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Management of Dehydration and Special Issues. Abdulwahab Telmesani FRCPC, FAAP Umm Al-Qura University. Scientific Methodology. Latest publications through best and well known search engines (Ovid, Blackwell, MD Consult, etc.) Cochrane Database of Systematic Reviews. - PowerPoint PPT Presentation
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Management of Dehydration and Special Issues
Abdulwahab Telmesani
FRCPC, FAAP
Umm Al-Qura University
Scientific Methodology
Latest publications through best and well known search engines (Ovid, Blackwell, MD Consult, etc.)
Cochrane Database of Systematic Reviews
Management of Dehydration
Why it is important?
Management of Dehydration
2 million infant and child die every year in the developing countries
Diarrhea
Rota virus is a major worldwide cause of infant morbidity and
mortality
Rotavirus
Rates of rotavirus illness among children in industrialized and less developed countries are similar, indicating that clean water supplies and good hygiene have little effect on virus transmission.
AAP
Rotavirus
Trials of pentavalent rotavirus vaccine in the United States and 10 other countries show efficacy rates of 98% for prevention of severe illness and 74% for prevention of rotavirus-induced diarrheal episodes of any severity.
AAP
Rotavirus
Rota Virus Live Oral Vaccine is out and soon available KSA
Management of Dehydration
Management at the primary health care centers
By PHCC Physicians
Who is our target patient?
?
Who is our target patient?
Previously well baby or child who has diarrhea with mild- moderate
dehydration
Who is our target patient?
NOT
Renal failure, cardiac patients, severely malnourished baby, toxic, etc.
Degree of Dehydration
Assess the degree of dehydration
Degree of Dehydration
Mild dehydration (3-5%)
Moderate dehydration (7-10%)
Sever dehydration (10-15%)
Degree of Dehydration
Mild dehydration (3-5%) -Normal P/E,
-Normal or increased pulse rate
-Decreased U/O and
-Thirsty
Degree of Dehydration
Moderate dehydration (7-10%) -Increased pulse rate
-Decreased U/O and tears -Sunken eyes and fontanel -Dry mucous membrane. -Mild skin tenting, pale, cool periphery and -Decreased capillary refill.
Degree of Dehydration
Sever dehydration (10-15%) -Rapid weak pulse.
-Low BP, sunken eyes and fontanel
-No tears or urine & v. dry mucous membrane
-Clear skin tenting. Cool mottled skin with
delayed capillary refill.
Fluid Maintenance
?
Fluid Maintenance
Body Wt Fluid per day
0 – 10 kg 100 ml/kg
11 -20 kg 50 ml/kg
20 kg 20ml/kg
e.g. a child of 25kg
First 10 kg = 1000 ml
Second 10 kg = 500 ml
Remaining 5 kg = 20 ml
Total = 1700 ml/ pay
i.e. per hr = 70 ml/ hr
Calculate the deficit
Percent of dehydration x Weight
e.g. 7% dehydrated 10 kg baby
0.07 x 10 = 0.7 L i.e. 700 ml
Lab work
None Required
Lab work
Na and K Urea and creatinine pH/ Bicarb. Urinalysis
ORS
Oral Rehydration Solution
ORS
Developed 1940s in Dhaka Bangladesh
ORS
A revolution in the management of diarrhea
Olivier Fontaine Bulletin of WHO
Geneva 2001
ORS
Most important medical discovery of the 20th century
The Lancet
ORS
5 million deaths / year
After ORS
2 million deaths / year
ORS components
WHO/UNICEF
Na = 90 mmol/l k = 20 mmlo/l cl = 80 mmol/l glucose = 111mmol/l Osmol = 311 mmol/l
WHO vs. Hypo-osmolar ORS
WHO/UNICEF Hypo-osmolar
Na = 90 mmol/l Na = 60 mmol/l k = 20 mmlo/l k = 20 mmlo/l cl = 80 mmol/l cl = 50 mmol/l glucose = 111mmol/l glucose = 84 mmol/l Osmol = 311 mmol/l Osmol = 224 mmol/l
Hypo-osmolar ORS
Many studies support the use of reduced osmolarity ORS but the debate is not resolved. It is preferred in severely malnourished (marasmic) child as the standard (old) WHO ORS may cause hypernatremia
Hypo-osmolar ORS
In May 2002 WHO moved to reduced osmolality ORS
ORT vs. I/V Therapy
?
