention sc continuous infusion; what medication
    do you use for the infusion?
    Thanks
    we use different ones, depending on etiology and hx of txs.

    cyclizine, haldol, zofran, dexamethasone, hyoscine butyl/hydrobromides, octreotide, methotrimeprazine, metoclopramide.

    maybe more.
    this is off the top of my head.

    leslie

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