Pediatric Corner

These factors ID children at high risk for acidosis

Interventions can be started earlier

A 3-year-old boy with gastroenteritis presents with dry mucous membranes, and his mother tells you he has been sick for several days. This child is at high risk for acidosis, according to a new study.1

In the study, of 118 children ages 3 months to 7 years with vomiting and/or diarrhea who came to a pediatric ED, 25% had acidosis. Three factors predicted acidosis with 90% sensitivity: being younger than age 9, dry mucous membranes, and illness for more than two days. These findings could be used to develop a triage assessment tool, suggest the researchers.1

The study's lead author, P. Jamil Madati, MD, director of emergency medical services at Rady Children's Hospital in San Diego, says he was pleasantly surprised by two things: That a simple tool can predict a group of patients at high risk for acidosis, and "that triage nurses were also pretty good at predicting which kids were more likely to be acidotic on clinical appearance alone."

The take-home message for ED nurses: There is a group of children with gastroenteritis that can be identified early in their ED course and have certain interventions initiated without having to wait for a room or a physician. "These days, EDs are faced with overcrowding and long waits," says Madati. "If an ED nurse can initiate a treatment early for certain high-risk patients, this can and will help with the overall flow of patients through the ED."

Consider oral rehydration

Madati says most patients "do fine with oral rehydration alone or a combination of [ondansetron] and oral rehydration. Having worked in three different EDs in my career, I think there is an overwhelming predominance or inclination for practitioners to want to place an IV and give patients IV fluids," he says. "I would like to see more patients being treated by oral rehydration rather than by IV."

Madati says he hopes his study "forces people to think about instituting a relatively simple intervention such as oral rehydration early — in triage or upon arriving in treatment room — and thus, be able to rehydrate and discharge them quickly to outpatient follow-up."

For children presenting with simple, clear-cut gastroenteritis, Madati says oral rehydration therapy can be started while the patient is in the waiting room. "The difficult part is that a small percentage of patients presenting with vomiting and/or diarrhea may have other [gastrointestinal] problems — appendicitis or pancreatitis — that would require them to be NPO," he says. For this reason, your triage assessment tool needs to be broad enough to include most patients with gastroenteritis, but specific enough so that you don't end up giving oral fluids to a child who may need to be NPO for a CT or surgery.

"It is difficult to get all physicians to agree on which patients to include in this triage tool and which should not," Madati acknowledges.

Signs such as bilious emesis, abdominal distention, significant blood in vomit or stool, significant abdominal pain associated with the illness, and lethargy should alert you that there might be something else besides gastroenteritis causing the patient's symptoms, he says. For severely dehydrated children, Madati says rapid fluid resuscitation — preferably intravenous fluid — should be quickly initiated to prevent a negative outcome.

In addition, Madati says he'd like to see ED nurses teaching parents and caregivers how to syringe feed, how much fluid to give, and how frequently to administer fluid. "When the patient is discharged, parents will actually have a skill set and tool to prevent their child from getting dehydrated in the future, thereby cutting down the number of unnecessary visits to the ED," he says.

Reference

  1. Madati P, Jamil MD, Bachur R. Development of an emergency department triage tool to predict acidosis among children with gastroenteritis. Ped Emerg Care 2008; 24:822-830.

Sources

For more information on pediatric patients with gastroenteritis, contact:

  • Kerry Gold, RN, CCRN, CEN, MICN, Pediatric Liaison Nurse, Emergency Department, University of California — Los Angeles Medical Center. E-mail: KTsakonas@mednet.ucla.edu.
  • P. Jamil Madati, MD, Division of Emergency Medicine, Rady Children's Hospital, San Diego. Phone: (858) 966-8036. Fax: (858) 966-7433. E-mail: jmadati@rchsd.org.