acute gastroenteritis (age).pdf

37
Last Updated: June 2015 Next Expected Review: June 2020 For questions concerning this pathway, contact: [email protected] © 2015, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Discharge Instructions · Continue ORT at home for 4- 6 additional hours; then resume regular diet, or lactose free formula if predominantly formula fed · ED Acute Gastroenteritis discharge instructions and ORT worksheet · Lactobacillus for 5 days Phase Change Acute Gastroenteritis v. 2.0: Oral Rehydration Therapy (ORT) ! Routine testing for stool pathogens not recommended No Yes Passed oral challenge (if attempted); Educate and prepare for discharge Moderate Dehydration (5-10%) · Prolonged capillary refill (>2 seconds) · Abnormal skin turgor ('tenting' or inelastic skin) · Tachypnea Overt Shock (Dehydration >10%) Minimal (<5%) to No Dehydration · Educate on prevention of dehydration Initial ORT Challenge · 5 mL q 5 mins if <10 kg · 10 mL q 5 mins if ≥10 kg ! Antimicrobials not recommended PHASE I (ED/Urgent Care): ORT Yes No Give Ondansetron if Moderately Dehydrated · Consider holding if diarrhea is chief complaint Begin ORT Inclusion Criteria · Vomiting and/or diarrhea of recent onset not due to chronic disease, with or without fever, nausea, or abdominal pain Exclusion Criteria · Patient < 3 months of age · Toxic appearance (consider sepsis) · Diarrhea >7 days (consider chronic disease, bacterial enteritis) · Bloody diarrhea (consider HUS) · Comorbid conditions (Medically Complex Children (MCC), renal failure, cardiac disease) · Bilious emesis (consider bowel obstruction) · On diuretic therapy · Hyponatremia (<130 mEq/L) or Hypernatremia (>155 mEq/L) · Acute surgical abdomen Hold ORT for 20 minutes · Then restart ORT at initial rate Increase ORT · 10 mL q 5 mins if <10kg · 20 mL q 5 mins if ≥10kg · Assess in 30-60 mins ! Anti-diarrheal agents are not recommended Off Pathway Emesis after initial ORT? Continued emesis? Reassess after 20 min Failed oral challenge (if attempted) Consider oral challenge Continue to Phase II Executive Summary Explanation of Evidence Ratings Test your knowledge Summary of Version Changes Citation Information · Continue ORT at home for 4- 6 additional hours; then resume regular diet, or lactose free formula if predominantly formula fed Discharge Criteria · Clinical status improved · Tolerating ORT or regular diet · Adequate family teaching · Follow-up established

Upload: aries-chandra-ananditha

Post on 12-Dec-2015

35 views

Category:

Documents


7 download

TRANSCRIPT

Page 1: Acute Gastroenteritis (AGE).pdf

Last Updated: June 2015

Next Expected Review: June 2020

For questions concerning this pathway,

contact: [email protected]© 2015, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Discharge Instructions· Continue ORT at home for 4-

6 additional hours; then

resume regular diet, or

lactose free formula if

predominantly formula fed

· ED Acute Gastroenteritis

discharge instructions and

ORT worksheet

· Lactobacillus for 5 days

Phase Change

Acute Gastroenteritis v. 2.0: Oral Rehydration Therapy (ORT)

!Routine testing

for stool pathogens

not recommended

NoYes

Passed oral

challenge

(if attempted);

Educate and

prepare for

discharge

Moderate Dehydration (5-10%)· Prolonged capillary refill (>2 seconds)

· Abnormal skin turgor ('tenting' or

inelastic skin)

· Tachypnea

Overt Shock

(Dehydration >10%)

