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On Call Principles and Protocols

Tiêu chảy

Tránh điều trị tiêu chảy như 1 chẩn đoán. nó chỉ là triệu chứng của nhiều rối loạn tiềm ẩn và cần điều trị giảm nhu động. lúc nửa đêm, thường không tiện làm xét nghiệm, việc của bạn là xác định nguyên nhân có thể gây tiêu chảy, nên bổ sung xét nghiệm hay không và biến chứng cần điều trị nếu có

Phone Call

Câu hỏi

1.   Dấu hiệu sinh tồn của bệnh nhân?

2.   Tại sao bệnh nhân nhập viện?

3.   Tiêu chảy mới xuất hiện? nếu lâu rồi, nguyên nhân đã chẩn đoán?

4.   Bệnh nhân có phẫu thuật gần đây?

5.   Bệnh nhân có suy giảm miễn dịch (HIV)?

6.   Phân có nhày hay máu?

Máu trong phân lẫn nhày mủ gợi ý viêm, có thể do nhiễm khuẩn, viêm ruột hoặc viêm đại tràng thiếu máu cục bộ

7. Bệnh nhân có đau bụng?

Đau vừa hoặc nặng gợi ý viêm đại tràng thiếu máu cục bộ, viêm túi thừa hoặc viêm ruột

Đề nghị

chưa cần

Thông báo cho điều dưỡng

“tôi sẽ đến sau …. phút”

Nếu tiêu chảy lần đầu ở bệnh nhân khỏe manh có thể chưa cần đến ngay, nhưng ở bệnh nhân tiêu chảy kéo dài và bệnh nặng cần đánh giá càng sớm càng tốt. nếu bệnh nhân có tụt huyết áp, mạch nhanh hoặc sốt cần đánh giá ngay lập tức

Suy nghĩ

Nguyên nhân tiêu chảy?

Tiêu chảy cấp (<2 tuần)

The Four I’s

Bất kỳ nguyên nhân tiêu chảy cấp, nếu không điều trị sẽ tiến triển tiêu chảy mạn

  • Đe dọa tính mạng

•    Giảm thể tích nội mạch, rối loạn điện giải

•    Nhiễm khuẩn hệ thống

Giảm thể tích và rối loạn điện giải là nguyên nhân tử vong ở trẻ khi bị tiêu chảy tử vong do tiêu chảy hay gặp ở bệnh nhân nằm viện do giảm thể tích  và rối loạn điện giải

Tại giường

Đánh giá nhanh

Trông bệnh nhân khỏe, không khỏe hay nặng?

Đa số bệnh nhân tiêu chảy cấp đều trông không được khỏe, tuy nhiên tiêu chảy do vi khuẩn xâm nhập (e.g., Salmonella, Shigella), thường kèm đau đầu, đau cơ lan tỏa, rét run và sốt

Đường thở và dấu hiệu sinh tồn

What is the blood pressure?

Resting hypotension is indicative of significant volume depletion. If the resting blood pressure is normal, examine for postural changes. A postural rise in heart rate of more than 15 beats/min, a fall in systolic blood pressure of more than 15mm Hg, or any fall in diastolic blood pressure is indicative of significant hypovolemia.

What is the heart rate?

Intravascular volume depletion usually results in tachycardia unless the patient has a coexisting disorder (e.g., β-blockade, sick sinus syndrome, or autonomic neuropathy) that prevents the generation of tachycardia. However, in diarrheal diseases, tachycardia may also be caused by anxiety, pain, or fever. A relative bradycardia despite fever raises the suspicion of Salmonella infection.

What is the temperature?

Fever in a patient with diarrhea is nonspecific but is suggestive of the presence of inflammation, as may

occur with infectious diarrhea, diverticulitis, inflammatory bowel disease, intestinal lymphoma, tuberculosis, and amebiasis. Some organisms (Shigella and Salmonella species) may cause systemic sepsis. However, sepsis may occur in the absence of fever, especially in elderly patients.

Selective Physical Examination I

Is the patient volume depleted? Is there evidence of systemic sepsis?

