Академический Документы
Профессиональный Документы
Культура Документы
Executive Summary
Citation Information
Exclusion Criteria
Patient < 3 months of age
Toxic appearance (consider sepsis)
Diarrhea >7 days (consider chronic disease, bacterial
enteritis)
Bloody diarrhea (consider HUS)
Comorbid conditions (Medically Complex Children
(MCC), renal failure, cardiac disease)
Bilious emesis (consider bowel obstruction)
On diuretic therapy
Hyponatremia (<130 mEq/L) or Hypernatremia
(>155 mEq/L)
Acute surgical abdomen
!
Routine testing
for stool pathogens
not recommended
Minimal (<5%) to No
Dehydration
Educate on prevention
of dehydration
Give Ondansetron if
Moderately Dehydrated
Off
Pathway
!
Anti-diarrheal
agents are not
recommended
Failed oral
challenge
(if attempted)
Consider oral
challenge
Begin ORT
5 mL q 5 mins if <10 kg
10 mL q 5 mins if 10 kg
Antimicrobials
not recommended
Reassess after
20 min
Increase ORT
Yes
Emesis after
initial ORT?
No
Passed oral
challenge
(if attempted);
Educate and
prepare for
discharge
10 mL q 5 mins if <10kg
20 mL q 5 mins if 10kg
Assess in 30-60 mins
Discharge Instructions
Continue
to
Phase
Change
Phase
II
Yes
Continued
emesis?
No
Discharge Criteria
Executive Summary
Citation Information
Check vital signs
Check BP, HR, RR
Evaluate heart and lung sounds
!
Consider
checking
blood glucose
NG
Consider
myocarditis if
patient deteriorates
after fluid boluses
Not
tolerating ORT following
nd
Recheck Vital
Signs; Re-examine
Yes, meets
discharge
criteria
Off
Pathway
Admit on
AGE
pathway
Continue
Phase to
Phase
III
Change
Discharge Instructions
Continue
ContinueORT
ORTatathome
homefor
for4-6
4-6
additional
additionalhours;
hours;then
thenresume
resume
regular
regulardiet,
diet,or
orlactose
lactosefree
free
formula
formulaififpredominantly
predominantly
formula
formulafed
fed
ED Acute Gastroenteritis
discharge instructions and
ORT worksheet
Lactobacillus for 5 days
!
Consider secretory
diarrhea if there is
copious output in the
absence of oral intake
Anti-emetics are
not recommended
outside of the ED /
Urgent Care
Not ready
for ORT
Ready
for ORT
Discontinue IV or NG fluids
ORT: 5 mL q 5 mins if <10kg; 10 mL q 5 mins if
10kg, or resume regular diet (lactose-free formula if
predominently formula fed)
Reassess after 20 minutes
Send prescription for Lactobacillus GG
Emesis after
initial ORT?
No
10 mL q 5 mins if <10kg
20 mL q 5 mins if 10kg
Assess in 30-60 mins
Antimicrobials
not recommended
Emesis
No emesis
No emesis,
evaluate for
discharge
Discharge Criteria
Sufficient rehydration as
indicated by weight gain OR
normal respiratory rate,
capillary refill, and skin turgor
IV or NG fluids not required
Tolerating ORT or regular diet
Adequate family teaching
Follow-up established
Yes
Consider other
diagnoses
Discharge Instructions
Yes, RN notifies
MD when
discharge
criteria are met
Continue ORT, or
Resume regular diet, or
lactose free formula if
predominantly formula fed
Acute Gastroenteritis And
Oral Rehydration Therapy
handout (PE636)
Lactobacillus for 5 days
Return to Phase I
Continue to Dehydration
Categories
Return to Phase I
Back
Return to Phase I
Return to Phase I
Return to Phase II
Return to Phase I
Return to Phase I
Return to Phase I
Continue to Pg. 2
Return to Phase I
Back
Return to Phase I
Return to Phase I
Return to Phase II
Return to Phase II
Return to Phase II
Return to Phase II
Return to Phase II
Return to Phase II
Return to Phase II
Back
Return to Phase I
Return to Phase II
Return to Phase I
Return to Phase II
Executive Summary
Return to Phase I
Continue to Pg 2
Executive Summary
Return to Pg 1
Continue to Pg 3
Executive Summary
Return to Pg 2
Return to Phase I
Return to Home
Self-Assessment
Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a
part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.
(1)
(2)
(3)
The historical BRAT diet (consisting of bananas, rice, applesauce, and toast) is unnecessarily restrictive.
a)
true
b)
false
(4)
Which of the following statements is/are TRUE concerning the clinical assessment of dehydration in AGE?
a)
Prolonged capillary refill time, abnormal skin turgor, and respiratory rate are the best individual examination
measures
b)
A normal bicarbonate concentration may be useful in ruling out dehydration
c)
Acute body weight change is considered the gold standard measure of dehydration
d)
It is recommended that the history and physical examination be the primary basis for the diagnosis of AGE
e)
all of the above
(5)
(6)
Ondansetron has been shown to be a safe and effective therapy in hospitalized children.
a)
true
b)
false
(7)
Which of the following is(are) the recommended diet(s) to prevent or limit dehydration?
a)
BRAT diet
b)
clear liquid diet
c)
Paleo diet
d)
regular diet
e)
a and b
f)
a and d
g)
b and d
h)
a, b, and d
(8)
Which of the following liquids are appropriate for use in oral rehydration therapy?
a)
Pedialyte
b)
Gatorade
c)
Gatorade with added salt, in the ratio of 1L Gatorade + 1 tbsp salt
d)
a and b
e)
a and c
f)
all of the above
Return to Home
View Answers
Answer Key
Return to Home
Evidence Ratings
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Childrens. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.