Minimal (<5%) to No

Dehydration· Educate on prevention

of dehydration

Initial ORT Challenge · 5 mL q 5 mins if <10 kg

· 10 mL q 5 mins if ≥10 kg

!Antimicrobials

not recommended

PHASE I (ED/Urgent Care): ORT

Yes No

Give Ondansetron if

Moderately Dehydrated· Consider holding if diarrhea is chief

complaint

Begin ORT

Inclusion Criteria· Vomiting and/or diarrhea of recent onset not due

to chronic disease, with or without fever, nausea,

or abdominal pain

Exclusion Criteria· Patient < 3 months of age

· Toxic appearance (consider sepsis)

· Diarrhea >7 days (consider chronic disease, bacterial

enteritis)

· Bloody diarrhea (consider HUS)

· Comorbid conditions (Medically Complex Children

(MCC), renal failure, cardiac disease)

· Bilious emesis (consider bowel obstruction)

· On diuretic therapy

· Hyponatremia (<130 mEq/L) or Hypernatremia

(>155 mEq/L)

· Acute surgical abdomen

Hold ORT for 20

minutes· Then restart ORT

at initial rate

Increase ORT· 10 mL q 5 mins if <10kg

· 20 mL q 5 mins if ≥10kg

· Assess in 30-60 mins

!Anti-diarrheal

agents are not

recommended

Off

Pathway

Emesis after

initial ORT?

Continued

emesis?

Reassess after

20 min

Failed oral

challenge

(if attempted)

Consider oral

challenge

Continue

to

Phase II

Executive Summary Explanation of Evidence Ratings

Test your knowledge Summary of Version Changes

Citation Information

· Continue ORT at home for 4-

6 additional hours; then

resume regular diet, or

lactose free formula if

predominantly formula fed

Discharge Criteria· Clinical status improved

· Tolerating ORT or regular diet

· Adequate family teaching

· Follow-up established

Page 2: Acute Gastroenteritis (AGE).pdf

Last Updated: June 2015

Next Expected Review: June 2020

For questions concerning this pathway,

contact: [email protected]© 2015, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Acute Gastroenteritis v. 2.0: IV or NG Rehydration

Check vital signs· Check BP, HR, RR

· Evaluate heart and lung sounds

!Consider

myocarditis if

patient deteriorates

after fluid boluses

PHASE II (ED/Urgent Care):

IV or NG Rehydration

No, does not

meet discharge

criteria

Yes, meets

discharge

criteria

IV

Involve caregiver and patient in

decision to hydrate with IV or NG

Recheck Vital

Signs; Re-examine

Off

Pathway Discharge Instructions· Continue ORT at home for 4-6

additional hours; then resume

regular diet, or lactose free

formula if predominantly

formula fed

· ED Acute Gastroenteritis

discharge instructions and

ORT worksheet

· Lactobacillus for 5 days

Re-examine Exclusion Criteria· Patient < 3 months age

· Toxic appearance (consider sepsis)

· Diarrhea > 7 days (consider chronic

disease, bacterial enteritis)

· Bloody diarrhea (consider HUS)

· Comorbid conditions (MCC, renal failure,

cardiac disease)

· Bilious emesis (consider bowel obstruction)

· On diuretic therapy

· Hyponatremia (<130 mEq/L) or

Hypernatremia (>155 mEq/L) (if

electrolytes checked)

· Acute surgical abdomen

Urgent Care Transfer

Criteria:

· Not tolerating ORT following 2

nd IV/NG bolus (send by

BLS)

· Need for a 3rd

IV/NG bolus (send by BLS)

· Overt shock (IV access, bolus started, ALS transport)

· Worsening clinical status **Continue treatment as outlined by pathway while awaiting transport**

1st IV Fluid Bolus· NS 20 mL/kg over 30-60 mins (Max dose: 1,000 mL)

· Upon initiation of IV, check electrolytes

· Consider ondansetron if not already given or tolerated

2nd IV Fluid Bolus· NS 20 mL/kg over 30-60 mins

Recheck Vital Signs; Re-examine

· If improved, consider returning to ORT

!Consider

checking

blood glucose

1st NG Fluid Bolus· Pedialyte 20 mL/kg over 60 mins (Max dose: 600 mL)