Vitals (See preceding text)
Cardiovascular system Pulse volume, jugular venous pressure (JVP) (flat neck veins) Skin temperature, color

Management I

What measures need to be taken immediately to correct intravascular volume depletion?

1.   Normalize the intravascular volume. This can be achieved quickly by administering an intravenous (IV) fluid that remains in the intravascular space at least temporarily, such as normal saline or Ringer’s lactate. Give normal saline, 250 to 500 mL intravenously over 1 to 2 hours, titrating the IV fluid to the patient’s vital signs and JVP. Reassess the volume status after each bolus of IV fluid, aiming for a JVP of 2 to 3 cm H2O above the sternal angle and concomitant normalization of heart rate and blood pressure.

2.   Check the chart for a recent electrolyte determination. If the patient’s electrolytes have not been checked within the past 24 hours, order measurements of serum electrolytes, urea, and creatinine levels now.

3.   In a patient with fever (temperature >38.5°C), two sets of blood should be drawn for cultures. If the patient is also hypotensive, volume replacement should be instituted with normal saline, and empirical antibiotic coverage should be considered (see Chapter 12, page 102).

4.   A rectal examination should be performed, and stool samples should be examined for occult blood, culture, ova and parasite determination, C. difficile toxin, and white blood cell (WBC) stain. If unusual organisms are suspected (e.g., in a patient with acquired immunodeficiency syndrome [AIDS]), the laboratory should be alerted so that appropriate culture techniques and media can be used.

Selective Chart Review

Are potential causes of diarrhea apparent from the information in the patient’s chart? Is the patient taking any medications that may cause diarrhea?

Medications are the most common cause of diarrhea in the hospital. Frequent offenders include laxatives, stool softeners, magnesium-containing antacids, sorbitol-containing liquid formulations, digoxin, quinidine, colchicine, and xanthines. Laxatives and stool softeners should be discontinued. Magnesium-containing antacids may be withheld or replaced by aluminum-containing preparations. Do not discontinue other medications without first asking the resident or attending physician. Remember also that some medications (e.g., Anacin, Dristan, Dyazide) contain gluten, which is harmful to a patient with celiac disease.

Has the patient received antibiotics recently?

Many antibiotics cause transient diarrhea through alteration of the intestinal flora. In addition, pseudomembranous colitis caused by C. difficile enterotoxin may result in persistent diarrhea during or after antibiotic use. Diagnosis is usually made by means of an enzyme-linked immunoassay (ELISA), which is 85% sensitive and 100% specific. Treatment includes discontinuing the offending antibiotic and administering metronidazole, 500 mg orally (PO) every 6 hours for 10 to 14 days. Vancomycin, 125 to 500 mg PO every 6 hours for 10 to 14 days, is an alternative therapy, but it is more expensive and no more effective than metronidazole.

Does the patient have HIV disease?

Immunocompromised patients and patients with AIDS may develop diarrhea for many reasons,

including infections from a variety of pathogens, medications (especially protease inhibitors), and AIDS enteropathy. The most common infectious causes include Cryptosporidium, Microsporidium, Mycobacterium avium–intracellulare, Salmonella, Shigella, and Cytomegalovirus organisms. If this episode of diarrhea is the first one documented, stool samples should be obtained for acid-fast stain, WBC stain, bacterial and mycobacterial culture, and ova and parasite determination. The test with the highest yield is microscopic examination with a search for ova and parasites. The correct transport medium must be used for specific pathogen cultures, and laboratories often require identification of the possible pathogens—such as Cryptosporidium, Yersinia, and Aeromonas species and Escherichia coli O157—to select the most appropriate laboratory techniques. Diagnosis of anorectal infections may necessitate proctoscopy or sigmoidoscopy, with specimens obtained for gonorrhea testing, herpes simplex viral culture, and dark-field examination for syphilis; this can be arranged in the morning.

Has the patient had recent surgery?

Postgastrectomy dumping of hypertonic boluses of stomach contents into the jejunum is associated with vasomotor symptoms of flushing, anxiety, palpitations, sweating, and dizziness, and diarrhea may occur in association. Resections of the ileum and right colon may result in diarrhea because of bile acid malabsorption.

