Diarrhoeal Disease Overview : Dr S Harris

Department of Paediatrics

Diarrhoeal DiseaseDiarrhoeal DiseasePractical Practical MxMx

Dr S Harris Dr S Harris


Recently asked questionsRecently asked questions

•• 1996: Discuss infantile GE under the following headings 1996: Discuss infantile GE under the following headings ––prevention,prevention,aetiologyaetiology and managementand management

•• 1999: Write short notes on the composition of oral 1999: Write short notes on the composition of oral rehydrationrehydration solutions solutions (SOROL and WHO)(SOROL and WHO)

•• 3/2001: Discuss the diagnosis, treatment and prevention of chole3/2001: Discuss the diagnosis, treatment and prevention of cholerara

•• 9/2001: A 14 mo old child presents with a 3 day 9/2001: A 14 mo old child presents with a 3 day hxhx of of diarrhoeadiarrhoea and and vomiting. Examination reveals a well nourished child of 10kg whovomiting. Examination reveals a well nourished child of 10kg whom you m you estimate to be 5% dehydrated. The child is not shocked but is estimate to be 5% dehydrated. The child is not shocked but is tachypnoeictachypnoeic. . Blood results are as followsBlood results are as follows-- Na 165, K 4.5, Urea 25 and Blood sugar 25. Na 165, K 4.5, Urea 25 and Blood sugar 25. Discuss your management.Discuss your management.

•• 3/2004: Causes of infective bloody 3/2004: Causes of infective bloody diarrhoeadiarrhoea (dysentery) and its (dysentery) and its management in childrenmanagement in children

•• 3/2005: Write short notes on the formulations of oral 3/2005: Write short notes on the formulations of oral rehydrationrehydration fluid in fluid in diarrhoealdiarrhoeal disease in children. What advice would you give to the mother odisease in children. What advice would you give to the mother of f a child with a child with diarrhoealdiarrhoeal disease on the use of oral disease on the use of oral rehydrationrehydration fluid.fluid.


Cont:Cont:

•• ThandiThandi, an 18 mo old child, is brought by her mother to the clinic. , an 18 mo old child, is brought by her mother to the clinic. She has had D&V for 3/7. She is restless and irritable, has a slShe has had D&V for 3/7. She is restless and irritable, has a slow ow skin pinch and sunken eyes. She is skin pinch and sunken eyes. She is visably visably severely wasted. The severely wasted. The nurse offers nurse offers Thandi Thandi some ORS which she drinks eagerly. She some ORS which she drinks eagerly. She decides to refer her to the district hospital where you are the decides to refer her to the district hospital where you are the MO.MO.

1.1. How would you classify How would you classify ThandiThandi’’s diarrhoea s diarrhoea using the IMCI criteriausing the IMCI criteria2.2. Describe how you would make the assessment of a slow skin pinchDescribe how you would make the assessment of a slow skin pinch3.3. Explain the mechanism whereby ORS corrects dehydrationExplain the mechanism whereby ORS corrects dehydration4.4. Offer an explanation as to why Offer an explanation as to why Thandi Thandi was referred to hospital was referred to hospital

using the IMCI guidelinesusing the IMCI guidelines


Why is it ImportantWhy is it Important ??(for those not sitting the DCH)(for those not sitting the DCH)

•• Morbidity: Morbidity: –– common, delays healing/exacerbates common, delays healing/exacerbates

concomitant illness, precipitates concomitant illness, precipitates kwashiorkor/kwashiorkor/marasmusmarasmus

•• Mortality: Mortality: –– one of the commonest causes of one of the commonest causes of

preventable/avoidable mortality in the preventable/avoidable mortality in the developing world. developing world.

–– The second commonest cause of death in South The second commonest cause of death in South African hospitalsAfrican hospitals


How How to successfully manage GE in to successfully manage GE in kids?kids?

•• What do they die ofWhat do they die of??

•• What are the complications of GE?What are the complications of GE?

•• Who must we worry about most?Who must we worry about most?