· Consider ondansetron if not already given or tolerated

2nd NG Fluid Bolus· Pedialyte 20 mL/kg over 60 mins

Recheck Vital Signs; Re-examine

· If improved, consider returning to ORT

NG

Admit on

AGE

pathway

Evaluate for Discharge· Clinical status improved

· IV or NG fluids not required

· Tolerating ORT or regular diet

· Adequate family teaching

· Follow-up established

Phase

Change

Continue to

Phase III

· Upon initiation of IV, check electrolytes

· Consider ondansetron if not already given or tolerated

Executive Summary Explanation of Evidence Ratings

Test your knowledge Summary of Version Changes

Citation Information

· Continue ORT at home for 4-6

additional hours; then resume

regular diet, or lactose free

formula if predominantly

formula fed

Page 3: Acute Gastroenteritis (AGE).pdf

Last Updated: June 2015

Next Expected Review: June 2020

For questions concerning this pathway,

contact: [email protected]© 2015, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Discharge Instructions· Continue ORT, or

· Resume regular diet, or

lactose free formula if

predominantly formula fed

· Acute Gastroenteritis And

Oral Rehydration Therapy

handout (PE636)

· Lactobacillus for 5 days

Acute Gastroenteritis v. 2.0: Inpatient Management

Admit on AGE powerplan· Start IV D5 NS + 20 mEQ KCL/liter OR

NG Pedialyte at maintenance rate

· Assess need for additional NS or

Pedialyte bolus

Assess at 0800 (or after 4 hours of IV/NG

fluids if admitted between 0800-1600)

· Vomiting: ≤1 episodes in the past 4 hours?

· Intake > Output?

Continue maintenance IV/NG fluids· IV: Replace ongoing stool and emesis

losses with NS 1:1 every 4 hours

· NG: Replace ongoing stool and emesis

losses with Pedialyte 1:1 every 4 hours

ORT or Regular Diet Challenge· Discontinue IV or NG fluids

· ORT: 5 mL q 5 mins if <10kg; 10 mL q 5 mins if

≥10kg, or resume regular diet (lactose-free formula if

predominently formula fed)

· Reassess after 20 minutes

· Send prescription for Lactobacillus GG

Discharge Criteria

· Sufficient rehydration as

indicated by weight gain OR

normal respiratory rate,

capillary refill, and skin turgor

· IV or NG fluids not required

· Tolerating ORT or regular diet

· Adequate family teaching

· Follow-up established

!Consider secretory

diarrhea if there is

copious output in the

absence of oral intake

PHASE III: INPATIENT MANAGEMENT

No, not ready for

oral challenge

Yes, ready for

oral challenge

Ready

for ORT

No emesis,

evaluate for

discharge

Yes, RN notifies

MD when

discharge

criteria are met

!Antimicrobials

not recommended

Reassess for switch to ORT every 4

hours

Not ready

for ORT

YesNo

Increase ORT/ Diet· 10 mL q 5 mins if <10kg

· 20 mL q 5 mins if ≥10kg

· Assess in 30-60 mins

Hold ORT for 20

minutes· Then restart ORT

at initial rate

Continued

emesis

> 48 hrs

Consider other

diagnoses

!Anti-emetics are

not recommended

outside of the ED /

Urgent Care

Emesis after

initial ORT?

