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ACUTE GASTROENTERITIS
AND FLUID MANAGEMENT
BROUGHT TO YOU BY PAEDIATRIC TEAM SPONSORED BY Dr F. Mokgoadi
Presentation outline
• Introduction and Epidemiology
• Aetiology
• Pathophysiology
• Signs and symptoms
• Work-up includin...
Definitions and Terms:
Acute Gastroenteritis (AGE): diarrheal disease of rapid
onset, with or without accompanying symptom...
Diarrhea
• Acute: short in duration of < 7 days
• Persistent diarrhea: starts acutely and lasts longer than 1 week
Epidemiology
• One of the most common illness of infancy
• Second to respiratory illness as a cause of childhood deaths WW...
Aetiologies
• AGE is a clinical syndrome produced by a variety of Viral, Bacterial and
Parasitic enteropathogens.
• AGE is...
Causes of acute diarrhoea in infancy and
childhood
Non-enteric causes:
 otitis media. Meningitis, sepsis generally
Non-...
Common infectious causes of AGE
Viral
Rotavirus
Enterovirus, Calicivirus
Adenovirus, Astrovirus
Bacterial
E.Coli, Shigella...
parasitic
• Entamoeba Hystolitica
• Giardia lamblia
• Cryptosporidium
Aetiolgy cont
• Rotavirus is known to be the most common pathogen in children
• It is more severe than other causes and mo...
Pathophysiology
The 2 primary mechanisms
(1) Damage to the villous brush border of the
intestinemalabsorption of intestin...
Pathophysiology
• Rotavirus attach and enter mature enterocytes at the tip of the small
intestinal villi
• Cause structura...
Sign & Symptoms
• Nausea & Vomiting
• Diarrhea
• Loss of appetite
• Fever
• Headaches
• Abdominal pain
• Abdominal cramps
...
• Vomiting is largely attributed to local factors and poor gastric
emptying, and should not be treated with antiemetic dru...
clinical assessment of Hydration
• Recognize poor perfusion and other signs of shock
• Cold peripheries
• Depressed LOC
• ...
Work-up
• After resuscitation, in children with severe dehydration, shock or
other signs of metabolic, nutritional or othe...
Electrolyte disturbances
• Large amounts of Sodium are lost in diarrheal stools
• In acidosis, a shift of intracellular po...
Fluid and electrolyte management
First treat SHOCK if present
• Always SHOUT for HELP
• A…….B…..
• Circulation
• Establish vascular access or IO if failed ...
Treating Shock in severely Malnourished
• ABC still as essential as the normally nourished patients
• Give 15ml/kg infusio...
Rehydration fluids
• Its NB to use solutions with sufficient Na conc. To prevent Hyponatremia
• ½ DD is appropriate if IV ...
Maintenance fluids
• Should be given enterally wherever possible but intravenously where
nil per Os is absolute
• Fluid re...
Never forget the ongoing losses
• Losses need to be replaced by equal volumes of fluids of similar
composition
• For moder...
What else might help?
• Zinc: reduces the duration and severity of diarrhea
• Antimotility agents like loperamide are C/I ...
Electrolyte abnormalities
• Hypokalemia (<3): even when the serum K conc. Is normal, these
patients have a depletion of th...
Hypokalemia
K<2>1.5
• Attach ECG: prolonged QT and Flat
T waves
• Give stat doses as previous slide
• Oral KCl: 100mg/kg 6...
Hyponatremia Na<135mmol/l
Mild symptomatic (120-130)
• Evaluate pt: if euvolemic,
manage underlying illness
• Dehydrated: ...
©2011 MFMER | slide-28
References
• Handbook of Paediatrics 7th edition pg 121-129, 461-481
• Std Rx guidelines and Essential Medicines List 2013...
©2011 MFMER | slide-30
Anyone Ophidiophobic?
