<p> Clinical Pathway for Acute Gastroenteritis </p><p>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)</p><p>Signs of dehydration</p><p> 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</p><p> Decreased urine output</p><p>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</p><p>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</p><p>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)</p><p>Consider antimicrobial treatment for specific pathogens</p><p>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 </p><p>Prepared by Section of Gastroenterology with contributions from Section of Nephrology and Emergency Room Department; October, 2009</p>