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ORAL REHYDRATION SOLUTION,DIARRHEA,SAM
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Dr. Rajesh KulkarniPune
India- the PioneerOver 2,500 years ago, Indian physician
Sushruta described the treatment of acute diarrhea with rice water, coconut juice and carrot soup.
IV fluids in Cholera In 1831, William Brooke treated cholera patients with IV Fluids reducing mortality from 70 % to 40 %.
IV fluid replacement became the standard of care for moderate/severe dehydration for over a hundred years.
INDIA AGAIN!!Late 1950’s: Dr Hemendranath Chatterjee
1971: Dr. Dilip Mahalanabis 350,000 treated with mortality of 0.36%
Na-Glucose co-transportIn the early 1960s, Robert K. Crane
discovered the sodium-glucose co-transport as the mechanism for intestinal glucose absorption.
Around the same time, other scientists showed that the intestinal mucosa was not disrupted in cholera, as previously thought.
Importance Realized!!!1978 – In recognition of the lives saved with
ORT, The Lancet proclaims that “THE discovery that sodium transport and glucose transport are coupled in the small intestine, so that glucose accelerates absorption of solute and water, was potentially the most important medical advance this century.”
PRINICIPLE OF ORSThe sodium-coupled co-transport with
glucose and other carrier organic solutes remains intact, even with viral enteritis associated with epithelial damage .
Ingredient Standard WHO ORS mmol/l
Reduced osmolarity ORS mmol/l (2002)
Glucose 111 75
Na 90 75
K 20 20
Cl 80 65
Citrate 10 10
Osmolarity mOsm/kg
311 245
Limitation of high osmolarity ORS
Does not lower volume, frequency and duration of diarrhoea.
Induces vomiting due to taste, so acceptability poor.
More chances of dehydration, more chances of requiring iv fluid.
Hypernatremia.Good to correct fluid deficit, not good for
maintenance fluid.
LOW OSMOLARITY ORSCompared to WHO standard ORS , hypo-
osmolar ORS is associated with
a) fewer unscheduled intravenous fluid infusions(33%)
b)lower stool volumes (20%), and
c) less vomiting(30%)
Clinical relevance - low osmolarity ORSReduction in need of IV therapy results in
reduced hospitalization and in turn results:
Reduced risk of hospital acquired infections.
Reduced disruption of breastfeeding. Reduced use of needles and interventions Reduced therapy cost. Reduced risk of diarrheal deaths in areas
where IV therapy is not readily available.
Rice-based ORS, Maltodextrin-containing and Amino acid-containing ORS—SUPER ORS
They are not superior to glucose-based ORS for acute non-cholera diarrhea, provided that feeding was promptly resumed after initial rehydration of the child.
Flavored/Colored ORS Studies showed neither an advantage nor
disadvantage for the flavoured and coloured ORS when compared to the standard ORS with regard to safety, acceptability and correct use.
Concerns about the type of sweetners ,coloring and flavouring agents used.
More expensive
CASE STUDYPinky 18 month old girl was brought by her
mother to the OPD complaining of 4 episodes of loose stools without blood or mucus.
On examination,Pinky is alert and playful.She weighs 12 kg.
She does not have sunken eyes and her skin pinch goes back instantly.
DIAGNOSIS AND MANAGEMENT
PLAN AAfter each loose stool and in between them give
ORS
Continue breastfeeding
If not exclusively breastfed, give food based fluids(Soup, Rice water, Yoghurt drinks)
Age <2 years 50 to 100 ml
Age >2 years 100 to 200 ml
CASE STUDYMunna a 10 month old boy is brought by his
mother to OPD with complaints of loose motions since 2 days,12-14 episodes in the last 24 hours.
On examination his weight is 8 kg.When offered ORS,Munna drinks it eagerly.He is irritable and has sunken eyes.
His skin pinch goes back slowly.
DIAGNOSIS & TREATMENT
Some DehydrationIf the child has two or more of the following
signs, the child has some dehydration:
restlessness/irritabilitythirsty and drinks eagerlysunken eyesskin pinch goes back slowly.
PLAN BIn Clinic, give 75 ml/kg ORS over 4 hours
If < 6 months and exclusively breastfed, also give extra 100 to 200 ml clear water over this period.
CASE STUDYPayal is a 14 months old girl weighing 10 kg.
She is brought to the emergency department with complaints of 20-25 episodes of loose stools within the last 12 hours.