©2011 MFMER | slide-31
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Acute gastroenteritis and fluid management

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Acute Gastroenteritis by Dr Maila

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Acute gastroenteritis and fluid management

  1. 1. ACUTE GASTROENTERITIS AND FLUID MANAGEMENT BROUGHT TO YOU BY PAEDIATRIC TEAM SPONSORED BY Dr F. Mokgoadi
  2. 2. Presentation outline • Introduction and Epidemiology • Aetiology • Pathophysiology • Signs and symptoms • Work-up including Classification • Management • Fluid and Electrolytes • Feeding and Nutrition • Prevention
  3. 3. Definitions and Terms: Acute Gastroenteritis (AGE): diarrheal disease of rapid onset, with or without accompanying symptoms, signs, such as nausea, vomiting, fever, or abdominal pain Diarrhea: the frequent passage of unformed liquid stools (3 or more loose, watery stool per day) Dysentery: blood or mucus in stools
  4. 4. Diarrhea • Acute: short in duration of < 7 days • Persistent diarrhea: starts acutely and lasts longer than 1 week
  5. 5. Epidemiology • One of the most common illness of infancy • Second to respiratory illness as a cause of childhood deaths WW • It represents a major cause of morbidity and mortality • 3-10 episodes of diarrhea/year/subject in children <5 yrs and decreases to < 1 for children >5 • Deaths are usually a result of dehydration but malnutrition plays an important role as it increases the incidence and severity of diarrhea • By 3 years, virtually all children become infected by the most common agent
  6. 6. Aetiologies • AGE is a clinical syndrome produced by a variety of Viral, Bacterial and Parasitic enteropathogens. • AGE is almost entirely caused by infections acquired through fecal- oral route, but ingestion of contaminated food or water also plays a role • We have: Non-enteric, Non-infectious and Infectious causes of the Gastro-intestinal tract • Episodes usually last 5-10 days
  7. 7. Causes of acute diarrhoea in infancy and childhood Non-enteric causes:  otitis media. Meningitis, sepsis generally Non-infectious causes: milk/food allergies, drug side effects, malabsorption Infections of the gastrointestinal tract Viral Bacterial Protozoal
  8. 8. Common infectious causes of AGE Viral Rotavirus Enterovirus, Calicivirus Adenovirus, Astrovirus Bacterial E.Coli, Shigella Salmonella, Campylobacter C.difficile, V. Cholera
  9. 9. parasitic • Entamoeba Hystolitica • Giardia lamblia • Cryptosporidium
  10. 10. Aetiolgy cont • Rotavirus is known to be the most common pathogen in children • It is more severe than other causes and more often results in dehydration, Hospitalization, Shock, Metabolic disturbances and Death • Bacterial pathogens are more common where poor sanitation, hygiene and water supply play a role causing dysenterey
  11. 11. Pathophysiology The 2 primary mechanisms (1) Damage to the villous brush border of the intestinemalabsorption of intestinal contents an osmotic diarrhea (2) Release of toxins that bind to specific enterocyte receptorsrelease of chloride ions into the intestinal lumensecretory diarrhea
  12. 12. Pathophysiology • Rotavirus attach and enter mature enterocytes at the tip of the small intestinal villi • Cause structural changes to the bowel mucosa, including villous shortening and mononuclear inflammatory infiltrates in the lamina propria • This virus induce maldigestion of carbohydrates and their accumulation in the intestinal lumen (in the absence of lactase) • Malabsorption of nutrients and concomitant inhibition of water reabsorption can lead to a malabsorption component of diarrhea • Rotavirus secretes an enterotoxin, NSP4 which leads to a calcium- dependent chloride secretory mechanism
  13. 13. Sign & Symptoms • Nausea & Vomiting • Diarrhea • Loss of appetite • Fever • Headaches • Abdominal pain • Abdominal cramps • Bloody stools • Dehydration • Lethargic
  14. 14. • Vomiting is largely attributed to local factors and poor gastric emptying, and should not be treated with antiemetic drugs • Abdominal pains are usually spasmodic due to disordered motility or is associated with colitis in dysentery • Diarrhea is the manifestation of secretion or absorption disturbance and disordered motility, a symptom of damage already done in the infected gut.
  15. 15. clinical assessment of Hydration • Recognize poor perfusion and other signs of shock • Cold peripheries • Depressed LOC • Increase capillary refill time (>3sec) • Poor/weak peripheral pulses • Reduced urine-output • signs of dehydration.docx
  16. 16. Work-up • After resuscitation, in children with severe dehydration, shock or other signs of metabolic, nutritional or other co-morbidities • Electrolytes and serum acid base determination • All severely dehydrated patients, mod dehydration with an atypical presentation, malnourished children • Blood glucose disturbances occur in severely ill patients as a result of glycogen depletion with lack of intake, or associated with the stress response of dehydration
  17. 17. Electrolyte disturbances • Large amounts of Sodium are lost in diarrheal stools • In acidosis, a shift of intracellular potassium to EC compartment results in a spurious elevation of the serum level despite intracellular potassium loss • Give K+ to all patients with severe diarrhea until dehydration and acidosis are corrected • Sodium disturbances occur frequently • Sodium content of the stool water varies from plasma-like in secretory diarrhea , to very low in pure Osmotic diarrhea
