Acute Childhood Vomiting & Diarrhea Pathway

Presentation OutlineHow Pathway developed?Typical Case

Your current practice…..

Why is a pathway helpful?Review key highlights of the pathwayWhat kinds of children is the pathway

intended for?Review evidence on which pathway is

based

Pathway for CHRDeveloped 2008/9Regional Representation

Nurses, Pharmacists, Dieticians & Physicians

Rural, Urban, ACH

Will be implemented ACH Fall 2010 & rest of Calgary Zone hospitals/UCCs Winter/Spring 2010

Your are in your ED….. 17 month old healthy boy 36 hrs profuse vomiting & diarrhea (non-

bilous, non-bloody) Parents unsuccessful at keeping down

Pedialyte Concerned because child is lethargic and

hasn’t urinated since last evening

Your are in your ED….. Remainder of PE – Cap refill is normal (< 2

seconds) & has tears with crying

VS HR 138, BP 90/72, RR 32, T 37.5 TM, O2SatRA 98%

What would you do currently?

How dehydrated is he?

PO? IV fluids? NG? How much? Which type of fluids? Over what time

frame?

Antiemitics? If so, which one(s)?

Antidiarrheals? If so, which one(s)?

Nutritional therapy? Probiotics?

Why use an algorithm for gastroenteritis?

Most common reason for children to visit an ED

Largely ‘straight-forward’ diagnosis

Ensure all use best practice

“Everybody on the same page”

Best practice canLower rate of IV useReduce ED length of

stayReduce hospital

admissions

PATHWAY HIGHLIGHTS ED/UCC Algorithm

Validated clinical score (Gorelick) Use by nurses at triage

Discourage ‘oral challenges’ and Pedialyte use in children with no to mild dehydration

Encourage oral rehydration with ORS in children with moderate dehydration

To facilitate, use oral ondansetron in children with active vomiting

Provide explicit guidelines for how to give ORS Provide criteria for judging if oral rehydration is failed

Encourage use of rapid IV rehydration in children with severe and moderate, failed dehydration

Patient Education Pamphlet and Teaching Video

Who does it apply to?For children >3 months & <10 years Vomiting and/or diarrhea with or without

accompanying nausea, fever or abdominal pain.Excludes Localized abdominal pain Children with significant chronic medical conditions Signs suggesting GI obstruction such as abdominal

distension, bilious vomiting or absent bowel sounds Vomiting and diarrhea > 7 days

‘Gorelick Score’ One point for each of:

cap refill > 2 sec absent tears dry MM ill general appearance

Score 0-1 = None to Mild (<5% dehydrated) Score 2 = Moderate (5-10% dehydrated)

Sensitivity 79% Specificity 87%

Score 3 or 4 = Severe (> 10% dehydrated) Sensitivity 82% Specificity 83%

Gorelick,et al. Pediatrics 1997;99;e6

AntiemiticsLatest Systematic Review11 articles met criteria

Ondansetron (n=6),Domperidone (n=2)Trimethobenzamide (n=2)Pyrilamine-pentobarbital (n=2)Metoclopramide (n=2)Dexamethasone (n=1)Promethazine (n=1)

Arch Pediatr Adolesc Med. 2008;162(9):858-865

Antimetics:Ondansetron Decreased risk of further vomiting (5 RCTs)

RR 0.45 [0.33-0.62]; NNT=5

Reduced need for intravenous fluid (4 RCTs) RR 0.41 [0.28-0.62]; NNT=5

Decreased risk of hospital admission (5 RCTs) RR 0.52 [0.27-0.95]; NNT=14

Increased diarrheal episodes (3 RCTs) Not all found; short duration; small increase in # NEJM (1.4 vs. 0.5 episodes)

Return to care (5 RCTs) RR 1.34 [0.77-2.35]

Antimetics:Ondansetron

RECOMMENDED BUT LIMITED USE Only in children with moderate dehydration &

active vomiting One dose only

Antiemitics: dimenhydranate

Commonly used in Calgary Zone EDsOne RCT – decrease in vomiting but

no change in other outcomesAnother RCT currently underway in

Sainte-Justine HospitalNOT RECOMMENDED

Pediatrics 2009;124:e622-32

Antidiarrheal: Loperamide Peripheral opiate receptor agonist

Antisecretory & antimotility properties SR (Li et al, PLoS Med. 2007;4:E98)

