Download Diarrhoea +/- vomiting

 Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Child and Adolescent Health Service Princess Margaret Hospital for Children Diarrhoea +/‐ vomiting
Nurse Practitioner
Clinical Protocol Emergency Department Background and practice notes Scope Assessment and initial intervention Clinical protocol authorship and approval References Acknowledgement Disclaimer Working diagnosis and investigations Management Patient education and discharge information Medications Management flowchart Associated documents Clinical audit Definition of terms Background and practice notes Most children presenting to the Emergency Department (ED) with gastroenteritis and no co‐morbidities will not require any intervention other than parental reassurance and education. Mild cases of gastroenteritis are usually self limiting and may cause mild dehydration, which can be treated or prevented by continued feeding and drinking appropriate amounts of fluids. Breastfeeding of affected babies should continue even during oral rehydration1,8,11 as it is thought that this may reduce stool output and shorten duration of diarrhoea.1 Parameters of severity of dehydration vary widely in the literature.6,8,9 For the purpose of this clinical protocol, the following diagnostic criteria of mild and moderate dehydration will be used.8 No dehydration Mild to moderate dehydration
(< 3% weight loss) (3‐8% weight loss)
• No signs •
•
•
•
•
Dry mucous membranes Reduced urine output Sunken eyes Minimal or no tears Diminished skin turgor (pinch test 1‐2 secs) Use of oral rehydration solution is the recommended first line therapy for treating mild to moderate dehydration in children with gastroenteritis.2,11 Enteral (oral or nasogastric) rehydration is a much safer means of rehydration compared with intravenous rehydration because it avoids the risks associated with rapid fluid and electrolyte shifts.8 Diarrhoea and vomiting settles more quickly and appetite returns earlier with use of oral rehydration therapy.8 Oral rehydration therapy has been shown to be as effective as intravenous therapy in treating mild to moderate dehydration in acute gastroenteritis.2 The use of antiemetics for children with gastroenteritis who are vomiting are not routinely indicated, however this issue remains controversial.3,4 Ondansetron has been shown to reduce the frequency of vomiting, improve the success and compliance with oral rehydration therapy2,4,5 and reduce the need for intravenous therapy in some cases.2 There have been reports of increased frequency of diarrhoea after its usage, however this is usually transient and well tolerated.2 Some workplace practice supports Ondansetron use in children with gastroenteritis but is reserved as a single oral dose for those 9
1,8
with persistent vomiting. Antidiarrhoeals should not be used for acute diarrhoea in children. They do not reduce fluid and 1
electrolyte loss, may delay expulsion of organisms and may cause adverse effects. Features suggestive of a diagnosis other than gastroenteritis include: abdominal pain with significant tenderness, distension, mass or guarding, hepatomegaly, vomiting of blood or bile, bloody diarrhoea, red current jelly stools, pallor, jaundice, 8
systemically unwell out of proportion to the degree of dehydration, shock and a neonate with diarrhoea. Vomiting alone 8 should not be diagnosed as gastroenteritis. The following conditions should be excluded as they may have similar features: appendicitis, antibiotic associated diarrhoea, meningitis, haemolytic uraemic syndrome, urinary tract infection and other gastrointestinal surgical conditions such as intussusception and partial bowel obstruction. Nurse Practitioner Clinical Protocol Date Issued: October 2011 Diarrhoea +/‐ vomiting Date Revised: January 2012 Emergency Department Review Date: October 2013 Princess Margaret Hospital Authorised by: PMH Emergency Department Perth, Western Australia Review Team: PMH Emergency Department This document should be read in conjunction with disclaimer in this clinical protocol
Page 1 of 10 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Scope Outcomes Nurse Practitioner Medical Practitioner +/‐
