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Nurse Practitioner Clinical Protocol Diarrhoea +/ ‐ vomiting

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Child and Adolescent Health Service Princess Margaret Hospital for Children

Diarrhoea +/ ‐ vomiting Nurse PractitionerClinical Protocol Emergency Department

Background and practice notes

Working diagnosis and investigations

Medications Clinical protocol authorship and approval Management flowchart

Scope Management Associated documents References Assessment and initial intervention

Patient education and discharge information

Clinical audit Acknowledgement Definition of terms Disclaimer

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 rehydration 1,8,11 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 therapy 2,4,5 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 with persistent vomiting. 9 Antidiarrhoeals should not be used for acute diarrhoea in children. 1,8 They do not reduce fluid and electrolyte loss, may delay expulsion of organisms and may cause adverse effects. 1

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,

systemically unwell

out

of

proportion

to

the

degree

of

dehydration,

shock

and

a neonate

with

diarrhoea.

8 Vomiting

alone

should not be diagnosed as gastroenteritis. 8 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.

Date Issued: October 2011 Date Revised: January 2012 Review Date: October 2013 Authorised by: PMH Emergency Department Review Team: PMH Emergency Department

Nurse Practitioner Clinical Protocol Diarrhoea +/ ‐ vomiting Emergency Department Princess Margaret Hospital Perth, Western Australia

This document should be read in conjunction with disclaimer in this clinical protocol


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Emergency Department Nurse Practitioner Princess Margaret Hospital for Children Clinical Protocol

Diarrhoea +/ ‐ vomiting

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Scope Outcomes

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

Medical Practitioner +/ ‐Nurse Practitioner

• Infants less than 12 months of age • Underlying significant medical pathology

eg: previous gastrointestinal surgery, metabolic disorders, inflammatory bowel disease

• Evidence of failure to thrive • Children presenting with history of vomiting bile or

blood, red current jelly stools or malena or pale, floppy episodes

• 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

Identify patients not suitable for ENP clinical protocol and refer to Senior Medical Practitioner (SMP)

However, patient can be managed by ENP in consultation with SMP if appropriate

Assessment and initial intervention Outcomes

Primary survey • Airway • Breathing • Circulation • Disability • Exposure

Abnormal primary survey identified – exit ENP clinical protocol and refer to SMP

History • 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

Identify patients not suitable

for ENP clinical protocol and refer to SMP

Examination • Vital signs • Urinalysis if appropriate (eg: unsettled, poor

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 standard 7)

Abnormal examination outside defined scope ‐ refer to SMP


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Assessment and initial intervention (continued) Outcomes

Pain assessment • Use appropriate pain assessment tool Determine need for and type of analgesia

Analgesia • Administration of analgesia as required (refer to Pain Management and Procedural Sedation ENP Clinical Protocol)

• Not routinely indicated

Relief of pain

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 Blood in stool Suspected epidemic for food poisoning Severe or prolonged diarrhoea (> 2 weeks) Recent overseas travel Child residing in an institution

• Campylobacter, Cryptosporidium, Shigella, Salmonella and rotavirus are notifiable diseases 12

• Blood tests are not routinely indicated but may be clinically useful in the following circumstances: 8 Bloody diarrhoea – consider full blood count

(FBC), urea, creatinine Dehydration with ‘doughy’ feel to skin that

might indicate hypernatraemia 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


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Management Outcomes

Antiemetics and antidiarrhoeals are not routinely indicated for children with acute diarrhoea +/ ‐ vomiting. 1,8,11

No or mild 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

Patient identified as suitable for ENP clinical protocol and discharged home

Moderate dehydration • 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

Consultation with SMP if no or minimal improvement or if condition deteriorates

Severe dehydration Exit ENP clinical protocol and refer to SMP


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Management (continued) Outcomes

Recommendations for admission

• 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

Appropriate patient admission

Acute referral • Referral as appropriate to: Interpreter Allied health Aboriginal Liaison Officer

