CLINICAL PROTOCOL MUHC

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1 CLINICAL PROTOCOL MUHC (PROTOCOLE CLINIQUE - CUSM) Medication included No Medication included MCH MGH RVH MNH MCI LACHINE THIS IS NOT A MEDICAL ORDER Title: This document is attached to: Post-operative surveillance and screening of dumping syndrome after fundoplication in neonates and children Selection of an antiseptic skin solution for skin preparation for intravenous access and for site care in children Obtaining a blood specimen by heel stick using a Quickheel Lancet Pediatric Blood glucose (BG) testing with Nova STAT STRIP glucometer for adults and pediatrics Dumping syndrome is a reported complication of fundoplication, a surgical procedure to correct severe gastro-intestinal reflux disease (GERD) in children. Dumping syndrome occurs as a result of the rapid emptying of hyperosmolar carbohydrate containing solutions into the small bowel leading to reactive hypoglycemia. Postprandial hypoglycemia occurs 60 minutes to180 minutes post end of feeds. Symptoms may include shakiness, pallor, diaphoresis, headaches, fatigue, mood or behavior changes and/or general feeling of discomfort. Postprandial hypoglycemia occurs more commonly in children with fundoplication but can occur in any patient who has abnormal motility or gut anatomy. Children, including those with neurological impairment, may become hypoglycemic without additional symptoms or signs. Clinically relevant hypoglycemia associated with dumping syndrome is diagnosed when postprandial blood glucose (BG) level less than 3.5 mmol/l (confirmed in laboratory), is measured on one (1) occasion. 1. PURPOSE The purpose of this protocol is to develop postoperative surveillance guidelines for the screening of dumping syndrome in children following a fundoplication. 2. PROFESSIONALS All nurses and physicians providing post-operative care to patients who undergo a fundoplication Licensed practical nurses providing post-operative care to patients who undergo a fundoplication Nutritionists involved in the care of patients with a fundoplication. 3. PATIENT POPULATION All post-operative children following a fundoplication, with or without the placement of a gastrostomy tube 1

2 4. ELEMENTS OF CLINICAL ACTIVITY Professionals are responsible to know the limits and extent of their practice as related to the particular protocol. Equipment needed: Refer to the Inter-professional Protocol: Blood Glucose Testing with Nova STATSTRIP Glucometer for adults and pediatrics) Bedside glucometer Glucose test strips Antiseptic swab for skin preparation (refer to protocol Selection of an antiseptic skin solution for skin preparation for intravenous access and for site care in children ) Non-sterile gloves Lancet Procedure: All children undergoing a fundoplication procedure require consultation with a nutritionist to establish guidelines for the re-introduction of feeds post-fundoplication. Begin BG testing at bedside once bolus feeds have been initiated or if patient shows symptoms suggestive of hypoglycemia. Testing is spread over two days to screen for hypoglycemia during one morning, one afternoon and one evening feed at any additional time points if signs/symptoms suggestive of hypoglycemia. Time intervals for BG testing: Pre-feed 60 minutes post end of feed 90 minutes post end of feed 120 minutes post end of feed 180 minutes post end of feed (may coincide with the start of the following feed) If fasting greater than 180 minutes overnight, test 240 minutes post end of feed (may coincide with the start of the following feed) If at any time, point of care BG is less than 3.5 mmol/l, send a STAT capillary blood specimen to the laboratory for confirmation and initiate treatment as described below. Note: A BG result less than 3.5 mmol/l, confirmed in laboratory, is considered a hypoglycemic event even if the patient feels no symptoms ( hypoglycemia unawareness ) Advise treating physician, and take the following actions: Step 1- Treatment of Hypoglycemia (BG less than 3.5 mmol/l): Conscious patient -Patients admitted in the Neonatal Intensive Care Unit (NICU), recommendations are to: Restart continuous feeds or go back to previous mode of feeding that achieved normal blood glucose. Retest BG 15 minutes later If the blood glucose remains less than 3.5 mmol/l, advise attending team 2

