Ors indore pedicon 2014 workshop

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ORAL REHYDRATION SOLUTION,DIARRHEA,SAM

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Ors indore pedicon 2014 workshop

  1. 1. Dr. Rajesh Kulkarni Pune
  2. 2. India- the Pioneer Over 2,500 years ago, Indian physician Sushruta described the treatment of acute diarrhea with rice water, coconut juice and carrot soup.
  3. 3. IV fluids in Cholera  In 1831, William Brooke treated cholera patients with IV Fluids reducing mortality from 70 % to 40 %. IV fluid replacement became the standard of care for moderate/severe dehydration for over a hundred years.
  4. 4. INDIA AGAIN!! Late 1950’s: Dr Hemendranath Chatterjee 1971: Dr. Dilip Mahalanabis 350,000 treated with mortality of 0.36%
  5. 5. Na-Glucose co-transport In the early 1960s, Robert K. Crane discovered the sodium-glucose co-transport as the mechanism for intestinal glucose absorption. Around the same time, other scientists showed that the intestinal mucosa was not disrupted in cholera, as previously thought.
  6. 6. Importance Realized!!! 1978 – In recognition of the lives saved with ORT, The Lancet proclaims that “THE discovery that sodium transport and glucose transport are coupled in the small intestine, so that glucose accelerates absorption of solute and water, was potentially the most important medical advance this century.”
  7. 7. PRINICIPLE OF ORS The sodium-coupled co-transport with glucose and other carrier organic solutes remains intact, even with viral enteritis associated with epithelial damage .
  8. 8. Ingredient Standard WHO ORS mmol/l Reduced osmolarity ORS mmol/l (2002) Glucose 111 75 Na 90 75 K 20 20 Cl 80 65 Citrate 10 10 Osmolarity mOsm/kg 311 245
  9. 9. Limitation of high osmolarity ORS Does not lower volume, frequency and duration of diarrhoea. Induces vomiting due to taste, so acceptability poor. More chances of dehydration, more chances of requiring iv fluid. Hypernatremia. Good to correct fluid deficit, not good for maintenance fluid.
  10. 10. LOW OSMOLARITY ORS Compared to WHO standard ORS , hypo-osmolar ORS is associated with a) fewer unscheduled intravenous fluid infusions(33%) b)lower stool volumes (20%), and c) less vomiting(30%)
  11. 11. Clinical relevance - low osmolarity ORS Reduction in need of IV therapy results in reduced hospitalization and in turn results: Reduced risk of hospital acquired infections.  Reduced disruption of breastfeeding.  Reduced use of needles and interventions  Reduced therapy cost.  Reduced risk of diarrheal deaths in areas where IV therapy is not readily available.
  12. 12. Rice-based ORS, Maltodextrin-containing and Amino acid-containing ORS—SUPER ORS They are not superior to glucose-based ORS for acute non-cholera diarrhea, provided that feeding was promptly resumed after initial rehydration of the child.
  13. 13. Flavored/Colored ORS Studies showed neither an advantage nor disadvantage for the flavoured and coloured ORS when compared to the standard ORS with regard to safety, acceptability and correct use. Concerns about the type of sweetners ,coloring and flavouring agents used. More expensive
  14. 14. CASE STUDY Pinky 18 month old girl was brought by her mother to the OPD complaining of 4 episodes of loose stools without blood or mucus. On examination,Pinky is alert and playful.She weighs 12 kg. She does not have sunken eyes and her skin pinch goes back instantly. DIAGNOSIS AND MANAGEMENT
  15. 15. PLAN A After each loose stool and in between them give ORS Age <2 years 50 to 100 ml Age >2 years 100 to 200 ml Continue breastfeeding If not exclusively breastfed, give food based fluids(Soup, Rice water, Yoghurt drinks)
  16. 16. CASE STUDY Munna a 10 month old boy is brought by his mother to OPD with complaints of loose motions since 2 days,12-14 episodes in the last 24 hours. On examination his weight is 8 kg.When offered ORS,Munna drinks it eagerly.He is irritable and has sunken eyes. His skin pinch goes back slowly. DIAGNOSIS & TREATMENT
  17. 17. Some Dehydration If the child has two or more of the following signs, the child has some dehydration: restlessness/irritability thirsty and drinks eagerly sunken eyes skin pinch goes back slowly.
