“Emergency Department Clinical Pathway for Healthy Children with Gastroenteritis/ Dehydration” From CHOP

Today I link to and embed the outstanding Emergency Department Clinical Pathway for Healthy Children with Gastroenteritis/ Dehydration <– use this flow chart link rather than the copy in this post because the flow chart is easier to follow. I just copy links on my blog because it helps me retain the material. From The Children’s Hospital Of Philadelphia [accessed 11-26-2023]

Emergency Department Clinical Pathway for Healthy Children
with Gastroenteritis/ Dehydration

Goals and Metrics

Patient Education

Provider Resources

• Related Pathway
• Gastroenteritis/Dehydration, Inpatient

Healthy Child with Gastroenteritis
and/or Dehydration

Triage
ED Nursing Pathway Standing Orders: Gastroenteritis/Dehydration

Oral Rehydration Therapy (ORT)

• Preferred method very successful in treating healthy children with GE/dehydration
  • Children with no/mild dehydration can be discharged home after ORT education
  • Provide 1-2 mL/kg, max 30 mL every
    5 mins
  • Differs from PO challenge which is offering ad lib fluids
• ORT Instructions for the Medical Team
• Instructions for the Family
• ORT Record Sheet
• How to Treat Dehydration from Stomach Bugs in Children

Definition of ORT Failure

• > 1 emesis after ondansetron
• Refusal to take from syringe/cup for
  > 30 mins

Hypoglycemia

• Defined as glucose < 70 in all ages
• Give 2mL/kg of D10W
• Start glucose containing maintenance fluids immediately
• Recheck glucose in 30 mins

Weight (kg)	PO ondansetron Dose (mg)
8-15	2
> 15-30	4
> 30	8
Consider PO ondansetron if any emesis within the preceding 4 hrs Children less than 6 mos and/or 8 kg, consult attending physician Relative Contraindications with Ondansetron

• FLOC/RN Team Assessment
• Mental status, VS
• History and physical exam
• Dehydration Assessment Tools
• Consider POC glucose, BOHB if suspected moderate/severe dehydration

Significant hypoglycemia, straight to IV rehydration

Minimal/Mild Dehydration

• Consider ondansetron
• RN discharge teaching, give instruction sheet to family
• Provide oral syringes, medicine cup
• ORT video  

Moderate Dehydration

Beta-
hydroxybutyrate,
BOHB < 3

Beta-
hydroxybutyrate,
BOHB > 3

• Consider ondansetron
• RN plays ORT video  
  Provides ORT record sheet, syringe
• Initiate ORT 20 mins after ondansetron
• Assess PO intake 1 hr after ondansetron

ORT Success

ORT Failure

IV Rehydration

• Basic metabolic profile
• Treat hypoglycemia with 2 mL/kg of D10W
  • Recheck glucose every 30 mins until normal
• NS 20 mL/kg IV
• Consider D5NS 20 mL/kg (max 500 mL) over 60 mins to assist in ketone clearance
• Start glucose containing maintenance fluids if initially hypoglycemic
• ORT vs. admission

Reassess
Vital signs, clinical appearance, ongoing losses

Discharge

• Dehydration mild or resolved
• ORT teaching to continue
  at home
• Family reviews
  Oral Rehydration Video

Admit EDECU or Inpatient
EDECU Rehydration Recommendations

• Considerations for admission:
  • Significant ongoing losses
  • Unable to tolerate PO fluids, ORT failure
  • Continued need for IV rehydration
  • Hypoglycemia or significant electrolyte abnormalities
  • Medical condition requiring inpatient care

Discharge

Severe Dehydration

Posted: August 2007
Revised: August 2023

• Authors:
  • M. Blackstone, MD;
  • J. Lavelle, MD;
  • D. Hoser-Glatts, RN

Editors: Clinical Pathways Team

Evidence

• Value of Point-of-care Ketones in Assessing Dehydration and Acidosis in Children with Gastroenteritis.  
• The Use of a Triage-Based Protocol for Oral Rehydration in a Pediatric Emergency Department  

Related Links

• CDC – Managing Acute Gastroenteritis Among Children  
• CDC – Norovirus  
• Diarrhea and Dehydration, Module 6 of the Pediatric Education in Disasters Manual  

Educational Media

• How to Treat Dehydration from Stomach Bugs in Children