3 Patients NOT admitted in NICU, recommendations are to: For infants less than 1 year: o Restart continuous feeds or go back to previous mode of feeding that achieved normal blood glucose. o Retest BG 15 minutes later o If the blood glucose remains less than 3.5 mmol/l, advise attending team For children 1 year and older: o 175 ml of juice or 4 white sugar packets diluted in 175 ml of water PO or GT. o Retest the BG 15 minutes later. If blood glucose is less than 3.5 mmol/l, repeat treatment and retest BG 15 minutes later. o If after three treatments BG remains less than 3.5 mmol/l, advise attending team. Unconscious or convulsing patient (All patients) Call Code Blue Pediatric (if NICU, call a Code Pink ), provide basic life support and prepare treatment as below If IV in place: o D10W 2 ml/kg to a maximum of 125 ml. Maximum rate: 2 ml/kg over 1 minute If no IV: o Neonates less than 28 days: Glucagon mg/kg SC or IM (maximum single dose 1mg). May repeat dose in 20 minutes if needed. o Patients aged 28 days to 6 years old: Give Glucagon 0.5 mg SC or IM o Patients older than 6 years: Give Glucagon 1 mg SC or IM Step 2- Consult Nutritionist: The management of confirmed hypoglycemia secondary to dumping syndrome consists primarily of dietary changes or adjustments in the administration rate & frequency of feeds. These adjustments are done by the nutritionist and may include: 1) Dietary modifications 2) Changes in type of formula 3) Slowing the rate of feeds 4) Decreasing the volume of feeds 5) Use of different therapies Step 3- Resume initial two day protocol testing as above with new feeding adjustments At the end of day two, if all BG results are greater than or equal to 3.5 mmol/l and less than 11.1 mmol/l, no further testing is required. Note: If BG is 11.1 mmol/l or more, advise the treating team and take the following actions: Check urine for glucose send specimen to laboratory. If urine is positive for glucose, repeat BG and urine glucose pre-feed. o If the repeat urine is positive for glucose, inform team and consider consultation with endocrinology. 3

4 If 48 hour testing cannot be completed during the hospital admission, children may be discharged to complete testing as an outpatient, in the Pediatric Day Centre Day Hospital, if otherwise medically stable and only requires blood glucose testing. Patient/Family Teaching Provide all families of children with information about fundoplication and about symptoms of potential dumping syndrome, including signs & symptoms of hypoglycemia For those children with confirmed hypoglycemia secondary to dumping syndrome, teaching includes: 1. Feeding plan 2. Indications for blood glucose monitoring 3. Use of glucometer & frequency of blood glucose monitoring at home 4. Treatment of hypoglycemic episodes at home 5. When to consult physician Follow-up Follow up plan is tailored to the individual needs of the patient in collaboration with the nutritionist and treating team, and documented accordingly. 5. MEDICATIONS (IF NECESSARY): GLUCAGON Indications: Treatment of severe hypoglycemia Contraindications Known hypersensitivity to glucagon, lactose, or any component of the formulation; Pheochromocytoma; Insulinoma; Glucagonoma Pharmacokinetics: Onset of action (blood glucose levels): IV: 5 to 20 minutes; IM: 30 minutes; SC: 30 to 45 minutes Duration of action (on blood glucose levels): IV, IM, SC: 60 to 90 minutes Metabolism: primarily hepatic Half-life elimination, plasma: IV: 8 to 18 minutes; IM: 26 to 45 minutes Dosage Neonatal: Less than 28 days: mg/kg SC or IM (maximum dose 1mg). May repeat dose in 20 minutes if needed. Pediatric: Infants and children aged 28 days to 6 years old: 0.5 mg SC or IM Children older than 6 years: 1 mg SC or IM Precautions Use with caution in patients with: adrenal insufficiency (levels of glucose stores in liver may be decreased); Cardiac disease; Chronic hypoglycemia (levels of glucose stores in liver may be decreased); Prolonged fasting and/or starvation (levels of glucose stores in liver may be decreased) 4

5 6. MAIN AUTHOR: Isabelle St-Sauveur, BSc(N), MSc(N). Clinical Nurse Specialist, Pediatric Day Center, Montreal Children s Hospital, McGill University Health Centre Anne Marie Sbrocchi, MD, Pediatric Endocrinologist, Montreal Children s Hospital, McGill University Health Centre Hema Patel, MD, Medical Director Complex Care Service, Montreal Children s Hospital, McGill University Health Center Marie Lefrançois,P.Dt., Nutritionist, Clinical Nutrition, Montreal Children s Hospital, McGill University Health Centre Sherif Emil, MD, Pediatric Surgeon, Montreal Children s Hospital, McGill University Health Centre Ana Sant Anna, MD, Pediatric Gastroenterologist, Montreal Children s Hospital, McGill University Health Center Montreal Stephanie Lepage, RN, BSc(N), MSc(A). Nursing Professional Development Educator, Pediatric Medical and Surgical Units, Surgical Day Center, Montreal Children s Hospital, McGill University Health Centre 7. CONSULTANTS: John Mitchell, MD, Pediatric Endocrinologist, Montreal Children s Hospital, McGill University Health Centre Elissa Remmer, NPDE, Neonatal Intensive Care Unit, Montreal Children s Hospital, McGill University Health Centre Dr Thésèse Perreault, MD, Neonatal Intensivist, Montreal Children s Hospital, McGill University Health Centre 8. APPROVAL PROCESS Institutional and professional approval [Delete explanatory text. This will represent the committees that have reviewed and/or approved the documents. This will vary related to practice and legal parameters. All medication related practice must be reviewed by Pharmacy and Therapeutics.] Committees Date approved [yyyy-mm-dd] Clinical Practice Review Committee (CPRC) (if applicable) Adult Pharmacy and Therapeutics (P&T) (if applicable) NA Pediatric Medication Administration Policy (PMAP) (if applicable) Pediatric Pharmacy and Therapeutics (Peds P&T) (if applicable) Multidisciplinary Council (MDC) (if applicable) NA 5

