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Acute Childhood Vomiting & Diarrhea Pathway. Presentation Outline  How Pathway developed?  Typical Case Your current practice…..  Why is a pathway.

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Presentation on theme: "Acute Childhood Vomiting & Diarrhea Pathway. Presentation Outline  How Pathway developed?  Typical Case Your current practice…..  Why is a pathway."— Presentation transcript:

1 Acute Childhood Vomiting & Diarrhea Pathway

2 Presentation Outline  How Pathway developed?  Typical Case Your current practice…..  Why is a pathway helpful?  Review key highlights of the pathway  What kinds of children is the pathway intended for?  Review evidence on which pathway is based

3 Pathway for CHR  Developed 2008/9  Regional Representation Nurses, Pharmacists, Dieticians & Physicians Rural, Urban, ACH  Will be implemented ACH Fall 2010 & rest of Calgary Zone hospitals/UCCs Winter/Spring 2010

4 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

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7 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%

8 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?

9 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 can  Lower rate of IV use  Reduce ED length of stay  Reduce hospital admissions

10 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

11 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

12 ‘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

13 Antiemitics  Latest Systematic Review  11 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):

14 Antimetics:Ondansetron  Decreased risk of further vomiting (5 RCTs) RR 0.45 [ ]; NNT=5  Reduced need for intravenous fluid (4 RCTs) RR 0.41 [ ]; NNT=5  Decreased risk of hospital admission (5 RCTs) RR 0.52 [ ]; 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 [ ]

15 Antimetics:Ondansetron RECOMMENDED BUT LIMITED USE  Only in children with moderate dehydration & active vomiting  One dose only

16 Antiemitics: dimenhydranate  Commonly used in Calgary Zone EDs  One RCT – decrease in vomiting but no change in other outcomes  Another RCT currently underway in Sainte-Justine Hospital NOT RECOMMENDED Pediatrics 2009;124:e622-32

17 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 ( ) Diarrhea duration  Mean 0.8 day shorter ( ) Adverse Events  Overall 10% versus 2% for placebo  Serious 0.9% (8/927) vs none for placebo  (Illeus, lethargy, death) NOT RECOMMENDED

18 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: 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

19 Nurtritional therapy: probiotics  Four systematic reviews; report most recent  SR, Allen. Cochrane, RCTs/1917 patients (1449 kids) Range of different probiotics Reduced risk of diarrhea at 3 days  RR 0.7, 95% CI Reduce duration of diarrhea  Mean duration difference 30.5 h, 95% CI h

20 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

21 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 g (-207 to 154)  Total Fluid 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))

22 Oral vs. IV Rehydration (cont.)  Failure to rehydrate (18 RCTs (1811 children) ↑ ORT (RD 4% (1-7%), NNF 25)  Adverse Events Phlebitis ↑ 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

23 NG vs. IV Rehydration  1 RCT, 90 children, 3-36 mos., mild- mod dehydration  Rapid 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 (2.38) Recommended as backup route to IV Nager et al. Pediatrics 2002;109:566–72.

24 Rapid IV rehydration  Commonly used in NA PED Various def ml/kg over 1-4 hours 11 studies – generally small, non-RCT RCT at HSC underway Appears effective (faster time to discharge) and safe RECOMMEND RAPID IV REHYDRATION IN SEVERE OR FAILED MODERATE DEHYDRATION

25 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(P Na <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

26 Questions?

27 So What Does This Mean To Me?

28 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

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31 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%

32 Walk through progress Consider Ondansetron See Oral Rehydration Table 5-10% dehydration Needs Oral Rehydration Weigh Child (clean diaper/underwear) Gorelick Score =2

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34 Ondansetron Needs to meet inclusion criteria Score of 2 (needs oral rehydration) Significant (> 6x in last 6 hrs) and recent (> 1 in past hour) vomiting If “no” to any NO ondansetron

35 Ondansetron Dosing Oral solution: 0.2 mg/kg (for <8 kg) Dissolve Tabs: 2mg 8-15 kg 4mg kg 8 mg > 30 kg

36 Oral Rehydration Table WeightSip Volume per 5 min** Sip Volume per 10 min** Volume per Hour * < 10 kg12.525mL150mL kg18.75mL37.5mL225mL kg25mL50mL300mL kg31.25mL62.5mL375mL mL75mL450mL kg43.75mL87.5mL525mL kg50mL100mL600mL >40 kg50mL100mL600mL

37 Monitor for Ins + Outs

38 Recommended Fluids Infants 3-6mosBreast milk/formula Pedialyte/Gastrolyte 6-12mosAs 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)

39 Gastro Flow Sheet

40 Reassess for ORT Success At 1 Hour Normal VS – Gorelick <1 Taken 15mL/kg Pedialyte <1 vomit/diarrhea At 2 Hours Normal VS – Gorelick <1 Taken 30mL/kg Pediallyte <4 vomit/diarrhea >2% weight gain At 4 Hours Normal VS – Gorelick <1 Taken 60mL/kg Pediallyte > 2% weight gain Urine present

41 Reassess for ORT Success At 6 hrs Well appearing, Normal VS Gorelick score <1 Taken > 60mL/kg >2% weight gain Urine present If any of the following occur at ANYTIME have MD reassess re: starting IV rehydration Abnormal VS and/or altered LOC < 6mL/kg hourly intake Ongoing losses from V+D > intake (assume one vomit or diarrhea = ~ 8mL/kg)

42 Key Points Many of our “mod” V+D patients of the past will likely classify into <5% dehydration “hydrated” category Need 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

43 Key Points Teaching for families has changed Use regular and preferred diet for “hydrated” kids Use Pedialyte if 5-10% dehydrated Keep offering fluids despite frequent vomiting and or diarrhea Use of Ondansetron is a one-time dose Hand washing is always in style!

44 New Teaching Pamphlet

45 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

46 Monitor  Response 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

47 Questions?


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