Nurse Practitioner • Children older than 12 months of age with acute onset of diarrhoea +/‐ nausea, vomiting, fever, abdominal pain Identify patients suitable for Emergency Nurse Practitioner (ENP) clinical protocol Identify patients not suitable • Infants less than 12 months of age for ENP clinical protocol and • Underlying significant medical pathology refer to Senior Medical eg: previous gastrointestinal surgery, metabolic Practitioner (SMP) disorders, inflammatory bowel disease • Evidence of failure to thrive • Children presenting with history of vomiting bile or However, patient can be managed by ENP in blood, red current jelly stools or malena or pale, consultation with SMP if floppy episodes appropriate • Unwell looking or septic appearance • Evidence of shock or severe dehydration • Cardiovascular instability • Severe abdominal pain • Vomiting without diarrhoea • History of diarrhoea for greater than 10 days +/‐ vomiting for greater than 7 days Assessment and initial intervention Primary survey History •
•
•
•
•
•
•
•
•
•
•
•
•
•
Outcomes Airway Breathing Circulation Disability Exposure Signs and symptoms of current illness: frequency and nature of stools and vomits Oral intake, volume and fluid type Urine output, number of wet nappies Abdominal pain Urinary symptoms Level of activity Risk factors; recent travel, known infectious contacts, antibiotic related diarrhoea Past medical history Allergies, immunisation status, medications Abnormal primary survey identified – exit ENP clinical protocol and refer to SMP Identify patients not suitable for ENP clinical protocol and refer to SMP Abnormal examination • Vital signs outside defined scope ‐ refer • Urinalysis if appropriate (eg: unsettled, poor to SMP feeding, vomiting without diarrhoea) • General examination • Abdominal examination • Hydration status; mental status, capillary refill time, skin turgor, mucous membranes, fontanelle, presence of tears, +/‐ eyes sunken • Weight (bare if < 12 months of age); comparison with pre‐illness and post treatment if available (gold standard7) Examination Page 2 of 10 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Assessment and initial intervention (continued) Outcomes Pain assessment • Use appropriate pain assessment tool Analgesia • Administration of analgesia as required Relief of pain (refer to Pain Management and Procedural Sedation ENP Clinical Protocol) • Not routinely indicated Determine need for and type of analgesia Working diagnosis and investigations Meets inclusion criteria. History and examination findings support working diagnosis of gastroenteritis. Imaging • Not routinely indicated Pathology • Stool culture required for the following:8 ƒ Blood in stool ƒ Suspected epidemic for food poisoning ƒ Severe or prolonged diarrhoea (> 2 weeks) ƒ Recent overseas travel ƒ Child residing in an institution • Campylobacter, Cryptosporidium, Shigella, Salmonella and rotavirus are notifiable diseases12 • Blood tests are not routinely indicated but may be clinically useful in the following circumstances:8 ƒ Bloody diarrhoea – consider full blood count (FBC), urea, creatinine ƒ Dehydration with ‘doughy’ feel to skin that might indicate hypernatraemia ƒ Dehydrated children where history and clinical examination are inconsistent with straight forward diarrhoeal episode • Any child receiving intravenous (IV) rehydration should have screening tests prior to therapy including FBC, urea and electrolytes Appropriate follow up of stool culture or blood tests if specimen taken during presentation Any child requiring a blood test must be discussed with SMP prior Page 3 of 10 Emergency Department Princess Margaret Hospital for Children Management Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Outcomes Antiemetics and antidiarrhoeals are not routinely indicated for children with acute diarrhoea +/‐ vomiting.1,8,11 No or mild dehydration Moderate dehydration Severe dehydration •
•
•
•
•
•
ENP with view to discharge home Advise small frequent fluids and feeds Continue breastfeeding if applicable Provide fact sheet – Gastroenteritis Health Facts Discuss re‐presentation criteria Commence oral fluid trial using appropriate departmental documentation • Oral fluid trial should consist of oral rehydration solution or water 1 ml/kg every 5 mins and review in 1 hour • Provide parental support and reassurance during this time • Consider use of single oral dose of Ondansetron for children with persistent vomiting and difficulty tolerating oral/ nasogastric (NG) fluid rehydration Improvement in hydration status • Prepare for discharge • Advise small frequent fluids and feeds • Continue breastfeeding if applicable • Provide fact sheet – Gastroenteritis Health Facts • Discuss re‐presentation criteria No or partial improvement • Discuss with and patient review by SMP • Consider