02.Management of Gastroenteritis

7/30/2019 02.Management of Gastroenteritis

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Management ofManagement ofGastroenteritisGastroenteritis

Department of PaediatricsDepartment of Paediatrics


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Assessment of HydrationAssessment of Hydrationsymptomsymptom NoNo

DehydrationDehydrationSomeSome

DehydrationDehydrationSevereSevere

DehydrationDehydration

Mental st.Mental st. AlertAlert restlessrestless LethargicLethargic

ThirstThirst drinksdrinks ThirstyThirsty Unable to drinkUnable to drink

Heart rateHeart rate NormalNormal IncreasedIncreased increasedincreased

PulsePulse NormalNormal decreaseddecreased WeakWeak

BreathingBreathing NormalNormal Normal/FastNormal/Fast DeepDeep

EyesEyes NormalNormal Sl. sunkenSl. sunken SunkenSunken

TearsTears PresentPresent reducedreduced AbsentAbsent

TongueTongue moistmoist drydry ParchedParched

Skin foldSkin fold normalnormal Recoil 2 sec

Cap refillCap refill NormalNormal prolongedprolonged ProlongedProlonged

UOPUOP NormalNormal decreaseddecreased minimalminimal


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AssessmentAssessmentProlonged skin fold is the best predictorProlonged skin fold is the best predictor

Other good predictors areOther good predictors are Altered neurological stateAltered neurological state

Sunken eyesSunken eyes

Dry mucus membranesDry mucus membranes The degree of dehydration is expressed asThe degree of dehydration is expressed as

a percentage of body weighta percentage of body weight

Some dehydration 3-8% weight lossSome dehydration 3-8% weight loss

Severe dehydration > 8% weight lossSevere dehydration > 8% weight loss In clinical practice the most important is toIn clinical practice the most important is to

identify severely dehydrated children withidentify severely dehydrated children with

shockshock


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AssessmentAssessment

Pinching the skin of the abdomen to check for skin turgorPinching the skin of the abdomen to check for skin turgor



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Admission criteriaAdmission criteria

There are no formal criteriaThere are no formal criteria Following are usefulFollowing are useful

Severe dehydrationSevere dehydration

Younger age ( less than 6 months)Younger age ( less than 6 months) Blood in stoolsBlood in stools

High grade feverHigh grade fever

Pre existing FTTPre existing FTT Poor fluid intakePoor fluid intake


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InvestigationsInvestigations

Rarely helpfulRarely helpful Electrolyte disturbances are rareElectrolyte disturbances are rare

unless severely dehydratedunless severely dehydrated Therefore routine bloodTherefore routine blood

investigations are not justifiedinvestigations are not justified One important thing to pick up isOne important thing to pick up is

hypernatraemiahypernatraemia Unless blood in the stools, stoolUnless blood in the stools, stool

cultures are rarely helpfulcultures are rarely helpful


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Six pillars of good practiceSix pillars of good practice

Use ORS to correct estimated dehydrationUse ORS to correct estimated dehydrationover 3-4 hoursover 3-4 hours

Use hyposmolar solution *Use hyposmolar solution *

Continue breast feeding throughoutContinue breast feeding throughout Early resumption of normal diet after 4Early resumption of normal diet after 4

hours of rehydrationhours of rehydration Prevention of further dehydration byPrevention of further dehydration by

supplementing maintenance fluid with ORSsupplementing maintenance fluid with ORS No unnecessary medicationNo unnecessary medication

* In Developed countries


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Children with no dehydrationChildren with no dehydration

FeaturesFeatures Moist mucus membranesMoist mucus membranes

Normal skin fold retractionNormal skin fold retraction

Alert and responsiveAlert and responsive Review risk factors for dehydrationReview risk factors for dehydration

Young ageYoung age

Rapid rate of fluid lossRapid rate of fluid loss Reduce fluid intakeReduce fluid intake

Underlying malnutritionUnderlying malnutrition


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Children with no dehydrationChildren with no dehydration High riskHigh risk

Admit for period of observationAdmit for period of observation

Give 10 ml/kg ORS after each vomit orGive 10 ml/kg ORS after each vomit or

watery stoolwatery stool

ObserveObserve Normal dietNormal diet

Low riskLow risk

Normal diet and fluidNormal diet and fluid EducateEducate

Allow homeAllow home


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Management of Some DehydrationManagement of Some Dehydration

FeaturesFeatures

Dry mucus membranesDry mucus membranes


Skin fold retraction prolonged >1 secSkin fold retraction prolonged >1 sec

Restless and irritableRestless and irritable


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Oral rehydrationOral rehydration

Give 30-80 ml/kg of ORS over 3-4 hoursGive 30-80 ml/kg of ORS over 3-4 hours

If vomiting give little and oftenIf vomiting give little and often (5-10 ml(5-10 mlat a time)at a time)

Consider nasogastric infusion if vomitingConsider nasogastric infusion if vomiting

persists or child refusing ORSpersists or child refusing ORS

Commence normal diet after initialCommence normal diet after initial

rehydrationrehydration

Give ORS 10 ml/kg for significant lossesGive ORS 10 ml/kg for significant losses

of vomiting or diarrhoeaof vomiting or diarrhoea


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ContCont Intravenous rehydrationIntravenous rehydration