Emesis

No emesis

Executive Summary Explanation of Evidence Ratings

Test your knowledge Summary of Version Changes

Citation Information

· Resume regular diet, or

lactose free formula if

predominantly formula fed

Page 4: Acute Gastroenteritis (AGE).pdf

Return to Phase I

Page 5: Acute Gastroenteritis (AGE).pdf

Return to Phase IContinue to Dehydration

Categories

Page 6: Acute Gastroenteritis (AGE).pdf

Return to Phase IBack

Page 7: Acute Gastroenteritis (AGE).pdf

Return to Phase I Return to Phase II Return to Phase III

Page 8: Acute Gastroenteritis (AGE).pdf

Return to Phase I

Page 9: Acute Gastroenteritis (AGE).pdf

Return to Phase I Return to Phase III

Page 10: Acute Gastroenteritis (AGE).pdf

Return to Phase I Return to Phase III

Page 11: Acute Gastroenteritis (AGE).pdf

Return to Phase IContinue to Pg. 2

Page 12: Acute Gastroenteritis (AGE).pdf

Return to Phase IBack

Page 13: Acute Gastroenteritis (AGE).pdf

Return to Phase I

Page 14: Acute Gastroenteritis (AGE).pdf

Return to Phase II

Page 15: Acute Gastroenteritis (AGE).pdf

Return to Phase II

Page 16: Acute Gastroenteritis (AGE).pdf

Return to Phase II

Page 17: Acute Gastroenteritis (AGE).pdf

Return to Phase II

Page 18: Acute Gastroenteritis (AGE).pdf

Return to Phase II

Page 19: Acute Gastroenteritis (AGE).pdf

Return to Phase II

Page 20: Acute Gastroenteritis (AGE).pdf

Return to Phase II

Page 21: Acute Gastroenteritis (AGE).pdf

Return to Phase III

Page 22: Acute Gastroenteritis (AGE).pdf

Return to Phase IIIGo to Oral Feeding Page 2

Page 23: Acute Gastroenteritis (AGE).pdf

Return to Phase IIIBack

Page 24: Acute Gastroenteritis (AGE).pdf

Return to Phase III

Page 25: Acute Gastroenteritis (AGE).pdf

Return to Phase IIIReturn to Phase IIReturn to Phase I

Page 26: Acute Gastroenteritis (AGE).pdf

Return to Phase IIIReturn to Phase IIReturn to Phase I

Page 27: Acute Gastroenteritis (AGE).pdf

Return to Phase I

Executive Summary

Continue to Pg 2

Page 28: Acute Gastroenteritis (AGE).pdf

Executive Summary

Continue to Pg 3Return to Pg 1

Page 29: Acute Gastroenteritis (AGE).pdf

Executive Summary

Return to Phase IReturn to Pg 2

Page 30: Acute Gastroenteritis (AGE).pdf

Acute Gastroenteritis (AGE) Citation

Title: Acute Gastroenteritis (AGE) Pathway

Authors:

· Seattle Children’s Hospital

· James O’Callaghan

· Sabreen Akhter

· Elizabeth Austin

· Bryan Dryer

· Sara Fenstermacher

· Jeffrey Foti

· Kristi Klee

· Michael Leu

Date: June 2015

Retrieval Website: http://www.seattlechildrens.org/pdf/acute-gastroenteritis-algorithm.pdf

Example:

Seattle Children’s Hospital, O’Callaghan J, Akhter S, Austin E, Dryer B, Fenstermacher S, Foti J,

Klee K, Leu MG. 2015 June. Acute Gastroenteritis (AGE) Pathway. Available from: http://

www.seattlechildrens.org/pdf/acute-gastroenteritis-algorithm.pdf

Return to Home

Page 31: Acute Gastroenteritis (AGE).pdf

Return to Home View Answers

Self-Assessment

· Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a

part of required departmental training at Seattle Children’s Hospital, you MUST logon to Learning Center.

(1) Which one of the following is NOT an exclusion criteria?

a) toxic appearance

b) bloody diarrhea

c) rotavirus infection

d) diarrhea for more than 7 days

e) bilious emesis

(2) Which of the following statements concerning probiotics is/are TRUE?

a) probiotics are considered adjunctive therapy.

b) probiotics may be more effective for rotavirus diarrhea, compared to all-cause diarrhea

c) yogurt is considered a good source of probiotics

d) a and b

e) a and c

f) b and c

g) all of the above

(3) The historical BRAT diet (consisting of bananas, rice, applesauce, and toast) is unnecessarily restrictive.

a) true

b) false

(4) Which of the following statements is/are TRUE concerning the clinical assessment of dehydration in AGE?

