Abdominal Emergencies 1 Flashcards
1
Q
Acute Gasteroenteritis (3)
A
- Acute Gastroenteritis (AGE) - major cause of morbidity and mortality in the USA
- Worldwide diarrheal disease is the leading cause of morbidity and mortality; 1.5-2.5 million deaths annually among children younger than 5
- Even though the number of death associated to AGE worldwide is still high, a decrease has been noticed since the start of Oral Rehydration Therapy (ORT) campaigns
2
Q
Oral Rehydration Therapy Phases (2)
A
Rehydration Phase: Water and electrolytes are provided via an oral rehydration solutions (ORS) replacing existing losses
Maintenance Phase: Replacement of ongoing fluid and electrolyte losses and adequate dietary intake
3
Q
Physiologic Basis of ORT (8)
A
- During diarrheal disease the intestinal output increases greatly, overwhelming its re-absorptive capacity
- Studies done among patients with cholera, salmonella, E. Coli, shigella, rotavirus demonstrated an intact Na-couple solute co-transport mechanism allowing efficient salt and water reabsorption
- The mechanism essential for the efficacy of oral rehydration solution (ORS) is the couple transport of sodium and glucose in the intestinal brush border
- Water passively follows the osmotic gradient
- SGLT1- sodium glucose co-transporter which moves Na and glucose from the luminal membrane into the enterocyte
- Rehydration solutions with low osmolarity and 1:1 ration glucose to sodium perform optimally
- GLUT2- glucose transporter, moves the glucose in the enterocyte into the blood
- Na+ K+ ATPase provides the gradient that drives the process
4
Q
Basic Guidelines for the management of dehydration (7)
A
- ORS should be use for rehydration
- Oral rehydration - within 3-4 hr
- Rapid realimentation, an age-appropriate unrestricted diet is recommended as soon as dehydration is corrected. Gut rest is not indicated
- In breastfeed infants, nursing should continue
- Diluted formula or special formulas-not indicated
- Additional ORS can be administer for ongoing losses
- No unnecessary labs or medications (i.e. antidiarrheals)
5
Q
Acute Gasteroenteritis Management (3)
A
Home Management
1. ORS is simple and enable management of uncomplicated cases at home
- 5 cc every 5 minutes if vomiting and gradually increase over 12 hours If the patient has diarrhea, can feed and use normal amount of fluid at the same time
- Educate regarding the signs of dehydration
6
Q
Recommendations for medical evaluation of children with Diarrheal Illness (9)
A
- Young age (< 6 months or < 8 kg)
- History of premature birth, chronic medical conditions or concurrent illness
- Fever > 38°C for infants < 3 months or > 39°C aged 3-36 months
- Blood in stool or diarrhea lasting more than 2 wks
- High output diarrhea, including frequency and volume
- Caregiver’s report of signs consistent with dehydration
- Change in mental status
- Persistent vomiting
- Suboptimal response to ORT or inability of caregiver to provide ORT
7
Q
Dehydration Assessment (5)
A
- Sunken anterior fontanel can be unreliable or misleading
- Decreased BP is a late finding and it heralds shock, corresponds to >10% of fluids losses
- Tachycardia and decrease capillary refill are more sensitive
a. GET A HR and CAP REFILL to chek hydration - Decrease urine output is sensitive but nonspecific
- Increase of urine specific gravity can indicate dehydration
8
Q
AGE Dehydration Management: Info About Phases (5)
A
- Rehydration – fluid is replaced rapidly, over 3-4 hr
- Maintenance – calories and fluids are administered
- Rapid realimentation, the patient should continue an age-appropriate diet as tolerated
- Breastfeeding should continue
- Lactose restriction is usually not necessary
9
Q
AGE Dehydration Management: Minimal Dehydration (3)
A
- Provide adequate fluid and age appropriate diet
- ORS should be encouraged
- Fluid intake should be increased to compensate for emesis or diarrhea
i. 10 ml/kg of additional fluid per every diarrhea or 2 ml/kg per every emesis
ii. As an alternative in children < 10 kg provide 2-4 oz of ORS per diarrhea or emesis and 4-8 oz in children > 10 kg
10
Q
AGE Dehydration Management: Mild to Moderate Dehydration (11)
A