6 9. REVIEW DATE To be updated in maximum of 4 years or sooner if presence of new evidence or need for practice change. 10. REFERENCES Borovoy, J., Furuta, L., Nurko, S. (1997). Benefit of uncooked cornstarch in the management of children with dumping syndrome fed exclusively by gastrostomy, The American journal of Gastroenterology, 93(5), Bufler,P., Ehringhaus, C., Koletzko, S. (2001). Dumping syndrome: a common complication following NIssen fundoplication in young children, Pediatric Surgery International, 17(5-6), Calabria, A.C., Gallagher, P.R., Simmons, R., Blinman, T., De Leon, D. (2011). Postoperative Surveillance and Detection of Postprandial Hypoglycemia after Fundoplication in Children, The Journal of Pediatrics, 159(4), Cook, R.,C., Bilnman, T., A. (2014). Alleviation of retching and feeding intolerance after fundoplication, Nutrition in Clinical Practice, 29(3), Di Lorenzo, C., Orenstein, S. (2002). Fundoplication : friend or foe? Journal of Pediatric Gastroenterology & Nutrition, 34(2), Halbert, K., L. (2011). Nissen vs. Toupet Fundoplication in the treatment of gastroesophageal reflux disease. Pediatric Nursing, 37(4), Surveillance for Post-Prandial Hypoglycemia (PPH): Protocol in infants post-operative Nissen Fundoplication, The Children s Hospital of Philadelphia. Ukleja, A. (2005). Dumping Syndrome: Pathophysiology and Treatment. Nutrition in Clinical Practice, 20, Version History (for Administrative use only) Version Description Author/responsable Date No 1 Development and Approval Isabelle St-Sauveur CNS No No No Description (Création, Adoption, Révision avec modification, Révision sans modifications, etc.) Description (Création, Adoption, Révision avec modification, Révision sans modifications, etc.) Description (Création, Adoption, Révision avec modification, Révision sans modifications, etc.) Acronyme direction, Nom fonction Acronyme direction, Nom fonction Acronyme direction, Nom fonction 6

7 APPENDIX 1:Treatment of Hypoglycemia secondary to Dumping Syndrome Treatment of Hypoglycemia: Blood Glucose (BG) less than 3.5 mmol/l Conscious Unconscious or convulsing patient Patients admitted in NICU Patients NOT admitted in NICU All patients Restart continuous feeds or go back to previous mode of feeding that achieved normal BG values Infants less than 1 year Children 1 year and older Call a Code Blue pediatric or Code Pink (NICU) Provide basic life support and prepare treatment as below Recheck BG 15 minutes later Restart continuous feeds or go back to previous mode of feeding that achieved normal BG value Give 175 ml of juice or 4 white sugar packets diluted in 175 ml of water PO or GT If IV in place: D10W 2 ml/kg to a maximum of 125 ml. Maximum rate: 2 ml/kg over 1 minute Recheck BG 15 minutes later Recheck BG 15 minutes later BG remains less than 3.5 mmol/l Advise attending team BG remains less than 3.5 mmol/l Advise attending team BG is less than 3.5 mmol/l, repeat treatment and retest BG in 15 minutes. If after three treatments the BG remains less than 3.5 mmol/l In no IV: Neonates less than 28 days: Glucagon mg/kg SC or IM (maximum single dose 1mg). May repeat dose in 20 minutes if needed. Patients aged 28 days to 6 years old: Glucagon 0.5 mg SC or IM Advise attending team Patients older than 6 years: Glucagon 1 mg SC or IM