Inpatient and Outpatient Specialty Care Clinical Pathway for Prevention of Acute Chemotherapy-Induced Nausea and Vomiting (CINV) in Children

  • Related Order
  • Oncology Anti-Emetics Order Set
Patient Assessment and Chemotherapy Emetogenic Assessment
  1. Determine chemotherapy emetogenic potential based on planned chemotherapy.
  2. 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
  1. Review anti-emetic contraindications prior to selecting anti-emetics.
  2. 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
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: April 2020
Authors: C. Croy, PharmD; C. Diorio, MD; C. Elgarten, MD; J. Freedman, MD; T. Jubelirer, MD; J. Mauro, PharmD; K. Oranges, CRNP