NG rehydration at 50 ml/kg over 4 hours • IV fluids may be considered if older child and has difficulty tolerating NG tube • If required 0.9% Sodium Chloride and 5% Glucose is the IV rehydration fluid of choice in children (unless hypernatraemic or hypovolaemic shock, in which case Sodium Chloride 0.9% is preferred) Refer to medication section of this protocol for calculation of IV fluid requirements • Admit to Short Stay Unit • Regular reassessment of hydration status during this time, weigh patient post rehydration and compare weight with pre‐hydration weight • If condition improves, prepare for discharge in consultation with SMP • Advise small frequent fluids and feeds • Continue breastfeeding if applicable • Provide fact sheet – Gastroenteritis Health Facts • Discuss re‐presentation criteria Deterioration in condition • Refer to SMP
Patient identified as suitable for ENP clinical protocol and discharged home Patient identified as suitable for ENP clinical protocol and discharged home Consultation with SMP if no or minimal improvement or if condition deteriorates Exit ENP clinical protocol and refer to SMP
Page 4 of 10 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Management (continued) Recommendations for admission Acute referral Outcomes • Those children whose parents are not able to manage the child’s condition at home • Children at higher risk of becoming dehydrated may be observed for at least 4 hours to ensure adequate maintenance of hydration eg: young age, high frequency of watery stools and vomits, children with disability or feeding issues • Children with severe dehydration • No or partial improvement with ED regimen • Referral as appropriate to: ƒ Interpreter ƒ Allied health ƒ Aboriginal Liaison Officer Patient education and discharge information
Discharge criteria Treatment instructions Medication instructions Follow‐up/ referral Re‐presentation criteria Documentation Expected outcome Appropriate patient admission Patient/parent understands referral process Outcomes • Tolerating oral fluids • Improvement in hydration (is no more than mildly dehydrated) • No signs of sepsis or likely alternate diagnosis • Consider time of day, distance from medical care, parent confidence and understanding
• Verbal and written instructions regarding fluid regimen, breastfeeding, diet, medication use and infection control measures • Identify likely progression of the illness, expected outcome, re‐presentation criteria and referrals
• Verbal instructions given by ENP • Simple analgesia short term if required • Not routinely required unless specific concerns • Advise GP follow up within 24 hours if concerned or other risk factors eg: younger than 12 months, significant losses (watery stools +/‐ vomits) • Seek further medical advice if not improving • Verbal and written instructions as appropriate • Not tolerating oral fluids • Significant increase in losses • Significantly reduced urine output, increased lethargy, generally more unwell • Parental concern
• Parent education – Gastroenteritis Health Facts • GP letter if applicable • Medical certificate/ certificate of attendance • Patient medical record • Appropriate fluid order documentation • Adequate hydration status achieved prior to discharge from ED • Hydration status maintained following discharge • Gradual resolution of symptoms and return to pre‐
illness bowel habits within 7‐10 days
Patient suitable for discharge Patient/ parent understands instructions given Patient/ parent understands instructions given Patient/ parent understands follow‐up arrangement Patient/ parent understands criteria for re‐presentation and is discharged home Appropriate documentation completed Page 5 of 10 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Medications Preparation • Powder for oral liquid in sachets • Oral liquid Route/administration
• Oral or nasogastric use only Dose • Oral fluid trial: 1 ml/kg every 5 mins for 1 hour8 • NG rapid rehydration: 50 ml/kg over 4 hours8 Pharmacology • Provides fluid, electrolyte and glucose replacement Pharmacodynamics
• Well tolerated Indication • Moderate dehydration – correction of fluid and electrolyte loss associated with diarrhoea +/‐ vomiting Contraindications for ENP use • Children with history of diabetes, hypertension, renal disease, phenylketonuria • Known hypersensitivity to any ingredient in oral rehydration salts Interactions • None reported Paediatric considerations • Replacement solutions may be better tolerated if frozen and presented as an ice block Adverse effects • None reported Patient education
