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Rehydration in acute diarrhea. Jorge Amil Dias Porto, Portugal [email protected] Water and electrolyte movement across the intestinal mucosa. K Hodges and R Gill, Gut Microbes, 2010. K Hodges and R Gill, Gut Microbes, 2010. K Hodges and R Gill, Gut Microbes, 2010.

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Rehydration in acute diarrhea

Rehydration in acute diarrhea

Jorge Amil Dias

Porto, Portugal

[email protected]


Water and electrolyte movement across the intestinal mucosa
Waterandelectrolytemovementacrossthe intestinal mucosa

K Hodges and R Gill, Gut Microbes, 2010




Stool electrolyte losses
Stool electrolyte losses

AM Molla et al. J Pediatr 1981


History of oral rehydration
History of Oral Rehydration

1910 Intestinal absorption in patients with cholera

Sellards, Phillip J Sci

1953 186 patients with cholera treated without iv lfuids

Chatterjee, Lancet

1960’s Identification of glucose-solute co-transport

1971 WHO recommended the use of ORS



“Oral rehydration is potentially the most important medical advance in the 20th century”

Lancet, 1978


Is this child dehydrated
Is This Child Dehydrated? medical advance in the 20th century”

  • The best measure of dehydration is the percentage loss of body weight.

  • Classification into subgroups with no or minimal dehydration, mild or moderate dehydration, and severe dehydration is an essential basis for appropriate treatment

ESPGHAN/ESPID Guidelines, JPGN 2008


Assess dehydration by clinical history
Assess Dehydration by Clinical History? medical advance in the 20th century”

  • Parental reports on dehydration symptoms are low in specificity. They may not be clinically useful.

  • Parental report of normal urine output decreases the likelihood of dehydration.

  • Infants and young children with frequent high output diarrhea and vomiting are most at risk.

ESPGHAN/ESPID Guidelines, JPGN 2008


Assess dehydration based on signs and symptoms
Assess Dehydration Based on Signs and Symptoms? medical advance in the 20th century”

  • Clinical tests for dehydration are imprecise.

  • Historical points are moderately sensitive as a screening test for dehydration.

  • The best 3 individual examination signs for assessment of dehydration are:

    • prolonged capillary refill time

    • abnormal skin turgor

    • abnormal respiratory pattern

ESPGHAN/ESPID Guidelines, JPGN 2008


Items that reflect hydration
Items that reflect hydration medical advance in the 20th century”

  • Urine output

  • General appearance

  • Capillaryrefill

  • Skin turgor

  • Eyes

  • Mucousmembranes

  • Tears

  • Respiratory rate

  • Heart rate

(>3” = iv resuscitation!)


Blood electrolytes
Blood electrolytes? medical advance in the 20th century”

  • Electrolytes should be measured:

    • In moderately dehydrated children whose history and physical examination findings are inconsistent with a straight diarrheal disease.

    • in all severely dehydrated children.

    • In all children starting intravenous (IV) therapy, and during therapy, because hyper- or hyponatremia will alter the rate at which IV rehydration fluids will be given


Indications for admission
Indications for admission medical advance in the 20th century”

  • Shock

  • Severe dehydration (>9% of body weight)

  • Neurologicalabnormalities (lethargy, seizures, etc)

  • Intractable or bilious vomiting

  • ORS treatment failure

  • Caregivers cannot provide adequate care at home and/or there are social or logistical concerns

  • Suspected surgical condition


Oral rehydration
Oral rehydration medical advance in the 20th century”

  • First-line therapy for the management of children with AGE

  • When oral rehydration is not feasible, enteral rehydration by the nasogastric route is as effective if not better than IV rehydration.

  • Enteral rehydration is associated with significantly fewer major adverse events and a shorter hospital stay compared with IV therapy and is successful in most children.

  • Children who are able to receive oral rehydration therapy (ORT) should not be given IV fluids.


Role of osmolality in ors
Role of osmolality in ORS medical advance in the 20th century”

  • Lowerosmolalityincreaseswaterabsorption

    • (osmolargradient)

  • Hypertonic solutions (old WHO-ORS, Na+90 mmol/l) may increase the risk of hypernatremia

  • Current WHO (Na 75mmol/l) has a balancedcompositionthatis safe both for choleraand non-choleradiarrhoea


Composition of who ors
Composition of WHO ORS medical advance in the 20th century”


Soft drinks
Soft drinks medical advance in the 20th century”

Soft drinks are NOT recommended for rehydration, specially in infantsorsmallchildren


Alternatives to ors
Alternatives to ORS? medical advance in the 20th century”

  • Home-made solutions?

