1. Mual Muntah Afifah Machlaurin>

2. Siapkan kertas.... 1. Sebutkan titik yang bertanggung jawab terhadap respon mualmuntah ! 2. Sebutkan 4 mekanisme stimulasi mualmuntah 3. Sebutkan 4 nama reseptor yang berhubungan dengan mual muntah!

3. Video etiologi mual muntah....

4. 1) Chemoreceptor Trigger Zone 2) Vestibular 3) Cortex 4) GI/peripheral pathways Etiology of Nausea

5. Yang perlu dikaji....  Onset  Frequency  Relationship to eating  Relationship to meds  Current anti-emetics  Chronic vs. Progressing  Alleviating factors  Severity (scale: 1-10)  Goal

6. Penyebab Umum..... * Drugs (chemo, opioids, NSAIDS, SSRIs) * Constipation * Gastroparesis * GERD * Uremia * Infection * Pain * Dehydration * Electrolyte imbalance (high Ca) * Endocrine dysfunction * Increased ICP (intra Cranial Pressure) * Anxiety

7. Penyebab lain... * Pregnancy * Cyclic Vomiting Syndrome * Hepatic disease * Migraine headaches * Following surgery * Myocardial infarction * Violent coughing * Hangover

8. Non Pharmacologic Treatment Reassurance/relaxation Correct dehydration, correct electrolyte distrubances correct constipation Oral hygeine Reduce portions and use cold food Reduce or eliminate tube feedings Avoid odors

9. Matching Etiology with Mechanism 1) Chemoreceptor Trigger Zone 2) Vestibular 3) Cortex 4) GI/peripheral pathways 1) D2 and 5HT3 antagonists 2) Antihistamines and Anti-muscarinics 3) Antihistamines and Anxiolytics 4) D2 and 5HT3 antagonists

11. CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING (CINV)  Depending on Chemotherapy agents

15. SSRI (Selective Serotonin Receptor Inhibitors )  SSRIs act by blocking presynaptic serotonin receptors on sensory vagal fibers in the gut wall.  SSRIs  dolasetron, granisetron, ondansetron, and palonosetron  The most common side effects associated with these agents are constipation, headache

16. Substance P/Neurokinin 1 Receptor Antagonists  Substance P is a peptide neurotransmitter in the NK family whose preferred receptor is the NK1 receptor. Substance P is believed to be the primary mediator of the delayed phase of CINV and one of two mediators of the acute phase of CINV.  Aprepitant is the first approved member of this class of drugs and is indicated as part of a multiple drug regimen for prophylaxis of nausea and vomiting associated with high-dose cisplatin-based chemotherapy

17. Corticosteroids  Dexamethasone has been used successfully in the management of chemotherapy-induced nausea and vomiting (CINV) and postoperative nausea and vomiting (PONV), either as a single agent or in combination with selective serotonin reuptake inhibitors (SSRIs).  For CINV, dexamethasone is effective in the prevention of both cisplatin- induced acute emesis and when used alone or in combination for the prevention of delayed nausea and vomiting associated with CINV

18. POSTOPERATIVE NAUSEA AND VOMITING (PONV)

19. DISORDERS OF BALANCE  Beneficial therapy for patients with nausea and vomiting associated with disorders of balance can reliably be found among the antihistaminic anticholinergic agents.  Neither the antihistaminic nor the anticholinergic potency appears to correlate well with the ability of these agents to prevent or treat the nausea and vomiting associated with motion sickness.

20. ANTIEMETIC USE DURING PREGNANCY  Initial management of nausea and vomiting of pregnancy often involves dietary changes and/or lifestyle modifications.  Pyridoxine (10 to 25 mg one to four times daily) is recommended as firstline therapy.  If symptoms persist, addition of a histamine-1 receptor antagonist, such as dimenhydrinate, diphenhydramine, or meclizine, is recommended

21. ANTIEMETIC USE IN CHILDREN  For children receiving chemotherapy of high or moderate risk, a corticosteroid plus SSRI should be administered. The best doses or dosing strategyhas not been determined.  For nausea and vomiting associated with pediatric gastroenteritis, thereis greater emphasis on rehydration measures than on pharmacologic intervention.

22. Questions and Answers