•• Get a feel for who can go homeGet a feel for who can go home


ShockShock

•• Shock refers to depleted Shock refers to depleted IINTRAVASCULAR volume NTRAVASCULAR volume

•• Shock IS NOT THE SAME AS dehydrationShock IS NOT THE SAME AS dehydration

•• Do not leave a shocked child as they will dieDo not leave a shocked child as they will die

•• Look for signs of shock in every childLook for signs of shock in every child


Is the child Is the child shockedshocked??

•• Signs of shock include: Signs of shock include: –– tachycardia, slow capillary refill, cool peripheries, weak pulsetachycardia, slow capillary refill, cool peripheries, weak pulses, s,

hypotension (this is a LATE sign)hypotension (this is a LATE sign)

•• Give 20ml/kg iv bolus as fast as possible. Use either Give 20ml/kg iv bolus as fast as possible. Use either Modified Ringers Lactate (MRL) or Normal SalineModified Ringers Lactate (MRL) or Normal Saline

•• Review after the bolusReview after the bolus•• If still shocked, repeat the bolus of 20ml/kgIf still shocked, repeat the bolus of 20ml/kg•• Thereafter, use 5Thereafter, use 5--10ml/kg boluses until there are 10ml/kg boluses until there are

signs of intravascular volume replenishment (liver signs of intravascular volume replenishment (liver becomes palpable), and ask for experienced becomes palpable), and ask for experienced assistanceassistance

•• Consider PICU/Ventilation/Inotropes after 40 Consider PICU/Ventilation/Inotropes after 40 ––50mls/kg50mls/kg


Do notDo not give give ½½ DD as a volume expander. It DD as a volume expander. It contains glucose and you will cause an contains glucose and you will cause an

OSMOTIC DIURESIS, and the child will not OSMOTIC DIURESIS, and the child will not get better. It also does not have the correct get better. It also does not have the correct electrolyte contentelectrolyte content and will rapidly leave the and will rapidly leave the

intravascularintravascular space and make your little patient space and make your little patient soggy.soggy.


Is the child Is the child dehydrateddehydrated??

•• Dehydration refers to depleted Dehydration refers to depleted EXTRAVASCULAR volume. Even 10% EXTRAVASCULAR volume. Even 10% dehydration IS NOT THE SAME AS shockdehydration IS NOT THE SAME AS shock

•• What are the signs of dehydration?What are the signs of dehydration?


The IMCI Way


Rehydration Rehydration FluidsFluids

•• For 5% dehydration, give 50ml/kg/24 hoursFor 5% dehydration, give 50ml/kg/24 hours•• For 10% dehydration, give 100ml/kg/24 For 10% dehydration, give 100ml/kg/24

hours (do not give more than 100 hours (do not give more than 100 ml/kg/24hours)ml/kg/24hours)

•• Give this IN ADDITION TO maintenance Give this IN ADDITION TO maintenance requirements (see belowrequirements (see below))

•• Give as ORS if hydrating orally or via NGT or Give as ORS if hydrating orally or via NGT or ½½ DD if hydrating IVIDD if hydrating IVI


Does the child have Does the child have ongoing lossesongoing losses??

•• Ongoing losses refers to Ongoing losses refers to abnormalabnormal water loss in water loss in the stool, the stool, vomitusvomitus or urine (see above). or urine (see above). NORMALLY a child loses about 10ml/kg/day of NORMALLY a child loses about 10ml/kg/day of water in the stool. So start by giving more than water in the stool. So start by giving more than thisthis::

•• A good starting guess is to give A good starting guess is to give 30 30 --50ml/kg/24 50ml/kg/24 hourshours

•• Give this IN ADDITION TO maintenance Give this IN ADDITION TO maintenance requirements (see below)requirements (see below)


Maintenance Fluid requirementsMaintenance Fluid requirements

•• 1st year: 120mls/kg1st year: 120mls/kg•• 22ndnd year: 100ml/kgyear: 100ml/kg•• 22--4 yrs: 85mls/kg4 yrs: 85mls/kg•• 44--10 yrs: 70mls/kg10 yrs: 70mls/kg

•• 100ml/kg for 1100ml/kg for 1stst 10kg10kg•• 50ml/kg for next 10kg50ml/kg for next 10kg•• 20ml/kg thereafter20ml/kg thereafter


What does this mean practically?What does this mean practically?