  18. 18. PLAN B In Clinic, give 75 ml/kg ORS over 4 hours If < 6 months and exclusively breastfed, also give extra 100 to 200 ml clear water over this period.
  19. 19. CASE STUDY Payal is a 14 months old girl weighing 10 kg. She is brought to the emergency department with complaints of 20-25 episodes of loose stools within the last 12 hours. On examination ,she is lethargic ,has sunken eyes and her skin pinch goes back very slowly. DIAGNOSIS AND MANAGEMENT
  20. 20. Severe Dehydrtion If any two of the following signs are present, severe dehydration is present lethargy or unconsciousness sunken eyes skin pinch goes back very slowly (2 seconds or more) not able to drink or drinks poorly.
  21. 21. PLAN C I.V. THERAPY POSSIBLE..GIVE RINGER LACTATE. AGE < 12 MONTHS 12 MONTHS TO 5 YEARS FIRST GIVE 30 ML/KG IN THEN GIVE 70 ML/KG IN ONE HOUR FIVE HOURS HALF HOUR TWO AND HALF HOURS
  22. 22. PLAN C IV THERAPY NOT POSSIBLE: ORAL OR NG TUBE ORS 20 ml/kg/hour for 6 hours (i.e. total 120 ml/kg over 6 hrs) Reassess Hourly If not better in 3 hours,IV therapy MUST be given(Refer)
  23. 23. Limitations Altered mental status with concern for aspiration Abdominal ileus Underlying disorder that limits intestinal absorption of ORT (e.g, short gut, carbohydrate malabsorption)
  24. 24. PRACTICAL PROBLEMS Vomiting: Give less amount more frequently,wait for 10 minutes and try again.Give food in the form of Kanji,Amylase rich food. Taste: It is a MEDICINE and the most important medicine in diarrhea. Convince the parents. First drug in your prescription. If affording, flavoured ORS may help.
  25. 25. ORS IV fluids Once ORT has been initiated, intervention with intravenous hydration is indicated: If stool output continues to be excessive, and ORT is unable to adequately rehydrate the child If there is severe and persistent vomiting, and inadequate intake of ORS
  26. 26. WHO Statement 2006: The World Health Organization states that, “there is no evidence to support the ongoing use of IV therapy for the first-line management of most cases of childhood gastroenteritis.”
  27. 27. CASE STUDY-special scenario Roshan is a 14 month old boy.He was brought to the hospital with a history of loose stools since one day 67 episodes. His weight is 6 kg , mother gives h/o faulty feeding since 5 months of age.(SAM) He has sunken eyes and his skin pinch goes back slowly. Peripheral pulses are palpable and sensorium is normal DIAGNOSIS AND MANAGEMENT
  28. 28. DIAGNOSIS AND MANAGEMENT SAM with AGE with dehydration without shock. (History very important) NO IV Rehydration, manage with ReSoMal or low osmolarity ORS(in 1 litres) with added potassium 20mmol/L .(IAP 2006) How often to give ORS Amount to give Every 30 minutes for first 2 hours 5ml/kg Alternate hours for up to 10 hours 5-10 ml/kg
  29. 29. CASE STUDY Anita is a 14 month old girl. She was brought to the hospital with a history of loose stools since one day 67 episodes. Her weight is 6 kg, mother gives h/o faulty feeding since 5 months of age.(SAM) She has sunken eyes and her skin pinch goes back very slowly. She is lethargic and her peripheral pulses are very feeble . DIAGNOSIS AND MANAGEMENT
  30. 30. Preventing and Treating Diarrhea
  31. 31. RESOMAL COMPOSITION Water 2 litres WHO-ORS One 1-litre packet*  Sucrose 50 g  Electrolyte/mineral solution** 40 ml (* 3.5 g sodium chloride, 2.9 g trisodium citrate dihydrate, 1.5 g potassium chloride, 20 g glucose). ** If this cannot be made up, use 45 ml of KCl solution (100 g KCl in 1 litre of water) instead.
  32. 32. Electrolyte/mineral solution-COMPOSITION  Potassium chloride: KCl 224 gm 24 mmol/20 ml Tripotassium citrate 81gm, 2 mmol/20 ml Magnesium chloride: MgCl2.6H2O 76gm, 3 mmol/20 ml Zinc acetate: Zn acetate.2H20 8.2gm, 300 µmol/20 ml Copper sulfate: CuSO4.5H2O 1.4gm, 45 µmol/20 ml Water: make up to 2500 ml If available, also add selenium (0.028 g of sodium selenate, NaSeO4.10H20) and iodine (0.012 g of potassium iodide, KI) per 2500 ml.
  33. 33. WHO ALTERNATIVE TO RESOMAL 2 LITRES WATER 1 PACK LOW OSMOLARITY ORS 45 ml Potassium Chloride solution(from stock solution containing 100 gm KCL/Litre) 50 gm Sucrose

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