Inpatient and Outpatient Specialty Care Clinical Pathway for Prevention of Acute Chemotherapy-Induced Nausea and Vomiting (CINV) in Children
- Related Pathways
- Oncology Patient with Fever, ED and Outpatient Specialty Care
- Tumor Lysis Syndrome, All Settings
- Related Order
- Oncology Anti-Emetics Order Set
Patient Assessment and Chemotherapy Emetogenic Assessment
- Determine chemotherapy emetogenic potential based on planned chemotherapy.
- Review patient’s past experience with acute CINV in prior cycles.
New chemotherapy orders and/or patient had poor control of CINV in previous cycles
Repeat chemotherapy orders and patient had complete control in previous cycles
Continue anti-emetics and non-pharmacologic therapies from past chemotherapy cycle
Select Therapies
- Review anti-emetic contraindications prior to selecting anti-emetics.
- Consider non-pharmacologic/integrative therapies.
Minimal Emetogenicity |
---|
No prophylaxis required |
Low Emetogenicity |
---|
5HT3 antagonist |
Moderate Emetogenicity | |
---|---|
Contraindications | Anti-Emetic Regimen |
None | 5HT3 antagonist + dexamethasone |
No dexamethasone | 5HT3 antagonist + aprepitant |
No aprepitant | 5HT3 antagonist + dexamethasone |
No dexamethasone or aprepitant | 5HT3 antagonist |
High Emetogenicity | |
---|---|
Contraindications | Anti-Emetic Regimen |
None | 5HT3 antagonist + dexamethasone + aprepitant |
No dexamethasone | 5HT3 antagonist + aprepitant |
No aprepitant | 5HT3 antagonist + dexamethasone |
No dexamethasone or aprepitant | 5HT3 antagonist |
Assess for Complete Control of CINV
Patient reported outcomes survey questions may assist in this assessment.
- Complete Control defined as:
- No use of anti-emetic agents other than those given for CINV prevention
- No vomiting, retching, or nausea
- No nausea-related change in the child’s usual appetite and diet
- Assess daily through 24 hours after chemotherapy administration
5HT3 Antagonist | |
---|---|
Order of Preference | Medication |
1 | Ondansetron |
2 | Granisetron |
3 | Palonosetron |
This is the suggested order for naïve patients. For non-naïve patients, use the 5HT3 antagonist that has been effective in prior cycles. |
Poor Control
Complete Control
- Assess for other potential causes of nausea and vomiting
- Additional anti-emetics recommendations based on timeframe and symptoms
Continue current management
Nausea/Vomiting | Definition |
---|---|
Anticipatory CINV | 24 hours pre-therapy |
Breakthrough CINV | Occurs during acute or delayed phase despite adequate CINV prophylaxis |
Refractory CINV | Multiple days or cycles breakthrough CINV despite adequate CINV prophylaxis |
Consider additional non-pharmacologic/integrative therapies
Discharge
- Communicate changes to primary team
- Document changes to anti-emetic regimen in discharge summary/clinic note and discharge template email
Posted: February 2020
Revised: June 2022
Authors: C. Croy, PharmD; C. Diorio, MD; C. Elgarten, MD; J. Freedman, MD; T. Jubelirer, MD; K. Oranges, CRNP
Revised: June 2022
Authors: C. Croy, PharmD; C. Diorio, MD; C. Elgarten, MD; J. Freedman, MD; T. Jubelirer, MD; K. Oranges, CRNP