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Acute Childhood Vomiting & Diarrhea Pathway

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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Acute Childhood Vomiting & Diarrhea Pathway

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  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

  5. 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%

  6. 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?

  7. 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?

  8. 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

  9. 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

  10. ‘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

  11. 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

  12. 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]

  13. Antimetics:Ondansetron RECOMMENDED BUT LIMITED USE • Only in children with moderate dehydration & active vomiting • One dose only

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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))

  20. 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

  21. 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.

  22. 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

  23. 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

  24. Questions?

  25. So What Does This Mean To Me?

  26. 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

  27. 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%

  28. Walk through progress

  29. 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

  30. 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

  31. Oral Rehydration Table

  32. Monitor for Ins + Outs

  33. Recommended Fluids

  34. Gastro Flow Sheet

  35. Reassess for ORT Success

  36. Reassess for ORT Success

  37. 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

  38. 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!

  39. New Teaching Pamphlet

  40. 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

  41. 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

  42. Questions?

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