Pediatric emergency medicine trisk 2739 2739
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TABLE 98.10
MANAGEMENT OF CHEMOTHERAPY-INDUCED NAUSEA AND
VOMITING (CINV)
Agents with a high therapeutic index
Drug class
Specific drug
Serotonin -S3 receptor
antagonists
Ondansetron
Pediatric dosage and frequency
( usual adult maximum )
0.15 mg/kg ( 8 mg ) q 8 h or
0.45 mg/ kg ( 24 mg ) q24h
10-40|ig/kg ( 1 mg ) q24h
10 mg/m 2 ( 10 mg ) ql 2-24 h
Route
Comment
IV/PO
Ondansetron max IV dose: 16 mg
Steroid
Granisetron
Dexamethasone
NK receptor
Aprepitant
125 mg on day 1, followed by 80
mg once daily on days 2 and 3
PO
Scopolamine
1.5-mg fixed -dose transdermal
TDP
antagonist
IV/PO
IV/PO
Should not be used in patients with
steroid -sensitive malignancies without
consultation with oncologist ( e.g.,
ALL, lymphoma )
Use should be avoided/minimized in
patients at high risk of infection or if
at increased risk of mucosal toxicity
from chemotherapy ( e.g., AML,
advanced lymphomas, ALL during
induction )
For patients >20 kg
May be combined with serotonin
receptor antagonists
Other
patch
For patients >40 kg
Avoid concurrent use of anticholinergic
drugs such as diphenhydramine
Agents with a low therapeutic index
Pediatric dosage and frequency
Drug class
Specific drug
( usual adult maximum )
Route
Comment
Benzodiazepine
Lorazepam
0.05 mg/kg ( 1 mg ) q 6 h
IV/PO
Dopamine antagonist
Metoclopramide
0.5 mg/kg q 6 h
IV/PO
Other
Dronabinol
Olanzapine
5 mg/m2
2.5-10 mg
PO
PO
Overdosage may be common with
weight -based dosing strategies. Thus,
also consider 0.25 mg for <25 kg,
0.5 mg for >25-50 kg, and 1 mg for
>50 kg.
More potent as an anxiolytic than as an
antiemetic.
Children are at high risk of
ext r a py ra mi dal r ea ctions.
Must be given with diphenhydramine
prophylaxis.
No data in use younger than 5 yrs
Limited data in younger patients
IV, intravenous; PO, per os; ALL, acute lymphoblastic leukemia ; AML, acute myeloid leukemia ; NK , neurokinin ; TDP, transdermal patch.
Transaminitis with elevations in AST and/or ALT is common in pediatric cancer
patients. Many chemotherapy agents cause a mild reversible transaminitis.
Treatment-related transaminitis is usually a laboratory-only finding without any
clinical correlate. Transfusion-associated viral transaminitis can also occur in the
frequently transfused oncology population, but the direct and indirect screening of
donor blood has reduced the incidence of viral transmission. Immunosuppression
from treatment can also increase the risk of CMV and EBV. Isolated transaminitis
may be noted during an evaluation in the ED but rarely is an indication for further
laboratory evaluation.
Hyperbilirubinemia is common during cancer treatment, is usually mild and
reversible and rarely requires any further ED evaluation. Such elevations are likely
