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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
Sunken eyesSunken eyes
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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
Sunken eyesSunken eyes
Skin fold retraction prolonged >1 secSkin fold retraction prolonged >1 sec
Restless and irritableRestless and irritable
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Management of Some DehydrationManagement of Some Dehydration
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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Management of Some DehydrationManagement of Some Dehydration
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
Sunken eyesSunken eyes
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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Oral rehydration solutionOral rehydration solution
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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Oral rehydration solutionOral rehydration solution
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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