ORT vs. I/V Therapy
ORT is as effective as I/V fluid for rehydration of moderately dehydrated children due to G/E in the E/D. ORT Demonstrated no inferiority for successful rehydration at 4 hours and hospitalization rate.
A randomized controlled trial by P Spandorfer et al
Pediatrics Feb.2005
ORT vs. I/V Therapy
Although no clinically important differences between ORT and IVT, the ORT group did have a higher rate of paralytic ileus, and the IVT group exposed to risk of intravenous therapy. For every 25 children treated with ORT one fail and require IVT
L Hartlig The Cochrane Database of Systematic Reviews 2006 Issue 4
Reluctance to use ORT
?
Reluctance to use ORT
People do not consider ORT high-tech enough.
Physicians prefer I/V fluids. It takes time to educate parents re ORT. Time consuming for busy parents.
ORS Additives
ORS Additives
Amylase-Resistant Starch
ORS Additives
In children with acute diarrhea, the addition of amylase-resistant starch to glucose ORS significantly shortened duration of diarrhea compared with slandered treatment
Randomized study By P Raghupathy
J Ped Gastro & nut April 2006
ORS Additives
Amino Acids
ORS Additives
Adding amino acids to ORS found to improve it’s performance and help in the regeneration of the intestinal mucosa.
G Nappert Nutition review Mar. 2000
ORS Additives
Zinc
ORS Additives
Zinc supplement(20 mg per day) reduced severity and duration of diarrhea
T Bora et. al. Ped. Intern. October 2003
and many other publications
ORS Additives
Probiotics in ORS proved effective
Special Issues
Antibiotics
Antibiotics
None Required
Anti- emetics
Anti- emetics
Remains Controversial.
Anti- emetics
Small number of included trials provided some weak evidence in favor the use of ondansetron and metoclopromide
D Alhashimi et. al. Cochrane Database of Systematic
Reviews March 2006
Anti- emetics
A single dose of oral Ondansetron (a serotonin antagonist anti-emetic) in children with G/E and dehydration reduces vomiting, facilitate oral rehydration and suitable for the use in emergency department
Freedman New Eng. J of Med. April 2006
Anti-diarrheal agents
Anti-diarrheal agents
Less Controversial
Anti-diarrheal agents
Antimotility drugs, slow intestinal transit but have little effect on the total stool volume and may have serous side effect including ileus. They are not advised for infants or children
G Nappert Nutition review Mar. 2000
Anti-diarrheal agents
Three studies have suggested that drugs that slow intestinal peristalsis are associated with increased risk of Hemolytic Uremic Syndrome or more sever complications when given to children with infectious diarrhea.
P Tarr et. al. Canad. Med Asso. J.
Apr. 1999
Anti-diarrheal agents
We strongly discourage their use in acute childhood diarrhea
P Tarr et. al. Canad. Med Asso. J.
Apr. 1999
Probiotics and Diarrhea
Ample Evidence
Probiotics and Diarrhea
Use of Probiotic as functional food in the treatment of diarrhea
A strong evidence related to probiotics in prevention and treatment of Rotavirus-associated diarrhea
Effective in prevention and treatment of antibiotic diarrhea
Probiotics and Diarrhea
Authors’ conclusion;
Probiotics appear to be a useful adjunct to rehydration therapy in treating acute infectious diarrhea in adult and children.