•• First treat shock thenFirst treat shock then•• Calculate Calculate and document your fluid plan.and document your fluid plan.•• For example, a 5kg child, 5% dehydrated, For example, a 5kg child, 5% dehydrated,

having frequent watery stools:having frequent watery stools:

•• Maintenance: Maintenance: ⓂⓂ = 1= 1000 ml/kg/24hrs0 ml/kg/24hrs•• ReRehyhydrationdration:: ⓇⓇ = 50 ml/kg/24hrs= 50 ml/kg/24hrs•• Losses:Losses: ⓁⓁ = 50 ml/kg/24hrs= 50 ml/kg/24hrs


Using the same example aboveUsing the same example above……

•• If taking orally:If taking orally: ⓂⓂ = 1= 1000 ml/kg/24hrs: 0 ml/kg/24hrs: breast ad lib or formula breast ad lib or formula 8585 ml 4 hourlyml 4 hourly

•• ⓇⓇ = 50 ml/kg/24hrs= 50 ml/kg/24hrs•• ⓁⓁ = 50 ml/kg/24hrs= 50 ml/kg/24hrs

•• ⇒⇒ IV IV ½½ DD 20 ml/hrDD 20 ml/hr


•• If NPO:If NPO:•• ⓂⓂ = = 8080 ml/kg/24hrsml/kg/24hrs•• ⓇⓇ = 50 ml/kg/24hrs= 50 ml/kg/24hrs•• ⓁⓁ = 50 ml/kg/24hrs= 50 ml/kg/24hrs

•• ⇒⇒ IV IV ½½ DD DD 3838 ml/hrml/hr


Feed ASAPFeed ASAP

•• Withhold food only if there is good reason: Withhold food only if there is good reason: excessive vomits, excessive vomits, ileusileus, shock, shock. .

•• ReRe--introduce food as soon as possible.introduce food as soon as possible.


IVACS helpIVACS help

•• When giving a child intravenous fluids, When giving a child intravenous fluids, especially when reespecially when rehydrationhydration is required, is required, use an electronic flow controller (like an use an electronic flow controller (like an IVAC pump) EVEN IN DISTRICT IVAC pump) EVEN IN DISTRICT HOSPITALS. HOSPITALS.

•• Use an intake/output chart as well (there Use an intake/output chart as well (there is one in the Clinical Records Package).is one in the Clinical Records Package).


After the initial assessment and After the initial assessment and plan, what is the ongoing fluid plan, what is the ongoing fluid

management?management?•• Review regularlyReview regularly•• If the child is not improving, then more fluid is If the child is not improving, then more fluid is

goingoingg OUT than INOUT than IN::

•• Check:Check:

•• ??Drip tissuedDrip tissued•• ??Fluid not given as prescribed (see notes on infusion pump, Fluid not given as prescribed (see notes on infusion pump,

and charting above)and charting above)•• ??Osmotic diuresis (check urine dipstix)Osmotic diuresis (check urine dipstix)•• Bigger losses than you thoughtBigger losses than you thought


If the child is getting oedematous, If the child is getting oedematous, think of:think of:

•• Fluid is going in faster than requestedFluid is going in faster than requested

•• Losses are smaller than guessedLosses are smaller than guessed

•• The child is HYPOALBUMINAEMIC: if this is the The child is HYPOALBUMINAEMIC: if this is the case, the child may be depleted intravascularlycase, the child may be depleted intravascularly

•• After considering and assessing these After considering and assessing these possibilities, adjust fluids accordinglypossibilities, adjust fluids accordingly


Metabolic ManagementMetabolic Management……

AndAndWhat investigations?What investigations?


