Management of Acute Gastroenteritis (AGE) with Shock
Patients with AGE complicated by shock require immediate fluid resuscitation, close monitoring of clinical endpoints, and appropriate antimicrobial therapy when indicated.
Initial Resuscitation
Fluid Management
- Immediate rapid restoration of intravascular volume is essential 1
- For patients with septic shock, resuscitation should begin immediately when hypotension is identified 1
- Use crystalloid solutions as first-line fluid therapy 1
- Goal-directed therapy should be used, targeting:
- Mean arterial pressure (MAP) >65 mm Hg
- Urine output >0.5 mL/kg/h
- Improved skin color, capillary refill, and mental status 1
Monitoring During Resuscitation
- Clinical endpoints rather than predetermined protocols should guide resuscitation 1
- Monitor:
- Mean arterial pressure
- Skin color and capillary refill
- Mental status
- Urinary output 1
- Ultrasound measurement of IVC diameter can be a simple method for defining fluid requirements 1
Vasopressor Support
- Administer vasopressors if hypotension persists following adequate fluid loading 1
- Norepinephrine is the first-line vasopressor for septic shock 1
- Optimal timing: Evidence suggests mortality is lowest when vasopressors are delayed by 1 hour and infused from hours 1-6 following onset of shock 1
Antimicrobial Therapy
- Initiate antimicrobial therapy once intra-abdominal infection is diagnosed or considered likely 1
- For patients with septic shock, antibiotics should be administered as soon as possible 1
- For patients without septic shock, antimicrobial therapy should be started in the emergency department 1
- Maintain adequate antimicrobial drug levels during any source control intervention 1
Source Control
- Appropriate source control procedure is recommended for nearly all patients with intra-abdominal infection 1
- For diffuse peritonitis, emergency surgical procedure should be performed as soon as possible 1
- Percutaneous drainage of abscesses and well-localized fluid collections is preferable to surgical drainage where feasible 1
- For hemodynamically stable patients without evidence of acute organ failure, intervention may be delayed for up to 24 hours if appropriate antimicrobial therapy is given and careful clinical monitoring is provided 1
Nutritional Support
- Early oral feeding as tolerated is recommended rather than keeping the patient nil per os 1
- If unable to feed orally, enteral nutrition is preferred over parenteral nutrition 1
- For patients requiring enteral tube feeding, either nasogastric or nasojejunal routes can be used 1
Supportive Care
- Avoid hydroxyethyl starch (HES) fluids as they may increase risk of multiple organ failure 1
- Consider stress ulcer prophylaxis for patients with risk factors for GI bleeding 1
- Acetaminophen may be used for managing associated pain and discomfort 2
Special Considerations
- In patients with abdominal sepsis requiring urgent surgical intervention, overly aggressive fluid resuscitation may increase intra-abdominal pressure and worsen inflammatory response 1
- Be vigilant for development of intra-abdominal hypertension and abdominal compartment syndrome 1
- For patients with acute biliary pancreatitis, cholecystectomy during the initial admission is recommended 1
Pitfalls to Avoid
- Delaying antimicrobial therapy in patients with septic shock increases mortality 1
- Overaggressive fluid resuscitation can lead to complications including abdominal compartment syndrome 1
- Overuse of antimotility agents can interfere with oral rehydration therapy 2
- Routine use of prophylactic antibiotics is not recommended in the absence of specific indications 1
By following this approach, clinicians can effectively manage AGE with shock, minimizing morbidity and mortality through prompt resuscitation, appropriate antimicrobial therapy, and supportive care.