in actue diarrhea university of cape town急性腹泻的补液开普顿大学课件

Rehydration in acute diarrhea Jorge Amil Dias Porto, Portugal jamildiaszonmail.pt 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 Stool electrolyte losses InfectionStool sodium Cholera88.9 mMol/L ETEC53.7 mMol/L Rotavirus37.2 mMol/L AM Molla et al. J Pediatr 1981 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 1960s Identification of glucose-solute co-transport 1971 WHO recommended the use of ORS intestinal sodium co-transport “Oral rehydration is potentially the most important medical advance in the 20th century” Lancet, 1978 Is This Child Dehydrated? 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? 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? 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 Urine output General appearance Capillary refill Skin turgor Eyes Mucous membranes Tears Respiratory rate Heart rate (3” = iv resuscitation!) Blood electrolytes? 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 Shock Severe dehydration (9% of body weight) Neurological abnormalities (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 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 Lower osmolality increases water absorption (osmolar gradient) Hypertonic solutions (old WHO-ORS, Na+90 mmol/l) may increase the risk of hypernatremia Current WHO (Na 75mmol/l) has a balanced composition that is safe both for cholera and non- cholera diarrhoea Composition of WHO ORS grams/litremmol/litre Sodium chloride2.6Sodium75 Glucose, anhydrous13.5Chloride65 Potassium chloride1.5Glucose, anhydrous75 Trisodium citrate Potassium20 dihydrate2.9Citrate10 Total Osmolarity245 Soft drinks BrandAQUARIUSGATORADENESTEA COCA- COLA PEPSI- COLA SPRITE FANTA ORANGE Na (mEq/L)1323.5106586 K (mEq/L)150.5% 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 duration of diarrhoea 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 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 H2O Na+ Instruct caregivers for: Ongoing vomiting 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