Scenario 1Scenario 1

•• Sipho Sipho is a 13 month old little boy who weighs 10 kg. is a 13 month old little boy who weighs 10 kg. He has had D and V for 5 days. He is lethargic and He has had D and V for 5 days. He is lethargic and has cool hands and CRT is 4 s. has cool hands and CRT is 4 s. TachycardiaTachycardia 160. No 160. No BP cuff in casualty. RR 65/min. He has a very slow BP cuff in casualty. RR 65/min. He has a very slow skin pinch and sunken eyes and a dry mouth. skin pinch and sunken eyes and a dry mouth.

•• ABG: pH 7.1 pCO2 2.7 pO2 17 SBC 5 BE ABG: pH 7.1 pCO2 2.7 pO2 17 SBC 5 BE ––16 Na 16 Na 132 K 1.8132 K 1.8

•• Detail your initial management and fluid planDetail your initial management and fluid plan


Metabolic acidosisMetabolic acidosis

•• Five causesFive causes

•• Acidotic Acidotic breathingbreathing

•• When did you last use bicarb?When did you last use bicarb?


If pH < 7.1 despite adequate fluid If pH < 7.1 despite adequate fluid resuscitationresuscitation……

•• half correct the acidosis as a slow bolus:half correct the acidosis as a slow bolus:

–– calculation : ml 8.5 % NaHCOcalculation : ml 8.5 % NaHCO33 = = ½½ x 0.3 x 0.3 x body weight in x body weight in kg x Base deficitkg x Base deficit

–– NB. Exercise caution in patients with KNB. Exercise caution in patients with K+ + < < 3.4 3.4 mmolmmol/l or Na/l or Na++ > 145 > 145 mmolmmol/l AND if /l AND if the patient is the patient is hypoventilatinghypoventilating


HypokalaemiaHypokalaemia (K(K++<3.5)<3.5)

•• Clinically, Clinically, hypokalaemiahypokalaemia manifests as weakness, manifests as weakness, floppiness and floppiness and ileusileus..–– If KIf K++ < 3.4:< 3.4:

•• Give oral Rx: 0.Give oral Rx: 0.5ml 5ml –– 1ml/1ml/kg/dose MIST POT CHLOR kg/dose MIST POT CHLOR 8 hourly for 2 days8 hourly for 2 days

•• 1ml 1ml KClKCl (mist pot (mist pot chlorchlor) = 74.5mg ) = 74.5mg KClKCl = 1mmol K= 1mmol K++

•• If KIf K++ < 2.0 < 2.0 mmol/lmmol/l or < 3.0mm/l but NPOor < 3.0mm/l but NPO–– 1ml 15% 1ml 15% KClKCl = 2 = 2 mmolmmol KK–– maximum safe concentration in a paediatric maximum safe concentration in a paediatric

ward setting is 40mmol/litreward setting is 40mmol/litre


HyperkalaemiaHyperkalaemia (K(K++ > > 55.5).5)

•• Establish cause: e.g. renal failure; Establish cause: e.g. renal failure; excess supplementation; tissue necrosisexcess supplementation; tissue necrosis


If KIf K++ > 6.0 > 6.0 mmol/lmmol/l::

•• stop all Kstop all K++ intake intake -- check both prescription and fluid check both prescription and fluid therapy chartstherapy charts

•• check acidcheck acid--base status; correct acidosis by base status; correct acidosis by TREATING THE FLUID DEFICITSTREATING THE FLUID DEFICITS

•• monitor urine outputmonitor urine output

•• preferably monitor ECG (peaked tall T waves, broad preferably monitor ECG (peaked tall T waves, broad QRS, ventricular fibrillation)QRS, ventricular fibrillation)

•• 6 hourly serum K6 hourly serum K++, acid, acid--base, urea, creatininebase, urea, creatinine


If KIf K++ > 7.0 > 7.0 mmol/lmmol/l::