13 RCTs/1,788 patients Diarrhea at 24 hrs

Prevalence ratio – 0.66 (0.57-0.78) Diarrhea duration

Mean 0.8 day shorter (0.7-0.9) Adverse Events

Overall 10% versus 2% for placeboSerious 0.9% (8/927) vs none for placebo

(Illeus, lethargy, death)

NOT RECOMMENDED

Antidiarrheal: Dioctahedral smectite Naturally hydrated aluminomagnesium silicate that

increases H20 & electrolyte absorption Commonly used in Europe SR, Aliment Pharmacol Ther 2006;23:217

9RCTs/1238 patients Quality – most had significant methodological issues, eg.

lack of allocation concealment & blinding Duration of diarrhea

Mean difference 22.7 h (95%CI: 24.8-20.6 h) Cure on day 3

RR 1.64, 95% CI: 1.36–1.98; NNT 4, 95%CI: 3–5 Adverse effects

Constipation RR 5.8, 95% CI: 0.7–47.1

NO PRODUCT AVAILABLE IN CANADA

Nurtritional therapy: probiotics

Four systematic reviews; report most recent

SR, Allen. Cochrane, 200423 RCTs/1917 patients (1449 kids)Range of different probioticsReduced risk of diarrhea at 3 days

RR 0.7, 95% CI 0.6-0.8Reduce duration of diarrhea

Mean duration difference 30.5 h, 95% CI 19-43 h

Nurtritional therapy: probiotics

Probiotics are not created equal Only some strains are of proven

effectiveness

Quality control is important Most commercial products do not have

significant amounts

No products available in Canada which: are made with adequate quality standards; are safe in all populations; and have proven effectiveness

NOT RECOMMENDED

Oral vs. IV Rehydration SR (Cochrane Review, 2006) 18 RCTs (1811 children) Duration of diarrhea (8 RCTs, 960 pts)

No diff (WMD -5.9 hr (-12.7 to 0.8))

Weight gain (6 RCTs, 369 pts) No diff (WMD -26.33 g (-207 to 154)

Total Fluid Intake @ 6 hrs. (8 RCTs, 985 pts) No diff (WMD 32 ml/kg (-27 to 91 ml/kg))

Hospital LOS (6 RCTs (526 children)) ↓LOS ORT (WMD – 1.2 days (-2.38 to -0.02))

Oral vs. IV Rehydration (cont.)Failure to rehydrate (18 RCTs (1811

children)↑ ORT (RD 4% (1-7%), NNF 25)

Adverse EventsPhlebitis ↑IVT NNT 50 (25 to 100)Paralytic illeus ↑ORT, NNT 33 (20 to 100)

Low rate of occurrence; driven by 2 studies

RECOMMENDED FOR MODERATE DEHYDRATION

NG vs. IV Rehydration1 RCT, 90 children, 3-36 mos., mild-

mod dehydrationRapid rehydration - 50 ml/kg over 3

hrs. (Pedialyte NG or NS IV)Failure = NG 1/47 vs IV 2/46% Wt Gain = 2.21 (2.38) vs. 3.58 (2.38)Recommended as backup route to IV

Nager et al. Pediatrics 2002;109:566–72.

Rapid IV rehydration

Commonly used in NA PEDVarious def. 20-100 ml/kg over 1-4

hours11 studies – generally small, non-RCTRCT at HSC underwayAppears effective (faster time to

discharge) and safe

RECOMMEND RAPID IV REHYDRATION IN SEVERE OR FAILED MODERATE DEHYDRATION

Hypotonic vs. Isotonic solutions SR, 6 studies, 404 children

Mixed designs = 2 RCTs, 1 CT, 1 CC, 2 cohort (1 pro & 1 retro)

Mixed pt. population = most surgery, 1 GE with dehydration, 1 misc. hospitalized pts.

↑Hyponatremia(PNa<136) - OR 17.2 (8.7 to 34.2)

Mechanism – SIADH Case Reports and Series of Seizures

associated with hyponatremia in otherwise well children treated with hypotonic IVF

RECOMMEND ONLY ISOTONIC IV FLUIDS

Arch Dis Child 2006;91:828-35

Questions?

So What Does This Mean To Me?

Walk through example…..

17 month old previously healthy boy

36 hrs profuse vomiting & diarrhea (non-bilous, non-bloody)

Parents unsuccessful at keeping down Pedialyte

Concerned because child is lethargic and hasn’t urinated since last evening

Walk through example…..