• Follow administration directions provided and refer to product information • Do not reconstitute with diluents other than water Useful links • For full prescribing information refer to AMH online Route/administration
• Intravenous Dose Calculation of IV fluid requirements8
• 100 ml/kg per 24 hours for first 10 kg of body weight • Add 50 ml/kg per 24 hours for next 10 kg of body weight • Add 20 ml/kg per 24 hours for remaining kg of body weight 8
Estimation of deficit volume • This is based on the estimated percentage of dehydration % dehydration x body weight (kg) x 10 • Administer deficit volume over 24 hours – see note below Note: deficit volume is to be added to maintenance requirement and ongoing losses over 24 hours; give half of this total volume in the first 8 hours then rest over remaining 16 hours Indication • IV rehydration for children with moderate dehydration – correction of fluid and electrolyte loss associated with diarrhoea +/‐ vomiting Contraindications for ENP use • Children with hypernatraemia or hypovolaemic shock • Children with diabetes Oral rehydration solution Unscheduled Intravenous fluids 0.9% Sodium Chloride with 5% Glucose Unscheduled Page 6 of 10 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Medications (continued) Preparation • Wafer 4mg, 8mg • Liquid, each 5 ml contains 4 mg Ondansetron Route/ administration
• Oral/ sublingual use Dose • 0.15 mg/kg/dose to be given as a single dose only Pharmacology • Central and peripheral 5‐HT3 receptor blockade • Precise mode of action in the control of nausea and vomiting is not known Pharmacokinetics
• Tablet, wafer and oral liquid formulations are bioequivalent • Peak plasma concentrations are achieved in approximately 1.5 hours • Volume of distribution is 1.8 L/kg • Metabolised by P450 enzymes • Plasma protein binding is 70‐70% • Elimination half life is 4‐11 hours Indication • Persistent nausea and/or vomiting associated with acute gastroenteritis Contraindications for ENP use • Children with history of liver impairment, cardiac disease (can cause QT prolongation; usually transient and clinically insignificant), phenylketonuria (wafers contain aspartame) • Children younger than 2 years of age • Hypersensitivity to other selective 5‐HT3 receptor antagonists Interactions • Phenytoin, carbamazepine, rifampicin, tramadol Adverse effects • Rare but may include constipation, headache, dizziness, transient rise in aminotransferases, ECG changes (rare; is predominantly associated with intravenous infusion) Paediatric considerations • Seek advice from SMP for use in children younger than 2 years of age • Calculate lean body weight where child is overweight Practice points • Ondansetron may be useful to improve success and compliance with oral rehydration therapy2,4,5 Useful links • For full prescribing information refer to AMH online Ondansetron Poison schedule 4 Page 7 of 10 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Management flowchart Gastroenteritis management flowchart Diarrhoea +/‐ nausea, vomiting, fever and abdominal pain Yes •
•
•
•
•
•
•
•
•
Child younger than 12 months Underlying relevant medical pathology Systemically unwell or evidence of shock Cardiovascular instability Septic appearance Blood in vomit and/or bile stained vomit Malena or redcurrent jelly stools Hx diarrhoea > 10 days +/‐ vomiting for > 7 days Vomiting without diarrhoea Yes Discuss with SMP No No Working diagnosis of gastroenteritis Refer to SMP
Yes Yes Severe dehydration Refer to SMP No Yes Moderate dehydration Commence oral fluid trial Observe child over next hour
No Condition improved
Yes Partial or no improvement
Condition deteriorated
Discuss with SMP Consider admission and NG rehydration/ IV rehydration
Refer to SMP Yes
No or mild dehydration Yes Yes Meets discharge criteria Provide discharge advice Discharge home Page 8 of 10 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting Associated documents Gastroenteritis PMH Emergency Department Clinical Practice Guideline 2010 Pain Management and Procedural Sedation ENP Clinical Protocol Clinical audit Unexpected re‐presentation Emergency Department Information System and ENP clinical log Definition of terms Emergency Nurse Practitioner Emergency Department General Practitioner Australian Medicines Handbook Intravenous Nasogastric ENP ED GP AMH IV NG Clinical protocol authorship and approval Clinical protocol author Jemma Bates‐Smith Acting Nurse Practitioner Emergency Department Date written October 2011 Date for review October 2013 Page 9 of 10 Emergency Department Princess Margaret Hospital for Children Nurse Practitioner Clinical Protocol Diarrhoea +/‐ vomiting References 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Australian Medicines Handbook (online). 2011 Jul. [cited 2011 Sept 6]. Available from: http://www.amh.net.au.pklibresources.health.wa.gov.au/online/view.php?page=chapter12/treatdiarrhoea.t.html#d