Patient/parent understands referral process

Patient education and discharge information Outcomes

Discharge criteria • 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

Patient suitable for discharge

Treatment instructions • 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

Patient/ parent understands instructions given

Medication instructions • Verbal instructions given by ENP • Simple analgesia short term if required

Patient/ parent understands

instructions given Follow ‐up/ referral • 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

Patient/ parent understands follow ‐up arrangement

Re‐presentation criteria • Not tolerating oral fluids • Significant increase in losses • Significantly reduced urine output, increased

lethargy, generally more unwell •

Parental concern

Patient/ parent understands criteria for re ‐presentation and is discharged home

Documentation • Parent education – Gastroenteritis Health Facts • GP letter if applicable • Medical certificate/ certificate of attendance • Patient medical record • Appropriate fluid order documentation

Appropriate documentation completed

Expected outcome • 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


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Medications

Oral rehydration solution Unscheduled

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 hour 8 • NG rapid rehydration: 50 ml/kg over 4 hours 8

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

Intravenous fluids

0.9% Sodium Chloride

with 5% Glucose Unscheduled

Route/administration • Intravenous

Dose Calculation of IV fluid requirements 8• 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

Estimation of deficit volume 8 • 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


• Children with hypernatraemia or hypovolaemic shock • Children with diabetes


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Medications (continued)

Ondansetron Poison schedule 4

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


• 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 therapy 2,4,5

Useful links • For full prescribing information refer to AMH online


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Management flowchart

Gastroenteritis management flowchart

Severe dehydration

Moderate dehydration

No or mild dehydration

Refer to SMP

Commence oral fluid trial

Observe child

over

next

hour

• 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

Discuss with SMP

Condition improved

Condition deteriorated

Partial or no improvement

Discuss with SMP Consider admission and NG rehydration/ IV rehydration

Refer to SMP

No

Yes

Yes

Yes

No

Yes

Yes

Meets discharge criteria Provide discharge advice

Discharge home Yes

Yes

Yes

No

Working diagnosis of gastroenteritis No

Refer to SMP

Yes

Diarrhoea +/ ‐ nausea, vomiting, fever and abdominal pain


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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

ENP ED GP AMH IV NG

Emergency Nurse Practitioner Emergency Department General Practitioner Australian Medicines Handbook Intravenous Nasogastric

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


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References

1. 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#diarrhoea.t

2. Chow C, Leung A, Hon K. Acute gastroenteritis: from guidelines to real life. Clinical and Experimental Gastroenterology. 2010;3:97 ‐112.

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, Issue 9. Art No: CD005506. DOI:10.1002/14651858.CD005506.pub5.

4. 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.

5. 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.

6. 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.

7.

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+children+with+dehydration&source=bl&ots=GtOVyNiRjv&sig=A ‐CuDWWnPe3ZRD3zOWtSlNvgsB0&hl=en#v=onepage&q&f=false

8. Princess Margaret Hospital for Children, Perth, Western Australia. 2010. Emergency Department Clinical Practice Guideline, Gastroenteritis.

9. The Royal Children’s Hospital, Melbourne, Australia. 2009. Clinical Practice Guidelines, Gastroenteritis. 10. The Royal Children’s Hospital, Melbourne, Australia. 2004. Nurse Practitioner Clinical Practice Guideline, Diarrhoea

+/ ‐ vomiting. 11. 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/ 12. 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.

Date Issued: October 2011 Date Revised: January 2012 Review Date: October 2013 Authorised by: PMH Emergency Department Review Team: PMH Emergency Department

Nurse Practitioner Clinical Protocol Diarrhoea +/ ‐ vomiting Emergency Department Princess Margaret Hospital Perth, Western Australia

This document should be read in conjunction with disclaimer in this clinical protocol

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cahs_diarrhoea_vomiting.pdf