•• This is life threateningThis is life threatening. Manage as above, and commence stepwise . Manage as above, and commence stepwise treatmenttreatment::

–– nebulisednebulised salbutamolsalbutamol 1 ml in 2 ml saline; repeat 3 1 ml in 2 ml saline; repeat 3 hrlyhrly PRN PRN ((fenoterolfenoterol is also used for this purposeis also used for this purpose))

–– IV 10% calcium IV 10% calcium gluconategluconate 0.5 ml/kg over 10 minutes (use 0.5 ml/kg over 10 minutes (use cardiac monitor and stop immediately if cardiac monitor and stop immediately if bradycardiabradycardia occursoccurs))

–– KayexalateKayexalate 0.50.5--1 g/kg/dose per 1 g/kg/dose per osos or as retention enema; or as retention enema; repeat 6 hourly if repeat 6 hourly if necessarynecessary

–– 8.4% 8.4% NaBicNaBic 2ml/kg IV over 10 2ml/kg IV over 10 minutesminutes

–– NOTIFY CONSULTANT (insulin infusion and/or dialysis may be NOTIFY CONSULTANT (insulin infusion and/or dialysis may be needed)needed)



•• Emma is a 7 month old little girl who has had Emma is a 7 month old little girl who has had diarrhoea diarrhoea and and vomiting for 3 days. She had a vomiting for 3 days. She had a generalised generalised seizure this seizure this morning. Her weight is 8,5 kg. She is well morning. Her weight is 8,5 kg. She is well perfused perfused and has and has good volume pulses and warm peripheries. Her skin good volume pulses and warm peripheries. Her skin turgor turgor is is normal but her mouth is dry. Her eyes may be a bit sunken. normal but her mouth is dry. Her eyes may be a bit sunken. She is breathing rapidly and deeply. She is awake and She is breathing rapidly and deeply. She is awake and irritable. She is no longer vomiting much and her abdomen is irritable. She is no longer vomiting much and her abdomen is not distended.not distended.

•• ABG: pH 7.15 pCO2 3.2 pO2 14 SBC 13 BE ABG: pH 7.15 pCO2 3.2 pO2 14 SBC 13 BE ––9 Na 162 K 3.29 Na 162 K 3.2

•• Detail your initial management and fluid planDetail your initial management and fluid plan


HypernatraemiaHypernatraemia (Na(Na++ > 150mmol/l)> 150mmol/l)

•• Because dehydration will have been underBecause dehydration will have been under--estimated clinically, do not estimated clinically, do not change the initial fluid planchange the initial fluid plan

•• Use Use ½½ DD for rehydrationDD for rehydration•• Ensure that normovolaemia is attained and maintainedEnsure that normovolaemia is attained and maintained•• Half correct metabolic acidosis only if pH < 7.1 and not improviHalf correct metabolic acidosis only if pH < 7.1 and not improving on adequate ng on adequate

fluid managementfluid management

•• Failure of serum NaFailure of serum Na++ to drop is usually due to inadequate fluid replacementto drop is usually due to inadequate fluid replacement

•• Monitor Na 6 hourly. Aim to decrease serum NaMonitor Na 6 hourly. Aim to decrease serum Na++ by 1 mmol/hourby 1 mmol/hour•• Aim to correct dehAim to correct dehyydration over 24 hoursdration over 24 hours



•• Amy is a 2 year old child who has had Amy is a 2 year old child who has had diarrhoea diarrhoea for a week. She weighs 12kg. She is lethargic and for a week. She weighs 12kg. She is lethargic and floppy. She has sunken eyes and a very slow skin floppy. She has sunken eyes and a very slow skin pinch. She also has cold hands and feet and a pinch. She also has cold hands and feet and a thready thready pulse. The pulse rate is 170. Her pulse. The pulse rate is 170. Her respiratory rate is 22/min.respiratory rate is 22/min.