a) Prolonged capillary refill time, abnormal skin turgor, and respiratory rate are the best individual examination

measures

b) A normal bicarbonate concentration may be useful in ruling out dehydration

c) Acute body weight change is considered the gold standard measure of dehydration

d) It is recommended that the history and physical examination be the primary basis for the diagnosis of AGE

e) all of the above

(5) Which of the following discharge criteria are TRUE?

a) tolerating ORT and/or regular diet

b) tolerating BRAT diet

c) medical follow up is available via telephone or office visit

d) a and b

e) a and c

f) b and c

g) all of the above

(6) Ondansetron has been shown to be a safe and effective therapy in hospitalized children.

a) true

b) false

(7) Which of the following is(are) the recommended diet(s) to prevent or limit dehydration?

a) BRAT diet

b) clear liquid diet

c) Paleo diet

d) regular diet

e) a and b

f) a and d

g) b and d

h) a, b, and d

(8) Which of the following liquids are appropriate for use in oral rehydration therapy?

a) Pedialyte®

b) Gatorade©

c) Gatorade© with added salt, in the ratio of 1L Gatorade© + 1 tbsp salt

d) a and b

e) a and c

f) all of the above

Page 32: Acute Gastroenteritis (AGE).pdf

Return to Home

Answer Key

Page 33: Acute Gastroenteritis (AGE).pdf

Return to Home

Evidence Ratings

To Bibliography

This pathway was developed through local consensus based on published evidence and expert

opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include

representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical

Effectiveness, and other services as appropriate.

When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed

as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the

following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):

Quality ratings are downgraded if studies:

· Have serious limitations

· Have inconsistent results

· If evidence does not directly address clinical questions

· If estimates are imprecise OR

· If it is felt that there is substantial publication bias

Quality ratings are upgraded if it is felt that:

· The effect size is large

· If studies are designed in a way that confounding would likely underreport the magnitude

of the effect OR

· If a dose-response gradient is evident

Guideline – Recommendation is from a published guideline that used methodology deemed

acceptable by the team.

Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE

criteria (for example, case-control studies).

Page 34: Acute Gastroenteritis (AGE).pdf

Return to Home

Summary of Version Changes

· Version 1.1 (11/08/2011): Go Live

· Version 1.2 (07/28/2014): Administrative update

· Version 2.0 (06/17/2015): Periodic review; updated literature search,

recommendations, and pathway tools

Page 35: Acute Gastroenteritis (AGE).pdf

Return to Home

Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our

knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to provide

information that is complete and generally in accord with the standards accepted at the time of

publication.

However, in view of the possibility of human error or changes in medical sciences, neither the

authors nor Seattle Children’s Healthcare System nor any other party who has been involved in

the preparation or publication of this work warrants that the information contained herein is in

every respect accurate or complete, and they are not responsible for any errors or omissions or

for the results obtained from the use of such information.

Readers should confirm the information contained herein with other sources and are

encouraged to consult with their health care provider before making any health care decision.

Page 36: Acute Gastroenteritis (AGE).pdf

Bibliography

Identification

Screening

Eligibility

Included

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Literature Search Strategy

Search Methods, Acute Gastroenteritis, Clinical Standard Work

Studies were identified by searching electronic databases using search strategies developed and executed

by a medical librarian, Susan Klawansky. Searches were performed in November 2014 in the following

databases – on the Ovid platform: Medline and Cochrane Database of Systematic Reviews; elsewhere:

Embase, Clinical Evidence, National Guideline Clearinghouse, TRIP and Cincinnati Children’s Evidence-

Based Care Recommendations. Retrieval was limited to 2007 to current, ages 0-18, and English language.

In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used

respectively, along with text words, and the search strategy was adapted for other databases as appropriate.

Concepts searched were gastroenteritis, dysentery, enteritis, adenoviridae infections, rotavirus infections or

rotavirus. All retrieval was further limited to certain evidence categories, such as relevant publication types,

index terms for study types and other similar limits. Additional articles were identified by team members and

added to results.

