Intermittent Nasogastric Drainage Under Sedation for Unresponsive Vomiting in Terminal Bowel Obstruction
Article Outline
To the Editor:
Bowel obstruction is a common complication in patients with end-stage abdominal and pelvic cancer. The reported frequency ranges from 5% to 42%.1, 2 The pharmacological management of terminal bowel obstruction relies on the use of drugs for the relief of nausea, vomiting, and pain. However, vomiting cannot always be controlled by pharmacological treatment and it is very distressing for the patient. We report two patients with uncontrolled vomiting caused by bowel obstruction that was successfully managed using intermittent nasogastric drainage under short-term sedation with midazolam.
Case 1
A 32-year-old woman with an end-stage gastric cancer was admitted to our inpatient palliative care unit for symptom control. Four days prior to her admission, she had been treated on surgery service with a nasogastric tube for an intestinal obstruction. Surgery was not considered because she had had a gastrectomy two years earlier and her general condition was poor.
On admission she had abdominal pain, discomfort and slight throat–pharyngeal pain caused by the nasogastric tube. The nasogastric tube was removed and pharmacological treatment was started. She was treated with morphine chloride and several combinations of hyoscine butylbromide, haloperidol, ondansetron, and octreotide, following clinical practice recommendations.1 Unfortunately, all the above treatments proved to be ineffective and the patient continued having frequent daily episodes of vomiting despite using the drugs at the maximum recommended doses. She refused the suggestion of using the nasogastric tube suction again and asked us to look for another less distressing treatment. We suggested the possibility of the temporary use of the nasogastric drainage under sedation with midazolam and she and her family accepted the proposal.
The patient was sedated with subcutaneous midazolam, 3 mg plus another 5 mg thirty minutes later. The nasogastric tube was kept in place for an hour. She woke up peacefully five hours later. The pharmacological treatment was not changed. No adverse reactions were noted. The patient and her family were very satisfied with the procedure.
She was free of nausea and vomiting for two days. The procedure was repeated two more times, every 72 hours, because of new episodes of vomiting. Twenty-four hours after the last procedure, she died peacefully.
Case 2
A 68-year-old woman with advanced ovarian cancer was admitted to our palliative care unit for control of abdominal pain and vomiting caused by intestinal obstruction related to intra-abdominal carcinomatosis. On admission, she was treated with morphine chloride, hyoscine butylbromide, dexamethasone, and haloperidol administered by the subcutaneous route. This treatment failed to control vomiting for the following two days. The anti-emetic and anti-secretory treatment was successively changed to methotrimeprazine plus octreotide and ondansetron plus octreotide. Unfortunately, the treatments were not effective. The patient had two large vomiting episodes per day, each with fecal content, during the following 48 hours. She and her family accepted our proposal for a transitory gastric decompression with nasogastric tube under short-time sedation with midazolam.
Thirty minutes after the administration of 5 mg of subcutaneous midazolam, when sedation was reached, the nasogastric tube was inserted and left in place for forty minutes. No adverse reactions were noted. She woke up 3 hours later very satisfied with the procedure.
She was free of vomiting for the following three days. The procedure was repeated four days later because vomiting returned. She needed to be completely sedated two days later for an agitated delirium and she died peacefully twenty hours later.
Comment
The Working Group of the European Association for Palliative Care considers pharmacological treatment as one of the best options for the management of bowel obstruction in end-stage cancer patients.1 Vomiting may be controlled by either of two different pharmacological approaches:1, 3, 4 1) anti-secretory drugs that reduce secretions, such as the anticholinergics (hyoscine hydrobromide, hyoscine butylbromide, or glycopyrrolate) or somatostatin analogues (octreotide or vapreotide); 2) anti-emetics (metoclopramide, domperidone, neuroleptics, 5-HT3 antagonists or antihistamine drugs), used alone or in association with anti-secretory drugs.
These drugs are effective in the control of nausea and vomiting in most patients. Unfortunately, some patients may continue suffering episodes of distressing vomiting.2, 5 A venting gastrostomy should be considered if drugs fail to reduce vomiting.1 However, although this is a useful approach to the management of patients with complete bowel obstruction, it is rarely used in our palliative care environment. Moreover, in our cases, a venting gastrostomy was ruled out because of the presence of previous surgery (case 1) and intra-abdominal carcinomatosis (case 2), which might make placement of a gastrostomy difficult or dangerous.
The long-term use of a nasogastric tube is not recommended because it is intrusive and distressing for the patient,1, 2 and it is not free from complications such as nasal cartilage erosion, occlusion necessitating flushing, and nasal or pharyngeal irritation. To avoid these complications, we decided to use the nasogastric tube intermittently. Moreover, to improve the well-being of the patients, we carried out the placement of the tube under a short-term sedation with midazolam. For this procedure, midazolam has a favorable therapeutic profile because of its high hypnotic effect, its rapid action onset, and its short half-life.6
The use of intermittent nasogastric drainage as described here seems to be an adequate and proportionate therapeutic approach for the control of unresponsive vomiting in terminal intestinal obstruction. This procedure is especially useful when a venting gastrostomy is not feasible, the patients reject it, or they are in the last weeks of life.
References
- Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer. 2001;9:223–233
- . The pathophysiology and management of malignant intestinal obstruction. In: Doyle D, Hanks GWC, MacDonald N editor. Oxford textbook of palliative medicine. Oxford: Oxford University Press; 1998;p. 526–534
- Role of octreotide, scopolamine butylbromide and hydration in symptom control of patients with inoperable bowel obstruction having a nasogastric tube. A prospective randomized clinical trial. J Pain Symptom Manage. 2000;19:23–34
- Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Support Care Cancer. 2000;8:188–191
- . Use of clinical pictures in the management of nausea and vomiting (a prospective audit). Palliat Med. 2001;15:247–253
- . Midazolam (a review of its pharmacological properties and therapeutic use). Drugs. 1984;28:519–543
PII: S0885-3924(02)00600-0
© 2003 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
