Download - Acute Childhood Vomiting & Diarrhea Pathway
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?