Allen SJ Cochrane Database of Systematic Reviews
2006 Issue 4
Diarrhea and dehydration Guidelines I
CDC Guidelines for Treatment of Diarrhea and Dehydration
(Endorsed by The American Academy of Pediatrics)
R ShethAmerican Academy of Pediatrics
publications Aug. 2004
Diarrhea and dehydration Guidelines I
1. ORS should be used for dehydration.
2. Oral rehydration should be performed rapidly.
3. For rapid realimentation, age appropriate, unrestricted diet is recommended as soon as dehydration is corrected.
4. For breastfed infants, nursing should be continued.
Diarrhea and dehydration Guidelines I
5. For formula-fed infants, diluted formula is not recommended, and special formula usually is not necessary.
6. Additional ORS should be administered for ongoing losses through diarrhea.
7. No unnecessary laboratory tests or medications should be administered.
Diarrhea and dehydration Guidelines II
An Evidence Based and Consensus Based Guideline for Acute Diarrhea
Management
K Armon et al
Archives of Disease in Childhood
Aug. 2001
Diarrhea and dehydration Guidelines II
Intended to aid doctors in recognizing children who need admission for
observation and treatment and those who may safely go home
Diarrhea and dehydration Guidelines II
A. Differential diagnosis of child presenting with diarrhea:
(Intussusception, surgical abdomen, hemolytic uremic syndrome)
Look for Red Flags
Diarrhea and dehydration Guidelines II
A. Red Flags: * Abdominal pain with tenderness, with or without guarding * Pallor, jaundice, oligo/anuria, bloody diarrhea * Systemically unwell, out of proportion to the level of dehydration * Shock
Diarrhea and dehydration Guidelines II
B. Estimation of severity of dehydration:
Mild dehydration (3-5%) Moderate dehydration (7-10% Sever dehydration (10-15%)
Diarrhea and dehydration Guidelines II
C. Blood Tests:
It is thus unnecessary to measure electrolytes in those children who will be rehydrated with ORS.
Diarrhea and dehydration Guidelines II
D. Management of Rehydration:
* ORS is safer than I/V (failure rate 3.6%)
in mild to moderate dehydration.
* Small frequent aliquots (5 ml or more
if welling and no vomiting over 3-4 HRs)
* N/G or I/V over night or when parents
are not welling to carry ORT.
Diarrhea and dehydration Guidelines II
E. Composition of ORS (UK):
Na 60 mmol/l
K 20 mmol/l
Glucose 74-111 mmol/l
Diarrhea and dehydration Guidelines II
F. Maintenance of hydration:
* Allow free fluids.
* Encourage drinking more than usual.
Diarrhea and dehydration Guidelines II
G. Refeeding following rehydration:
* Brest fed infant should continue.
* Formula should be restarted as soon as
the child is rehydrated (HRs.)
Diarrhea and dehydration Guidelines II
H. Criteria for admission of children with
Gastroenteritis:
* Sever dehydration
* Mild- moderate dehydration observed (3-4 hrs)
ensure success rehydration.
* High risk patients e.g. infants less than 6 months,
frequent watery diarrhea (8/day) or persistent
vomiting
Diarrhea and dehydration Guidelines II
I. Role of medications:
* Infants and children with acute
gastroenteritis should not be
treated with antidiarrheal agents.
Telmesani Guidelines III
Facts
The body possess thermostat in the Gut and the Kidneys (feed back regulation)
Electrolyte deficit even in Hypernatremic dehydration
We are dealing with health mildly-moderately dehydrated baby/child
ADH and Gastroenteritis
Nonosmotic stimuli of ADH secretion are frequent in children with gastroenteritis.
The use of hypotonic saline for deficit replacement needs to be reassessed
K Nevile et al Pediatrics Dec 2005
Rapid rehydration in moderate dehydration
Using:
½ NS 2.5% dextrose at rate of 20 ml/kg for 2 hrs. via I/V.
Gastrolyte at the same rate via N/G
It reduced admission and length of stay in E/D
SJ Phin J of Ped. And Child health July 2003
Telmesani Guidelines III
Telmesani Guidelines III
Resolve parents anxiety. Explain what is G/E. Use ORS, Zamzam, Water, De-carbonated
soda or Coconut water. Use small frequent oral fluids if vomiting. Use yogurt (better with probiotics). Start feed once able (antidiarrheal food)
Telmesani Guidelines III
In moderate dehydration and vomiting
Child/ anxious parents: NPO patient. Use the rapid rehydration (20 ml/kg/hr x 2
hrs). OR give twice maintenance x 2 hrs. Use ½ N.S (caution in adding k). Start ORT afterward as above.
Telmesani Guidelines III
Cautious and rare use of anti-emetics.
Do not use antidiarrheal agents