To Bibliography, Pg 2

129 records identified

through database searching

1 additional records identified

through other sources

130 records after duplicates removed

130 records screened 84 records excluded

34 full-text articles excluded,

5 did not answer clinical question

6 did not meet quality threshold

1 outdated relative to other included study

19 duplicates

3 other

46 records assessed for eligibility

12 studies included in pathway

Return to Home

Page 37: Acute Gastroenteritis (AGE).pdf

Bibliography

Return to Pg 1

1. Diarrhoea and vomiting in children. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and

management in children younger than 5 years. National Collaborating Centre for Women's and Children's Health.

http://www.ncbi.nlm.nih.gov/books/NBK63844/. Updated 2009.

2. Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: An updated cochrane

systematic review with meta-analysis and mixed treatment comparison in a bayesian framework. BMJ Open.

2012;2(4).

3. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in

children and adolescents. Cochrane Database of Systematic Reviews. 2011;9.

4. Freedman SB, Ali S, Oleszczuk M, Gouin S, Hartling L. Treatment of acute gastroenteritis in children: An

overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health.

2013;8(4):1123-1137. Accessed 20130723; 11/27/2014 12:34:04 PM. http://dx.doi.org/10.1002/ebch.1932.

5. Guarino A. Albano F. Ashkenazi S. Gendrel D. Hoekstra JH. Shamir R. Szajewska H. European Society for

Paediatric Gastroenterology, Hepatology,and Nutrition.European Society for Paediatric Infectious Diseases.

European society for paediatric gastroenterology, hepatology, and Nutrition/European society for paediatric

infectious diseases evidence-based guidelines for the management of acute gastroenteritis in children in europe. J

Pediatr Gastroenterol Nutr. 2008;46(Suppl 2):S81-122. Accessed 20080507; 11/27/2014 12:34:04 PM. http://

dx.doi.org/10.1097/MPG.0b013e31816f7b16.

6. MacGillivray S, Fahey T, McGuire W. Lactose avoidance for young children with acute diarrhoea. Cochrane

Database of Systematic Reviews. 2013;10.

7. National GC. Best evidence statement (BESt). Use of Lactobacillus rhamnosus GG in children with acute

gastroenteritis. http://www.guideline.gov/

content.aspx?id=33576&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.

8. National GC. Evidence-based care guideline for prevention and management of acute gastroenteritis (AGE) in

children aged 2 months to 18 years. http://www.guideline.gov/

content.aspx?id=35123&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.

9. National GC. Oral rehydration therapy (ORT) in children. http://www.guideline.gov/

content.aspx?id=38900&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.

10. Seattle Children’s Hospital, O’Callaghan J, Beardsley E, Black K, Drummond K, Foti J, Klee K, Leu MG, Ringer

C. 2011 September. Acute Gastroenteritis (AGE) Pathway.

11. Szajewska H, Guarino A, Hojsak I, et al. Use of probiotics for management of acute gastroenteritis: A position

paper by the ESPGHAN working group for probiotics and prebiotics. J Pediatr Gastroenterol Nutr . 2014;58(4):531-

539.

12. Szajewska H, Ruszczynski M, Kolacek S. Meta-analysis shows limited evidence for using lactobacillus

acidophilus LB to treat acute gastroenteritis in children. Acta Paediatr. 2014;103(3):249-255. Accessed 20140211;

11/27/2014 12:34:04 PM. http://dx.doi.org/10.1111/apa.12487.

13. Szajewska H, Skorka A, Ruszczynski M, Gieruszczak-Bialek D. Meta-analysis: Lactobacillus GG for treating

acute gastroenteritis in children--updated analysis of randomised controlled trials. Aliment Pharmacol Ther.

2013;38(5):467-476. Accessed 20130813; 11/27/2014 12:34:04 PM. http://dx.doi.org/10.1111/apt.12403

Return to Home