Acute childhood vomiting diarrhea pathway
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Acute Childhood Vomiting & Diarrhea Pathway. 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.

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Presentation outline
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


Pathway for chr
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


Your are in your ed
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 ed1
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?

What would you do currently?


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

Why use an algorithm for gastroenteritis?


Pathway highlights
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
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
‘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


Antiemitics
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):858-865


Antimetics ondansetron
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 ondansetron1
Antimetics:Ondansetron

RECOMMENDED BUT LIMITED USE

  • Only in children with moderate dehydration & active vomiting

  • One dose only


Antiemitics dimenhydranate
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


Antidiarrheal loperamide
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 placebo

      • Serious 0.9% (8/927) vs none for placebo

        • (Illeus, lethargy, death)

          NOT RECOMMENDED


Antidiarrheal dioctahedral smectite
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
Nurtritional therapy: probiotics

  • Four systematic reviews; report most recent

  • SR, Allen. Cochrane, 2004

    • 23 RCTs/1917 patients (1449 kids)

    • Range of different probiotics

    • Reduced risk of diarrhea at 3 days

      • RR 0.7, 95% CI 0.6-0.8

    • Reduce duration of diarrhea

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


Nurtritional therapy probiotics1
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
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
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


Ng vs iv rehydration
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. 3.58 (2.38)

    Recommended as backup route to IV

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


Rapid iv rehydration
Rapid IV rehydration

  • Commonly used in NA PED

    • Various def. 20-100 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


Hypotonic vs isotonic solutions
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




Walk through example
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 example1
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%



Ondansetron
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


Ondansetron dosing
Ondansetron Dosing

Oral solution:

0.2 mg/kg (for <8 kg)

Dissolve Tabs:

2mg 8-15 kg

4mg 15-30 kg

8 mg > 30 kg








Key points
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


Key points1
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!



What if their score is 3
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


Monitor
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



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