On examination ,she is lethargic ,has sunken eyes and her skin pinch goes back very slowly.
DIAGNOSIS AND MANAGEMENT
Severe Dehydrtion
If any two of the following signs are present, severe dehydration is present
lethargy or unconsciousness
sunken eyes
skin pinch goes back very slowly (2 seconds or more)
not able to drink or drinks poorly.
PLAN CI.V. THERAPY POSSIBLE..GIVE
RINGER LACTATE.
AGE FIRST GIVE 30 ML/KG IN
THEN GIVE 70 ML/KG IN
< 12 MONTHS ONE
HOURFIVE HOURS
12 MONTHS TO 5 YEARS
HALF HOUR
TWO AND HALF HOURS
PLAN CIV THERAPY NOT POSSIBLE:
ORAL OR NG TUBE ORS 20 ml/kg/hour for 6 hours
(i.e. total 120 ml/kg over 6 hrs)
Reassess Hourly
If not better in 3 hours,IV therapy MUST be given(Refer)
Limitations
Altered mental status with concern for aspiration
Abdominal ileusUnderlying disorder that limits intestinal
absorption of ORT (e.g, short gut, carbohydrate malabsorption)
PRACTICAL PROBLEMSVomiting: Give less amount more
frequently,wait for 10 minutes and try again.Give food in the form of Kanji,Amylase rich food.
Taste: It is a MEDICINE and the most important medicine in diarrhea. Convince the parents. First drug in your prescription.
If affording, flavoured ORS may help.
ORS IV fluids Once ORT has been initiated, intervention
with intravenous hydration is indicated:
If stool output continues to be excessive, and ORT is unable to adequately rehydrate the child
If there is severe and persistent vomiting, and inadequate intake of ORS
WHO Statement2006: The World Health Organization states
that, “there is no evidence to support the ongoing use of IV therapy for the first-line management of most cases of childhood gastroenteritis.”
CASE STUDY-special scenarioRoshan is a 14 month old boy.He was
brought to the hospital with a history of loose stools since one day 6-7 episodes.
His weight is 6 kg , mother gives h/o faulty feeding since 5 months of age.(SAM)
He has sunken eyes and his skin pinch goes back slowly.
Peripheral pulses are palpable and sensorium is normal
DIAGNOSIS AND MANAGEMENT
DIAGNOSIS AND MANAGEMENTSAM with AGE with dehydration without shock.
(History very important)
NO IV Rehydration, manage with ReSoMal or low osmolarity ORS(in 1 litres) with added potassium 20mmol/L .(IAP 2006)
How often to give ORS Amount to give
Every 30 minutes for first 2 hours 5ml/kgAlternate hours for up to 10 hours 5-10
ml/kg
CASE STUDYAnita is a 14 month old girl. She was brought
to the hospital with a history of loose stools since one day 6-7 episodes.
Her weight is 6 kg, mother gives h/o faulty feeding since 5 months of age.(SAM)
She has sunken eyes and her skin pinch goes back very slowly.
She is lethargic and her peripheral pulses are very feeble .
DIAGNOSIS AND MANAGEMENT
Preventing and Treating Diarrhea
RESOMAL COMPOSITION
Water 2 litres WHO-ORS One 1-litre packet* Sucrose 50 g Electrolyte/mineral solution** 40 ml
(* 3.5 g sodium chloride, 2.9 g trisodium citrate dihydrate, 1.5 g potassium chloride, 20 g glucose).
** If this cannot be made up, use 45 ml of KCl solution (100 g KCl in 1 litre of water) instead.
Electrolyte/mineral solution-COMPOSITION Potassium chloride: KCl 224 gm 24 mmol/20 mlTripotassium citrate 81gm, 2 mmol/20 mlMagnesium chloride: MgCl2.6H2O 76gm, 3
mmol/20 mlZinc acetate: Zn acetate.2H20 8.2gm, 300 µmol/20
mlCopper sulfate: CuSO4.5H2O 1.4gm, 45 µmol/20 mlWater: make up to 2500 ml If available, also add selenium (0.028 g of sodium
selenate, NaSeO4.10H20) and iodine (0.012 g of potassium iodide, KI) per 2500 ml.
WHO ALTERNATIVE TO RESOMAL
2 LITRES WATER
1 PACK LOW OSMOLARITY ORS
45 ml Potassium Chloride solution(from stock solution containing 100 gm KCL/Litre)
50 gm Sucrose
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