- The fluid losses should be estimated and rapidly replaced
- Administer 50-100 ml of ORS/kg during 2-4 hr
- Additional ORS should be administer for ongoing losses
- Smaller volumes should be offered first and increase as tolerated using (i.e. 5 ml)
- More may be offered if the child wants more, but larger amounts have been associated with vomiting
- Children with tachycardia at discharge or with history of severe vomiting are more likely to require a second visit to the ED
- Clinical trials support the use NG feeding for those patients with persistent vomiting
- When compared to IV, NG feedings were found to be more cost effective and associated with fewer complications
- Hydration status should be assess on a regular basis
- Those children who do not improved with ORT or with high output should be held for observation
- Must assure follow-up
11
Q
AGE Dehydration Management: Severe Dehydration (5)
A
- Constitutes a medical emergency and requires immediate IV rehydration
- 20 ml/kg of Normal Saline should be administered until pulse, perfusion and mental status returns to normal
- Complete metabolic profile is not required for the diagnosis
- Electrolytes, BUN, Cr, CO2, and glucose should be obtained
- Vitals should be assess on a regular basis
12
Q
AGE Dehydration Management: ED Dehydration for severe dehydration (4)
A
- Multiple administrations of fluid in a short amount of time may be necessary
- Severe edema is rare as long as appropriate weight based amounts are provided with close observation
- With frail or severely malnourish infants smaller amounts (10ml/kg) are recommend because of their reduced ability of increasing the cardiac output
- If the patient does not respond to fluid boluses, think about septic shock, metabolic, cardiac or neurologic disorders
13
Q
General Info About AGE Dehydration Management (9)
A
- In children with abdominal ileus or signs of intestinal obstruction ORT should be held until surgical evaluation
- 1% of infants will have carbohydrate malabsorption
* Their diarrhea may be worsen by ORS or solutions with simple sugars - Children receiving a solid or semisolid diet should continue their usual diet
- Avoid foods with high simple sugars, which may cause osmotic diarrhea
- BRAT diets are unnecessary restrictive and provide suboptimal nutrition
- Withholding food for 24 hr is unnecessary
- Once rehydration is achieved, age- appropriate diets can be started if not vomiting
- Lactose-free or lactose-reduced formulas are not necessary, except in children with severe malnutrition
- Low ph or reducing substances in the stool without symptoms is not indicative of lactose intolerance
14
Q
Functional foods to manage AGE (8)
A
- Foods that have an effect on physiologic processes separate from their nutritional function
- Probiotics are live microorganisms in fermented foods promote improved balance in intestinal microflora
- Most common species studied included Lactobacilli and nonpathogenic Saccharomyces boulardii
- Mechanism of action include, enhancing host defenses, competition of pathogenic flora for receptor sites and production of antibiotic substances
- Probiotics – two separate meta-analysis showed the probiotics are safe and efficacious in the treatment of infections and antibiotic-associated diarrhea
* As probiotics are not regulated by the FDA, there may be great variability, wish make an informed recommendation rather challenging - Prebiotics are complex carbohydrates that stimulate the growth of health promoting intestinal flora
- The oligosaccharides contained in breast milk are the prototypic prebiotic
- Data have associated the oligosaccharides in breast milk to the lowered incidence of acute diarrhea in the breast feed infant
15
Q
Pharmacologic Therapy in AGE: Antimicrobials (4)
A
- Viruses are the predominant source of AGE in developed countries
- Antimicrobials wastes resources and may increases antimicrobial resistance
- Even when the cause is suspected to be microbial, usually antibiotics are not indicated as these disease processes tend to be self-limited
- Children with special needs or severe disease may benefit from antibiotics if microbial etiology is suspected