iarrhoea.t Chow C, Leung A, Hon K. Acute gastroenteritis: from guidelines to real life. Clinical and Experimental Gastroenterology. 2010;3:97‐112. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database of Systematic Reviews. 2011, Issue 9. Art No: CD005506. DOI:10.1002/14651858.CD005506.pub5. Freedman SB, Steiner MJ, Chan KJ. Oral ondansetron administration in emergency departments to children with gastroenteritis: An economic analysis. PLoS Medicine. 2010 Oct;7(10): e1000350. doi:10.1371/journal.pmed.1000350. Freedman SB, Alder M, Seshadri R, Powell E. Oral ondansetron for gastroenteritis in a pediatric emergency department. The New England Journal of Medicine. 2006 Apr;354(16):1698‐1705. Hartling L, Bellemare S, Wiebe N, Russell KF, Klassen TP, Craig WR. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children (Review). Cochrane Database of Systematic Reviews. 2006, Issue 3. Art No: CD004390. DOI:10.1002/14651858.CD004390.pub 2. Moyer VA, Elliott EJ. Evidence based pediatrics and child health [internet]. London: BMJ Publishing Group; 2004. Chapter 37, Acute Gastroenteritis; p 375‐89. [cited 2011 Sept 12]. Available from: http://books.google.com.au/books?id=V0axOhNjq_QC&pg=PA381&lpg=PA381&dq=gold+standard+weighing+childre
n+with+dehydration&source=bl&ots=GtOVyNiRjv&sig=A‐
CuDWWnPe3ZRD3zOWtSlNvgsB0&hl=en#v=onepage&q&f=false Princess Margaret Hospital for Children, Perth, Western Australia. 2010. Emergency Department Clinical Practice Guideline, Gastroenteritis. The Royal Children’s Hospital, Melbourne, Australia. 2009. Clinical Practice Guidelines, Gastroenteritis. The Royal Children’s Hospital, Melbourne, Australia. 2004. Nurse Practitioner Clinical Practice Guideline, Diarrhoea +/‐ vomiting. Therapeutic Guidelines online (eTG). Infectious diarrhoea: fluid and electrolyte therapy (rehydration). 2011 Feb. [Cited 22 Aug 2011]. Available from: http://online.tg.org.au.pklibresources.health.wa.gov.au/ip/ Western Australia, Department of Health. Notifiable diseases. [cited 2011 Sept 12]. Available from: http://www.public.health.wa.gov.au/3/284/2/notifiable_communicable_diseases.pm Acknowledgement Princess Margaret Hospital wishes to acknowledge The Royal Children’s Hospital in Melbourne, Joondalup Health Campus and the Department of Health, Western Australia for their valued advice and support with regards to the creation of this clinical protocol. Disclaimer/ Statement of intent This clinical protocol is intended for use by Emergency Nurse Practitioners (ENPs) working in the Emergency Department at Princess Margaret Hospital for Children in the management of children presenting with signs and symptoms suggestive of gastroenteritis. Standards of care are determined on the basis of clinical data available and are subject to change as scientific knowledge and technology advance and patterns of care evolve. The clinical protocols detail diagnostic criteria and appropriate management options. Departmental clinical practice guidelines are available to guide medical clinical decision making. They form the foundation for the ENP clinical protocols and ensure that the practice of the ENP is consistent, safe and that the boundaries of ENP practice are well defined. It should be noted that clinical protocols provide a framework but do not attempt to take the place of sound clinical judgement. Nurse Practitioners may be responsible for clinical decisions not adequately defined by clinical protocols and under these circumstances collaboration with a Senior Medical Practitioner (SMP) will ensure that decisions are appropriate. A SMP will be the ED Consultant or a Senior Registrar delegated by the ED Consultant. Nurse Practitioner Clinical Protocol Date Issued: October 2011 Diarrhoea +/‐ vomiting Date Revised: January 2012 Emergency Department Review Date: October 2013 Princess Margaret Hospital Authorised by: PMH Emergency Department Perth, Western Australia Review Team: PMH Emergency Department This document should be read in conjunction with disclaimer in this clinical protocol
Page 10 of 10