Page 39 - Critical Care Notes

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Diagnosis
■ Stool culture.
■ Glutamine dehydrogenase enzyme immunoassay (EIA).
■ Abdominal x-rays, CT, and colonoscopy may also be indicated.
Treatment
■ Discontinue current antibiotics. May give metronidazole (Flagyl) or oral or
rectal (retention enema) or vancomycin to treat diarrhea depending on
severity. Consider fidaxomicin (Dificid), which has also been shown to be
more effective for cancer patients with C-diff instead of vancomycin and
those resistant to vancomycin.
■ Contact precautions: Isolation in private room, gloves and gowns for
personnel and visitors.
■ Monitor fluid balance, electrolytes, albumin, and CBC.
■ Alcohol-based rubs not effective. Soap-and-water hand hygiene
recommended.
■ Data do not support the use of probiotics or antiperistaltic agents.
■ Opioids and loperamide may increase the risk of toxic megacolon.
■ Proton-pump inhibitors (PPIs) may increase the incidence of C-diff–
associated diarrhea.
■ Opioids and loperamide may increase the risk of toxic megacolon.
■ Consider adding cholestyramine (Questran) to drug regimen.
■ Consider fecal microbiota transplantation (FMT). Also referred to as fecal
bacteriotherapy or fecal transplant. Hospital must have a procedure and
protocol in place for implementation.
■ Healthy donor who meets select criteria.
■ Administer vancomycin preprocedure or per protocol.
■ Administer PPI the evening before and morning of procedure to reduce
gastric acid or per protocol.
■ Donor stool is prepared into a fecal slurry.
■ Administered via colonoscopy, retention enema, or NG tube.
• Average size adult: 50–200 mL via NG tube or 250–500 mL via
colonoscopy.
• To administer via NGT: Draw up slurry into 60-mL syringe and inject
50 mL/2–3 min.
• Follow with 50 mL flush of NS.
■ Keep HOB elevated 30° or more for at least 2 hr post procedure.
■ Document diarrhea post procedure. Procedure may be repeated
after 5 days.
■ Subtotal colectomy with preservation of the rectum may be indicated for
severely ill patients with grossly elevated WBC and serum lactate levels.

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