Unwell “looks ill” appearance, Dry mucous membranes Cap refill is normal (< 2 seconds) & Tears with crying

VS HR 138, BP 90/72, RR 32, T 37.5, O2SatRA 98%

Walk through progress

OndansetronNeeds to meet inclusion criteria

Score of 2 (needs oral rehydration)

Significant (> 6x in last 6 hrs) andrecent (> 1 in past hour) vomiting

If “no” to any NO ondansetron

Ondansetron DosingOral solution:

0.2 mg/kg (for <8 kg)

Dissolve Tabs: 2mg 8-15 kg 4mg 15-30 kg 8 mg > 30 kg

Oral Rehydration Table

Weight Sip Volume per 5 min**

Sip Volume per 10 min**

Volume per Hour *

< 10 kg 12.5 25mL 150mL

10-15 kg 18.75mL 37.5mL 225mL

15-20 kg 25mL 50mL 300mL

20-25 kg 31.25mL 62.5mL 375mL

25-30 37.5mL 75mL 450mL

30-35 kg 43.75mL 87.5mL 525mL

35-40 kg 50mL 100mL 600mL

>40 kg 50mL 100mL 600mL

Monitor for Ins + Outs

Please Help Us Keep Track of Your Child’s I ntake and Output NAME:____________________________ AGE:__________ DATE:_____________________________

TIME INPUT OUTPUT Fluids started: Please give your child _______mL or ______oz of

_________________________________________ and continue to give fluids even if vomiting/diarrhea

For example: vomited x 1 (large amount)

Legend: Indicate time of input Indicate time of output Indicate type of food/fluid given Indicate type of output; urine, stool (diarrhea) or emesis Indicate amount of food/fld given (oz or mL) Estimate amount of output (small, medium, large)

Recommended FluidsInfants 3-6mos Breast milk/formula

Pedialyte/Gastrolyte

6-12mos As above. If taking solids: cereal, bread, rice, pasta…etc

Children > 12mos

Pedialyte, milk, soup, fruit juice diluted 1:2 with water

Foods child normally eats: bread, crackers, cheese, eggs, lean meat, yogurt, fruit

Food and fluids to avoid

High sugar drinks (pop, JellO, undiluted juice, Gatorade,etc)

Gastro Flow Sheet

CHILDHOOD VOMITING & DIARRHEA PATHWAY FLUID BALANCE FLOWSHEET

DATE:__________________ Time:__________ BASELINE VS: T________ ºC HR ________ RR________ BP________ WT:________ GORELICK SCORE (1 each): Cap refill > 2secs Score: One or less: Maintain hydration, full diet as tolerated (<5% dehydrated) Absent tears Two: Needs oral rehydration, ORS (5-10% dehydrated) Dry mucous membranes Three or Four with normal VS: Needs IV rehydration (>10% dehydrated) Ill general appearance Three or Four with abnormal VS: Needs resuscitation (>10% dehydrated) Time Initial 1 hr Total 2hr Total 4hr Total Cap refill > 2secs (1 or 0) Absent tears (1or 0) Dry mucous membranes(1 or 0) Ill general appearance (1 or 0) Gorelick Score total Intake: Type Amount (mL) Output: Type (V or D) # of episodes *estimate amounts for >10% dehydration with abnormal VS based on ~8mL/kg per Vor D

Weight Temp HR RR BP Color Signature (initial) Summary: Comments: Ondansetron Time: IV Therapy Time:

Reassess for ORT Success

Reassess for ORT Success

Key PointsMany of our “mod” V+D patients of the past

will likely classify into<5% dehydration “hydrated” categoryNeed to keep feeding gut to enhance

healing

Many patients we would typically insert an IV for will classify in 5-10% “needs oral rehydration” category

Key PointsTeaching for families has changed

Use regular and preferred diet for “hydrated” kids

Use Pedialyte if 5-10% dehydratedKeep offering fluids despite frequent vomiting

and or diarrhea

Use of Ondansetron is a one-time dose

Hand washing is always in style!

New Teaching Pamphlet

What if their score is 3?Weigh in clean diaper/underwear

Needs IV rehydration

VS Q 30 min then hourly

IV NS 20ml/kg bolus over 30 min

Consider NG if no IV access

MonitorResponse to IV fluid bolus

Perfusion status: VS, pulses, cap refill, color, activity level, urine output

Document intake volume and # of emesis/diarrhea, and urination

Once VS and LOC are normalized – may start ORT, monitor, re-weigh and re-score

Questions?