•• ABG: pH 7.13 pCo2 6 pO2 10 SBC 13 BE ABG: pH 7.13 pCo2 6 pO2 10 SBC 13 BE ––10 Na 120 10 Na 120 K 2.0K 2.0

•• Detail her initial management and fluid planDetail her initial management and fluid plan


HyponatraemiaHyponatraemia (Na(Na++ < 130 < 130 mmolmmol/l)/l)

•• Clinically, Clinically, hyponatraemiahyponatraemia manifests as lethargy, altered level of manifests as lethargy, altered level of consciousness, and seizuresconsciousness, and seizures

–– If on oral fluids, repeat serum NaIf on oral fluids, repeat serum Na++ in 4 hoursin 4 hours

–– If on IV fluids, and NaIf on IV fluids, and Na+ + <125mmol/l, or the child is symptomatic, <125mmol/l, or the child is symptomatic, change change ½½ DD to a Normal Saline (NS) cocktail: add 2ml 15% KCl DD to a Normal Saline (NS) cocktail: add 2ml 15% KCl and 20 ml 50%Dextrose to 200ml NS. and 20 ml 50%Dextrose to 200ml NS.

–– This cocktail contains NaThis cocktail contains Na+ + 154 mmol/l, Cl154 mmol/l, Cl-- 154 mmol/l, K154 mmol/l, K++

20mmol/l, and 5% dextrose20mmol/l, and 5% dextrose•• calculation : ml NS = 4 x body weight in kg x (140 calculation : ml NS = 4 x body weight in kg x (140 -- serum Naserum Na++))•• Monitor serum NaMonitor serum Na++ 12 12 -- 24 hourly 24 hourly -- aim to correct over 24 hours.aim to correct over 24 hours.•• Change back to Change back to ½½ DD once serum NaDD once serum Na++ > 130 mmol/l> 130 mmol/l


When to give antibiotics?When to give antibiotics?

•• The very youngThe very young•• ImmunocompromisedImmunocompromised•• MalnourishedMalnourished•• DysenteryDysentery•• SepticaemiaSepticaemia•• Isolate specific pathogenIsolate specific pathogen


Vitamin A and zincVitamin A and zinc

•• WonWon’’t hurtt hurt


ORS QuestionsORS Questions

•• 3/2005: Write short notes on the formulations of oral 3/2005: Write short notes on the formulations of oral rehydrationrehydrationfluid in fluid in diarrhoealdiarrhoeal disease in children. What advice would you give disease in children. What advice would you give to the mother of a child with to the mother of a child with diarrhoealdiarrhoeal disease on the use of oral disease on the use of oral rehydrationrehydration fluid. fluid.

•• 1999: Write short notes on the composition of oral 1999: Write short notes on the composition of oral rehydrationrehydrationsolutions (SOROL and WHO)solutions (SOROL and WHO)

•• Explain the mechanism whereby ORS corrects dehydrationExplain the mechanism whereby ORS corrects dehydration


ORSORS

•• Coupled active transport of Na and Glucose in the small bowel Coupled active transport of Na and Glucose in the small bowel results in passive absorption of water and other electrolytes evresults in passive absorption of water and other electrolytes even en in the face of a in the face of a secretory diarrhoeasecretory diarrhoea

•• Provides a balanced electrolyte solution that replaces expected Provides a balanced electrolyte solution that replaces expected electrolyte losses in the form of Na and K , corrects to some electrolyte losses in the form of Na and K , corrects to some extent the acid base disturbances through the addition of citratextent the acid base disturbances through the addition of citrate e and provides a 2 and provides a 2 –– 2.5% glucose solution to enhance the active 2.5% glucose solution to enhance the active transport of Na (and water by solvent drag)transport of Na (and water by solvent drag)

•• Different formulations availableDifferent formulations available


Composition of ORSComposition of ORS

2.4%2.4%1.9%1.9%1.5 %1.5 %GlucoseGlucose

0010101010CitrateCitrate

646454546565ClCl

0020202020KK

646464647575NaNa

SSSSSSSOROLSOROLWHOWHO

Documents

Diarrhoeal Disease Overview : Dr S Harris