Clinical Pathway for Acute Gastroenteritis with Dehydration

Clinical Pathway for Acute Gastroenteritis

1st 2 hours >2 hours Prior to discharge Assessment Acute Gastroenteritis documented based on  Deterioration of sensorium  Able to tolerate food history and physical examination  Decrease urine output  Vital signs stable  Persistent hypotension  Adequate urine output Assess patient as stable or unstable  Hypoxemia  No fever  Hypercapnia  All abnormalities corrected History  Based on chemistry results, reassess patient’s fluid and electrolyte status  Onset frequency, quantity  Character - bile/blood/mucus  Fever  Vomiting  Past medical history, underlying medical conditions  Epidemiological clues (food, antibiotics, sexual activity, travel, outbreaks, season)

Signs of dehydration

 Decreased sensorium (severe dehydration)  Tachycardia  Postural hypotension  Supine hypotension and absence of palpable pulse (systolic BP <90 mmHg or >20 mmHg drop in usual BP)  Dry tongue  Sunken eyeballs  Skin pinch/turgor

 Decreased urine output

Diagnostics  Serum electrolytes (Na, K, Cl) -STAT  NGT if patient is obtunded  BUN, creatinine- STAT  Central line with CVP monitoring  CBC- STAT  Foley catheter for urine output monitoring  Fecalysis  Pulse oximeter  Stool for C. difficile toxin  Serum electrolytes and BUN, creatinine (if with recent/chronic antibiotic use) monitored at appropriate intervals  ABG (if with decreased sensorium/ tachypneic/dyspneic)  RBS (if with decreased sensorium

Treatments  Large bore IV access for rapid fluid  Adjust IV fluid according to fluid and  Continue oral medications when indicated resuscitation electrolyte status  Additional tests if necessary (ECG, chest X-  Correct fluid and electrolyte disturbances ray, urinalysis)  Specialty referral if needed  Admit  If still hypotensive consider ICU admission

Medications  Lactated ringer’s or NSS (rate depending on Symptomatic treatment  Continue medications when indicated clinical assessment)  If hypotensive, 500 ml boluses of crystalloid  Metoclopramide for persistent vomiting as fluid challenge until BP stable  Loperamide (should be avoided in bloody or suspected inflammatory diarrhea)

Consider antimicrobial treatment for specific pathogens

Teaching Relatives are informed of the condition of the Relatives are informed of patient’s condition,  Patient educated on the aspects of precaution patient means of monitoring patient, need for assistive (personal hygiene, clean environment, safe intervention and need for specialty referrals if food preparation) applicable  Continuity of care for those who are compromised

Prepared by Section of Gastroenterology with contributions from Section of Nephrology and Emergency Room Department; October, 2009