Does the patient have known inflammatory bowel disease, celiac disease, lactase deficiency, or other conditions known to cause chronic diarrhea?

Any of these pre-existncg conditions may be responsible for diarrhea occurring while hospitalized; providing the patient does not have volume depletion and is otherwise comfortable, no additional measures are required at night.

Has the patient traveled abroad recently?

E. coli enterotoxin is the most common cause of traveler’s diarrhea, although Salmonella organisms,

Shigella organisms, and Campylobacter jejuni may be responsible for some cases of acute, self-limited traveler’s diarrhea. Giardiasis, amebiasis, and tropical sprue may cause a more chronic picture.

Has the patient been admitted for the investigation of diarrhea?

If so, a plan of investigation has probably already been outlined. If the patient does not have volume

depletion and is otherwise comfortable, no additional measures are required at night.

Is the patient receiving tube feedings?

Diarrhea often complicates enteral tube feedings, but in many cases it results from factors other than the feeding formula itself, such as medications or underlying illnesses. On occasion, diarrhea may develop because of the formula’s composition (e.g., high fat, high osmolarity, presence of lactose), the manner in which it is delivered (bolus vs. continuous infusion), or contamination of the formula. In most cases, decisions regarding a change in formula or in the manner or rate of delivery can wait until morning.

Selective Physical Examination II

Look for clues to specific causes of diarrhea:

Management II

It is unusual for a clinician to be able to pinpoint the specific cause of diarrhea when a patient is seen for the first time at night. On occasion, a patient will say, “I’m sure it’s my Crohn disease acting up” or “I have lactose intolerance, and the kitchen gave me yogurt for dinner.” In these cases, the patient usually turns out to be right. When the diagnosis is not obvious at night, your goals are to ensure that the patient is adequately hydrated, does not have a serious electrolyte imbalance, and does not have a systemic infection. Additional specialized investigations for diarrhea can, in most cases, wait until the morning to be arranged.

Remember that in many cases of infectious diarrhea, frequent loose stools are the body’s way of expelling the offending organism or toxin. Do not compound the problem by inhibiting the body’s ability to do this. Diarrhea is always best treated by addressing the underlying cause, which may take a few days (and sometimes weeks) to identify. Unless the diarrhea is profuse or disabling, nonspecific antidiarrheal agents are best avoided. Explain this to the patient and to the nurses caring for him or her so that everyone is clear about the treatment approach.

If the patient’s diarrhea is severe and disabling, use of one of the following nonspecific antidiarrheal agents is occasionally warranted. However, none of these agents should be prescribed before the patient undergoes examination (including a rectal examination and possibly sigmoidoscopy) and before you decide on an appropriate plan of investigation.

Loperamide (Imodium), 4 mg PO every 4 hours, until diarrhea is controlled, up to a maximum dose of 16 mg in 24 hours. The drug is less effective if given on an as-needed basis (PRN). Side effects include dry mouth; abdominal distention and cramping; on occasion, nausea and vomiting; and in rare instances, toxic megacolon. Other side effects include rash, drowsiness, dizziness, and tiredness.

Diphenoxylate hydrochloride (Lomotil), 5 mg PO three or four times a day, until diarrhea is controlled, up to a maximum dose of 20 mg in 24 hours. It is as effective as loperamide for treating acute nonspecific diarrhea but has a slower onset of antidiarrheal action. Diphenoxylate is contraindicated in patients with hepatic failure or cirrhosis. Respiratory depression may occur when it is used in combination with phenothiazines, tricyclic antidepressants, or barbiturates. Toxic megacolon may result if ulcerative colitis is present.

Bismuth subsalicylate (Pepto-Bismol, Kaopectate in the United States), 30 mL or 2 tablets (262 mg/tablet) PO every 30 minutes, up to a maximum of eight doses per day. Bismuth is known to cause

blackening of the tongue and stools. It may inhibit the absorption of tetracycline. Salicylate overdose may occur, especially if the patient is also receiving aspirin.

Agents such as anticholinergics, kaolin, and pectin do not reduce fecal water loss in diarrheal illnesses and are best avoided.

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