When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed
as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the
following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):
Quality ratings are downgraded if studies:
Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings are upgraded if it is felt that:
The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
Guideline Recommendation is from a published guideline that used methodology deemed
acceptable by the team.
Expert Opinion Our expert opinion is based on available evidence that does not meet GRADE
criteria (for example, case-control studies).
Return to Home
To Bibliography
Return to Home
Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards accepted at the time of
publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor Seattle Childrens Healthcare System nor any other party who has been involved in
the preparation or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they are not responsible for any errors or omissions or
for the results obtained from the use of such information.
Readers should confirm the information contained herein with other sources and are
encouraged to consult with their health care provider before making any health care decision.
Return to Home
Bibliography
Literature Search Strategy
Search Methods, Acute Gastroenteritis, Clinical Standard Work
Studies were identified by searching electronic databases using search strategies developed and executed
by a medical librarian, Susan Klawansky. Searches were performed in November 2014 in the following
databases on the Ovid platform: Medline and Cochrane Database of Systematic Reviews; elsewhere:
Embase, Clinical Evidence, National Guideline Clearinghouse, TRIP and Cincinnati Childrens EvidenceBased Care Recommendations. Retrieval was limited to 2007 to current, ages 0-18, and English language.
In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used
respectively, along with text words, and the search strategy was adapted for other databases as appropriate.
Concepts searched were gastroenteritis, dysentery, enteritis, adenoviridae infections, rotavirus infections or
rotavirus. All retrieval was further limited to certain evidence categories, such as relevant publication types,
index terms for study types and other similar limits. Additional articles were identified by team members and
added to results.
Identification
129 records identified
through database searching
Screening
130 records after duplicates removed
84 records excluded
Eligibility
Included
To Bibliography, Pg 2
Return to Home
Bibliography
1. Diarrhoea and vomiting in children. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and
management in children younger than 5 years. National Collaborating Centre for Women's and Children's Health.
http://www.ncbi.nlm.nih.gov/books/NBK63844/. Updated 2009.
2. Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: An updated cochrane
systematic review with meta-analysis and mixed treatment comparison in a bayesian framework. BMJ Open.
2012;2(4).
3. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in
children and adolescents. Cochrane Database of Systematic Reviews. 2011;9.
4. Freedman SB, Ali S, Oleszczuk M, Gouin S, Hartling L. Treatment of acute gastroenteritis in children: An
overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health.
2013;8(4):1123-1137. Accessed 20130723; 11/27/2014 12:34:04 PM. http://dx.doi.org/10.1002/ebch.1932.
5. Guarino A. Albano F. Ashkenazi S. Gendrel D. Hoekstra JH. Shamir R. Szajewska H. European Society for
Paediatric Gastroenterology, Hepatology,and Nutrition.European Society for Paediatric Infectious Diseases.
European society for paediatric gastroenterology, hepatology, and Nutrition/European society for paediatric
infectious diseases evidence-based guidelines for the management of acute gastroenteritis in children in europe. J
Pediatr Gastroenterol Nutr. 2008;46(Suppl 2):S81-122. Accessed 20080507; 11/27/2014 12:34:04 PM. http://
dx.doi.org/10.1097/MPG.0b013e31816f7b16.
6. MacGillivray S, Fahey T, McGuire W. Lactose avoidance for young children with acute diarrhoea. Cochrane
Database of Systematic Reviews. 2013;10.
7. National GC. Best evidence statement (BESt). Use of Lactobacillus rhamnosus GG in children with acute
gastroenteritis. http://www.guideline.gov/
content.aspx?id=33576&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.
8. National GC. Evidence-based care guideline for prevention and management of acute gastroenteritis (AGE) in
children aged 2 months to 18 years. http://www.guideline.gov/
content.aspx?id=35123&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.
9. National GC. Oral rehydration therapy (ORT) in children. http://www.guideline.gov/
content.aspx?id=38900&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.
10. Seattle Childrens Hospital, OCallaghan J, Beardsley E, Black K, Drummond K, Foti J, Klee K, Leu MG, Ringer
C. 2011 September. Acute Gastroenteritis (AGE) Pathway.
11. Szajewska H, Guarino A, Hojsak I, et al. Use of probiotics for management of acute gastroenteritis: A position
paper by the ESPGHAN working group for probiotics and prebiotics. J Pediatr Gastroenterol Nutr . 2014;58(4):531539.
12. Szajewska H, Ruszczynski M, Kolacek S. Meta-analysis shows limited evidence for using lactobacillus
acidophilus LB to treat acute gastroenteritis in children. Acta Paediatr. 2014;103(3):249-255. Accessed 20140211;
11/27/2014 12:34:04 PM. http://dx.doi.org/10.1111/apa.12487.
13. Szajewska H, Skorka A, Ruszczynski M, Gieruszczak-Bialek D. Meta-analysis: Lactobacillus GG for treating
acute gastroenteritis in children--updated analysis of randomised controlled trials. Aliment Pharmacol Ther.
2013;38(5):467-476. Accessed 20130813; 11/27/2014 12:34:04 PM. http://dx.doi.org/10.1111/apt.12403
Return to Pg 1
Return to Home