Use only if oral and nasogastricUse only if oral and nasogastricrehydration failedrehydration failed

CannulateCannulate Base line urea and electrolytesBase line urea and electrolytes

Give deficit (30-80 ml/kg) over 4-8Give deficit (30-80 ml/kg) over 4-8hourshours

Use 0.45% saline with 5% dextroseUse 0.45% saline with 5% dextrose

Add 10 mmol of KCl for each 500 ml ifAdd 10 mmol of KCl for each 500 ml ifserum K is not raisedserum K is not raised


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Severe DehydrationSevere Dehydration

FeaturesFeatures

Very dry mucus membranesVery dry mucus membranes


Skin fold retraction > 2 secSkin fold retraction > 2 sec

TachycardiaTachycardia

Slow capillary refillSlow capillary refill

Acidotic breathingAcidotic breathing

Lethargic or comatoseLethargic or comatose


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Management of Severe DehydrationManagement of Severe Dehydration Intravenous fluid resuscitationIntravenous fluid resuscitation

Assume 10% dehydrationAssume 10% dehydration IV or intraosseous accessIV or intraosseous access

Send urea, electrolytes, FBC, blood gasSend urea, electrolytes, FBC, blood gasand cultureand culture

Give 20 ml/kg of Normal saline bolusGive 20 ml/kg of Normal saline bolus

ReassessReassess

If signs of shock persist repeat theIf signs of shock persist repeat the

second 20 ml/kg normal saline bolussecond 20 ml/kg normal saline bolus If circulation is not restored after theIf circulation is not restored after the

second bolus needsecond bolus need ColloidsColloids

ICU admissionICU admission


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Management of Severe DehydrationManagement of Severe Dehydration

If child responds to the first bolusIf child responds to the first bolus

with restoration of the circulationwith restoration of the circulation

Remaining deficit is restored withRemaining deficit is restored with

ORSORS

ORS 30-80 ml/kg over next 3-4ORS 30-80 ml/kg over next 3-4

hourshours

Consider nasogastric tube infusion ifConsider nasogastric tube infusion if

not tolerating or refusing ORSnot tolerating or refusing ORS


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Oral rehydration solutionOral rehydration solution

WHOWHO ESPGANESPGAN

Sodium mmol/lSodium mmol/l 9090 6060

Potassium mmol/lPotassium mmol/l 2020 2020

Chloride mmol/lChloride mmol/l 8080 6060Bicarbonate mmol/lBicarbonate mmol/l -- --

GlucoseGlucose 111111 9090

CitrateCitrate 1010 1010

OsmolalityOsmolality 331331

(mOsm/kg)(mOsm/kg)

240240

(mOsm/kg)(mOsm/kg)


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Absorb through small intestineAbsorb through small intestine

Na- Glucose co-transport mechanismNa- Glucose co-transport mechanism

is importantis important

Water follows the solute gradientWater follows the solute gradient

Overall failure rate for ORS is 3.6%Overall failure rate for ORS is 3.6%

Faster rehydrationFaster rehydration Less complicationsLess complications


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Problems with ORSProblems with ORS

IntoleranceIntolerance

PreparationPreparation

StorageStorage Cost effective ratioCost effective ratio

Perceived to fail in curing diarrhoeaPerceived to fail in curing diarrhoea


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Rice based ORSRice based ORS Reduces stool out put in cholera patientsReduces stool out put in cholera patients

No added advantages in paediatricNo added advantages in paediatric

practicepractice Flavoured ORSFlavoured ORS

Adding juices to ORS changes itsAdding juices to ORS changes itscompositioncomposition

ESPAGN guidelines are available toESPAGN guidelines are available toflavour ORSflavour ORS


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FEEDINGFEEDING

Breast fed children to continueBreast fed children to continue

breast feeding throughoutbreast feeding throughout

dehydration and maintenance phasedehydration and maintenance phase

Weaned children should receiveWeaned children should receive

normal diet once rehydratednormal diet once rehydrated


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FEEDINGFEEDING

AdvantagesAdvantages

Minimize protein energy deficitMinimize protein energy deficit

Reduces stool lossesReduces stool losses

Stimulate normal restoration of villiStimulate normal restoration of villi

Shorter duration of diarrhoeaShorter duration of diarrhoea


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ProbioticsProbiotics

Live micro-organismsLive micro-organisms Lactobacillus GG is the commonestLactobacillus GG is the commonest

usedused Some studies suggest that additionSome studies suggest that addition

of Lactobacilli to ORS reducesof Lactobacilli to ORS reducesduration of diarrhoea and lessduration of diarrhoea and less

protraction of casesprotraction of cases Meta-analysis showed no benefitsMeta-analysis showed no benefits Need further evidenceNeed further evidence


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DrugsDrugs

Anti-diarrhoealsAnti-diarrhoeals Not indicated in the managementNot indicated in the management

AntibioticsAntibiotics

Only in invasive diarrhoeaOnly in invasive diarrhoea SalmonellaSalmonella

ShigellaShigella

AmoebaAmoeba

GiardiasisGiardiasis CholeraCholera


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02.Management of Gastroenteritis