management of dehydration and special issues abdulwahab telmesani frcpc, faap umm al-qura university

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?


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 at the primary health care centers

By PHCC Physicians

Who is our target patient?

?


Previously well baby or child who has diarrhea with mild- moderate

dehydration


NOT

Renal failure, cardiac patients, severely malnourished baby, toxic, etc.

Degree of Dehydration

Assess the degree of dehydration


Mild dehydration (3-5%)

Moderate dehydration (7-10%)

Sever dehydration (10-15%)


Mild dehydration (3-5%) -Normal P/E,

-Normal or increased pulse rate

-Decreased U/O and

-Thirsty


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.


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


Less Controversial


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


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


We strongly discourage their use in acute childhood diarrhea

P Tarr et. al. Canad. Med Asso. J.

Apr. 1999

Probiotics and Diarrhea

Ample Evidence


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


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


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.


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


Intended to aid doctors in recognizing children who need admission for

observation and treatment and those who may safely go home


A. Differential diagnosis of child presenting with diarrhea:

(Intussusception, surgical abdomen, hemolytic uremic syndrome)

Look for Red Flags


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


B. Estimation of severity of dehydration:

Mild dehydration (3-5%) Moderate dehydration (7-10% Sever dehydration (10-15%)


C. Blood Tests:

It is thus unnecessary to measure electrolytes in those children who will be rehydrated with ORS.


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.


E. Composition of ORS (UK):

Na 60 mmol/l

K 20 mmol/l

Glucose 74-111 mmol/l


F. Maintenance of hydration:

* Allow free fluids.

* Encourage drinking more than usual.


G. Refeeding following rehydration:

* Brest fed infant should continue.

* Formula should be restarted as soon as

the child is rehydrated (HRs.)


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


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


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)


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.


Cautious and rare use of anti-emetics.

Do not use antidiarrheal agents

management of dehydration and special issues abdulwahab telmesani frcpc, faap umm al-qura university

Documents

mmoll slide

degree of dehydration

mlkg slide

aap slide

hr slide

mortality slide

thirsty slide

lancet slide