    • Risk of variable composition and osmolality

  • Fruit juice?

    • Benefit of potassium but content of fructose and osmolality load


Osmolality of fruit juices
Osmolality of fruit juices medical advance in the 20th century”


Fruit juice may affect duration of diarrhea
Fruit juice may affect duration of diarrhea medical advance in the 20th century”

N=90

S Valois et al Nutr J, 2005


Rehydration stages
Rehydration stages medical advance in the 20th century”

  • Compensate for previouslosses

    • Calculatefluid deficit

  • Compensate for ongoingelevatedlosses

    • Calculate 10ml/kg/liquidstool

  • Compensate for basic needs

    • 100-150ml/kg/d

Reassess regularly!


Fuid requirements

Basic daily needs medical advance in the 20th century”

First 10 kg

Second 10 kg

Subsequent kg

100 ml/kg

50 ml/kg

20 ml/kg

Fuid requirements

Previous losses

(rehydration)

Ongoing losses

(maintenance and

prevention of dehydration)

Normal losses


Espghan espid guidelines on acute diarrhoea
ESPGHAN/ESPID medical advance in the 20th century”guidelinesonacutediarrhoea

  • Dehydration is the main clinical feature.

  • Weight loss, prolonged capillary refill time, skin turgor, and abnormal respiratory pattern are the best clinical signs.

  • Microbiological investigations generally are not needed.

  • Rehydration is the key treatment - apply as soon as possible.

  • Low osmolality oral rehydration solution - offer ad libitum.

  • Regular feeding should not be interrupted - carry on after rehydration.

  • Regular milk formulas are appropriate in the majority of cases.


Espghan espid guidelines
ESPGHAN/ESPID Guidelines medical advance in the 20th century”

  • Drugs are generally not necessary.

  • Selected probiotics may reduce the duration and intensity of symptoms.

  • Other drugs require further investigations.

  • Antibiotic therapy is not needed in most cases

    • May induce a carrier status (Salmonella).

    • Antibiotic treatment mainly in shigellosis and in the early stage of Campylobacter infection.


Pilars for treatment of acute diarrhoea
Pilars medical advance in the 20th century” for treatmentofacutediarrhoea

  • Oral rehydration solution over 3-4 h

  • Rapid reintroduction of normal feedingthereafter.

  • Breast-feedingshould be continued as possible.

  • Hypotonic solution is safe and effective

  • Supplementation with oral rehydration solution.

  • Lactose-free formulae unjustified in the majority.

    • If diarrhea worsens check stool pH and/or reducing substances

    • Lactose-free formula if stool is acid and >0.5% red substances.

  • Do not dilute formula

  • Provide additional ORS to compensate for ongoing losses

  • Do not use unnecessary medication


Enteral vs parenteral rehydration length of hospital stay
Enteral vs parenteral rehydration - Length of hospital stay medical advance in the 20th century”


Enteral vs parenteral rehydration duration of diarrhoea
Enteral vs parenteral rehydration – duration of diarrhoea medical advance in the 20th century”

Enteral rehydration is as effective if not better than IV rehydration.

Enteral rehydration by the oral or nasogastric route is associated with significantly fewer major adverse events and a shorter hospital stay compared with IV therapy and is successful in most children


If iv fluids are necessary
If iv fluids are necessary medical advance in the 20th century”

  • Check blood electrolytes

  • Use isotonic saline solution (NaCl 0.9%) with 2.5% dextrose

  • Possible alternative: half DD solution

  • In case of hypernatremia, take additional care:

    • Use 75% of calculated volume.

    • Monitor serum Na+

    • Aim at reducing Na + by 10mmol/l per day


Na medical advance in the 20th century”+

H2O


Instruct caregivers for
Instruct caregivers for: medical advance in the 20th century”

  • Ongoingvomiting despite small fluid sips, especially if associated with abdominal distension or pain

  • Persisting fever after 24 hours of ORT

  • Increasing lethargy and failure to feed

  • Deteriorating hydration and failure to pass urine

  • Presence of blood in the stools

  • Diarrhoea persisting for more than 1 week.


Oral rehydration1
Oral rehydration medical advance in the 20th century”

  • Maynotreducestool volume ordurationofdiarrhoea

  • BUTsaveslifesbypreventingdehydration!

  • Pro’sandCon’sofadditionalmedication

    • Cost

    • Limitedbenefit

    • Drawparents’ attentionfromthemainintervention – Rehydration!


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