Overview of nausea and vomiting
Nausea and vomiting (NV) are unpleasant features of many medical conditions and are adverse effects of hundreds of medications. Commonly seen in the critically ill patient, these symptoms are not often the cause for admission to critical care, but complicate and may extend the length of hospital stay.1 Further, in these patients, nausea and vomiting can lead to seriouscomplications such as aspiration pneumonia, dehydration, malnutritionand disruption of the surgical site.2
A term often used together, nausea and vomiting are basic protective reflexes against the absorption of toxins, as well as responses to certain stimuli. Nausea is an unpleasant sensation associated with pallor, flushing andtachycardia, along with an awareness of the urge to vomit. Vomiting or emesis is characterized by abdominal muscles contraction and forceful expulsion of stomachcontents through the mouth.
The American Gastroenterological Association suggests a 3-step approach to the initial evaluation of nausea and vomiting 3
- Recognizing and correcting any consequences of the symptoms.
- Identifying the underlying cause.
- Providing specific therapies.
Causes of nausea and vomiting
A wide variety of disorders can induce nausea and vomiting. Common causes include the following:
- Gastrointestinal disorders—appendicitis, cholecystitis, pancreatitis, obstruction or motility problems.
- Central nervous system—conditions that increase intracranial pressure and migraine headaches.
- Post-operative—effect of anesthetics or analgesics.
- Labyrinth disorders—motion sickness and Meniere’s disease.
- Drug/treatment induced—cancer chemotherapy and radiotherapy, opiates.
The timing of the nausea and vomiting can indicate the cause. If the symptom occurs shortly after a meal, it may indicate peptic ulcer. Nausea or vomiting that start 1–8 h after a meal may indicate food poisoning. Those who experience nausea and vomiting for more than 1 week should be investigated for the possibility of pregnancy. Vomiting usually subsides within 6–24 h, and may be treated at home.
Management of nausea and vomiting
The management of patients with nausea and vomiting should address the following:
- Control of the symptoms.
- Correction of electrolyte, fluid or nutritional deficiencies.
- Identification and elimination of the underlying cause.
The occasional episode of nausea and vomiting requires no treatment except rest and frequent small amounts of fluid. Mild and uncomplicated nausea and vomiting may be treated empirically with oral antiemetics. Severe intractable episodes require fluid replacement, correction of electrolyte and acid-base abnormalities and parenteral administration of antiemetics.
Therapies for known etiologies of nausea and vomiting include the following:3
- Prochlorperazine, chlorpromazine, metoclopramide and methylprednisolone are recommended for hyperemesis gravidarum while meclizine, promethazine and thiamine supplementation are recommended for morning sickness.
- Ondansetron/dexamethasone for acute chemotherapy-induced and metoclopramide/dexamethasone for delayed chemotherapy-induced nausea and vomiting.
- Tricyclic antidepressants for adults with cyclic vomiting syndrome.
- Droperidol/dexamethasone or ondansetron for postoperative nausea and vomiting.
- Supportive treatment and possible gastric pacing for gastroparesis.
- Steele A, Carlson KK. Nausea and vomiting: Applying research to bedside practice. AACN Adv Crit Care. 2007; 18(1): 61–73.
- ASHP therapeutic guidelines on the pharmacological management of nausea and vomiting in adult and pediatric patients receiving chemotherapy or radiation therapy or undergoing surgery. Am J Health Syst Pharm. 1999; 56: 729–764.
- Scorza K, Williams A, Phillips JD, Shaw J. Evaluation of nausea and vomiting. Am Fam Physician. 2007; 76(1): 76–84.