What are the appropriate admitting orders for a 12-year-old female patient with suspected GERD or peptic ulcer, presenting with moderate dehydration, epigastric pain, and vomiting?

Admitting Orders for 12-Year-Old Female with Suspected GERD/Peptic Ulcer and Moderate Dehydration

This patient requires intravenous rehydration with isotonic fluids (normal saline or lactated Ringer's) given her moderate dehydration with inability to tolerate oral intake, followed by acid suppression therapy with a proton pump inhibitor, antiemetic support, and diagnostic workup for GERD/peptic ulcer disease. 1

Immediate Fluid Resuscitation

Administer isotonic intravenous fluids (0.9% normal saline or lactated Ringer's solution) at 20 mL/kg bolus over 1-2 hours (approximately 1080 mL for this 54 kg patient), then reassess hydration status. 1 The patient's moderate dehydration with persistent vomiting (4 episodes, unable to keep food down) and clinical signs (CRT >2 seconds, poor skin turgor, pale conjunctivae) indicate failure of oral rehydration and necessitates IV therapy. 1

• Continue with maintenance IV fluids using 0.9% normal saline at approximately 1620 mL/24 hours (30 mL/kg/day for adolescents) until the patient can tolerate oral intake. 1 Avoid hypotonic fluids as vomiting creates a state of arginine vasopressin excess, increasing hyponatremia risk. 2

• Replace ongoing losses from vomiting with additional 10 mL/kg (540 mL) of 0.9% normal saline for each episode of emesis. 1

Acid Suppression Therapy

Initiate omeprazole 20 mg once daily (weight >20 kg) given before meals for suspected GERD/peptic ulcer disease. 3 This 54 kg patient falls into the standard pediatric dosing category for treatment of symptomatic GERD or erosive esophagitis. 3, 4

• The initial dose of 1 mg/kg/day (approximately 20 mg for this patient) has been most consistently reported to heal esophagitis and provide symptom relief in pediatric patients. 4

• Treatment duration should be 4-8 weeks initially, with reassessment if symptoms persist beyond 8 weeks. 3

Antiemetic Support

Administer ondansetron to facilitate tolerance of oral rehydration once initial IV hydration improves clinical status. 1, 5 This patient is >4 years old, making ondansetron appropriate to reduce vomiting and enable transition to oral intake. 1, 5

• Ondansetron should only be given after adequate initial hydration, not as a substitute for fluid therapy. 1

Diagnostic Workup

Order complete blood count to assess anemia (given pale conjunctivae), comprehensive metabolic panel to evaluate electrolytes and renal function, and consider H. pylori testing given the clinical presentation. 1

• Serum bicarbonate level is particularly important; levels ≤13 mEq/L predict higher likelihood of requiring prolonged IV therapy and hospitalization. 6

• Upper endoscopy should be considered if symptoms persist despite appropriate PPI therapy or if alarm features develop (hematemesis, severe pain, weight loss). 4, 7

Dietary Management

Keep patient NPO initially until vomiting resolves and clinical hydration improves. 1 Once the patient tolerates small amounts of clear fluids without vomiting, advance to age-appropriate diet. 1

• Resume normal diet during or immediately after rehydration is complete; avoid restrictive diets or prolonged fasting. 1, 8

• Provide dietary counseling to avoid triggers: eliminate spicy foods, soda, coffee, and highly acidic foods that exacerbate GERD symptoms. 9 These dietary habits are significant contributors to her presentation.

Monitoring Parameters

Monitor vital signs every 4 hours, including heart rate, blood pressure, capillary refill time, and mental status. 1

• Reassess hydration status after initial bolus and every 4-6 hours: skin turgor, mucous membranes, urine output (should be >1 mL/kg/hour). 1

• Repeat electrolytes 4-6 hours after initiating IV fluids to ensure sodium remains 135-145 mEq/L and avoid hospital-acquired hyponatremia. 2

• Monitor for resolution of vomiting and ability to tolerate oral intake as criteria for transitioning from IV to oral fluids. 1

Transition to Oral Intake

Once vomiting resolves and patient tolerates 1-3 ounces of clear fluid without emesis, transition to oral rehydration solution (ORS) to replace remaining deficit. 1, 6

• Continue IV fluids at maintenance rate until patient consistently tolerates oral intake. 1

• Most patients with serum bicarbonate >13 mEq/L successfully transition to oral intake after rapid IV rehydration. 6

Important Cautions

Do NOT administer antimotility agents (loperamide) as this patient is <18 years old. 1, 8, 5 Antimotility drugs are contraindicated in pediatric acute gastroenteritis. 1

Avoid hypotonic IV fluids (0.45% or 0.2% saline) as they increase risk of hyponatremia in the setting of vomiting-induced AVP excess. 2 The incidence of hospital-acquired hyponatremia with hypotonic fluids reaches 18.5% in patients with gastroenteritis. 2

Do not delay rehydration while awaiting diagnostic testing. 8, 9 Fluid resuscitation takes priority over diagnostic workup.

Admission Orders Summary

1. Admit to pediatric ward for IV rehydration and observation
2. IV: 0.9% normal saline 1080 mL over 1-2 hours, then 1620 mL/24 hours maintenance 1
3. NPO initially, advance to clear liquids as tolerated 1
4. Omeprazole 20 mg PO once daily before meals (when tolerating oral intake) 3
5. Ondansetron as needed for persistent vomiting (after initial hydration) 1, 5
6. Labs: CBC, CMP, consider H. pylori testing 1
7. Vital signs every 4 hours with hydration assessment 1
8. Strict intake/output monitoring 1
9. Dietary counseling regarding GERD triggers 9