  18. 18. Fluid and electrolyte management
  19. 19. First treat SHOCK if present • Always SHOUT for HELP • A…….B….. • Circulation • Establish vascular access or IO if failed venous access after 2 good attempts • Give 20ml/kg of R/L or Normal Saline rapid infusion or 5ml/kg in aliquots X4 is much safer • Watch for signs of circulatory overload i.e hepatomegaly, gallop rhythm or basal crackles, puffiness of the eyelids, tachy-pnoea and –cardia. • Repeat R/L 20ml/kg if patient is still shocked. Re-assess and give more if still shocked • Don’t-Ever-Forget-Glucose • Re-assess ABC and response so far • Give 1st dose Ceftriaxone 80mg/kg stat to cover sepsis
  20. 20. Treating Shock in severely Malnourished • ABC still as essential as the normally nourished patients • Give 15ml/kg infusion over 30 minutes • Re-assess and repeat if still shocked • Give up to 4 boluses and thereafter, T/F to HC or ICU • Patient response should guide further fluid therapy • When shock has been treated successfully, proceed to the management of dehydration. • But remember your patient can go back into shocked if improperly rehydrated
  21. 21. Rehydration fluids • Its NB to use solutions with sufficient Na conc. To prevent Hyponatremia • ½ DD is appropriate if IV route is used, or ORS for enteral replacements • Where vomiting is the main source of fluid loss, rehydration fluid (0.45%NaCl and 5% Dextrose) with added K is appropriate • Dose of ½ DD or ORS for rapid rehydration over 4 hours • Some Dehydration: 50ml/kg over 4 hrs (12.5ml/kg/hour) • Severe Dehydration: 100mls/kg/4hours (25mls/kg./hour) • Rapid rehydration over 4hrs should not be used in severe malnutrition, cardiac failure, severe pneumonia, encephalopathy etc. • However, rehydrate over 24hours or even 48 hours • APPROPRIATE RESPONSE AT 4.docx • Severely malnourished have a deficient K and elevated Na levels, thus require a special ORS: ReSolMal
  22. 22. Maintenance fluids • Should be given enterally wherever possible but intravenously where nil per Os is absolute • Fluid restriction to approximately 50-60% of maintenance should be adhered to, where there is a risk of inadequate secretion e.g in Renal failure • NORMAL MAINTENANCE FLUID REQUIREMENTS.docx
  23. 23. Never forget the ongoing losses • Losses need to be replaced by equal volumes of fluids of similar composition • For moderate losses, add 30mls/kg to maintenance requirements. But give more if there’s a need • For those taking enterally: • <2years: 50-100mls AELS • >2years: 100-200mls AELS • Small frequent volumes of home based sugar salt solution as little as 5mls every minute, can be effective in preventing dehydration even in vomiting cases • Continue Breast feeding and oral feeding once perfusion is restored
  24. 24. What else might help? • Zinc: reduces the duration and severity of diarrhea • Antimotility agents like loperamide are C/I due to potentially serious side effects (malignant hyperpyrexia, lethargy and dystonia) • Vit A: reduces the severity of diarrhea, but do not give if a dose was given in the previous month • All children with diarrhea get vit A and Zinc according to age • Other drugs, Any use?
  25. 25. Electrolyte abnormalities • Hypokalemia (<3): even when the serum K conc. Is normal, these patients have a depletion of the total body potassium • Plasma k level doesn’t always provide an accurate est of total body deficit. There may be K shift from intracellular space to the plasma. • <3mmol/l: stat dose oral K <5kg= 250mg. 5-10kg=500mg and >10kg=1g stat • Ongoing losses: < 5kg: 125mg, 5-10kg:250mg and >10kg: 500mg tds • Re-assess after 4 hours • Stop when abnormal losses stop
  26. 26. Hypokalemia K<2>1.5 • Attach ECG: prolonged QT and Flat T waves • Give stat doses as previous slide • Oral KCl: 100mg/kg 6hrly with max dose 3g/day • Plus IV correction • Add to iv fluids (200mls): ½ DD=2ms 15%KCl, Saline=4mls 15%KCl • Recheck in 4hrs and manage accordingly K<1.5: paralysis, muscle weakness,apnoea • Admit to HC/ICU • Give stat dose accordingly • Oral K: 100mg/kg 6hrly • Plus IV correction • If ICU: 0.3mml/kg in 50mls N saline via C.Vein over 1hour • Recheck in 2hours • Manage ongoing losses and replacement
  27. 27. Hyponatremia Na<135mmol/l Mild symptomatic (120-130) • Evaluate pt: if euvolemic, manage underlying illness • Dehydrated: rehydrate over 24- 48 hours • Recheck electrolytes 4hourly, manage ongoing losses Severe symptomatic (<120) • ABC • Stop seizures (iv phenobarb 10mg/kg) • Single dose Hypertonic saline infusion over 1 hour (formula) • 4ml/kg 3% saline • Re-check electrolytes in 1 hour • Manage on-going losses
  28. 28. ©2011 MFMER | slide-28
  29. 29. References • Handbook of Paediatrics 7th edition pg 121-129, 461-481 • Std Rx guidelines and Essential Medicines List 2013 (Dept ofHealth) pg 2.9-2.17 • Gastroenteritis presentation by Prof T Rogers Dept of Clinical Microbiology • South African medical journal, vol 102,no.2 2012 (Management guidelines for Acute infective diarrhea in infants) prof F Wittenburg • Acute gastroenteritis in children by Dr Alta Terblanche, Professional Nursing Today 2010
  30. 30. ©2011 MFMER | slide-30 Anyone Ophidiophobic?
  31. 31. ©2011 MFMER | slide-31

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