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  1. 1. infantile diarrhea
  2. 2. Etiology Pathogenesis Clinical manifestations Diagnosis Treatment Differential diagnosis diarrhea
  3. 3. Definition <ul><li>Infantile diarrhea is syndrome caused </li></ul><ul><li>by multi-pathogens & multifactor. </li></ul><ul><li>Abnormally fluid content in the stool </li></ul><ul><li>It is easily complicated: </li></ul><ul><li>disturbances of water electrolyte and </li></ul><ul><li>acid- base balance </li></ul><ul><li>It can be classified </li></ul><ul><li>infectious non-infectious </li></ul>
  4. 5. Etiology <ul><li>Predisposing factors </li></ul><ul><li>Infectious factors </li></ul>1. Immature digestive function and rapid growth 2. Poor host defenses 3. Formula feeding 1. Intraintestinal infections 2 . Extraintestinal infections 1. Dietary factors 2. Weather factors Non-infectious factors
  5. 6. morbidity constituent ratio < 1y 38.65% 1- 2y 32.29% Etiology
  6. 7. Low gastric acidity the ability killing pathogens Low activity of digestive enzymes digestive ability Rapid growth nutrient requirements overburden in gastrointestinal tract Predisposing factors Immature digestive function and rapid growth
  7. 8. Poor host defenses <ul><li>IgM resistance to the infection of </li></ul><ul><li>gram-negative bacilli </li></ul><ul><li>SIgA resistance to the local infection </li></ul><ul><li>Newborn infants have not acquired normal </li></ul><ul><li>enteric flora </li></ul><ul><li>Prolonged administration of antibiotics </li></ul><ul><li>a shift in their balance </li></ul>Predisposing factors
  8. 9. <ul><li>Very few microbes are </li></ul><ul><li>always pathogenic </li></ul><ul><li>Many microbes are </li></ul><ul><li>potentially pathogenic </li></ul><ul><li>Most microbes are </li></ul><ul><li>never pathogenic </li></ul>Microbes and humans
  9. 10. Formula feeding <ul><li>Have much more opportunities for contamination </li></ul><ul><li>Some useful agents (C3,C4, lysozyme, lysosome, </li></ul><ul><li>lactoferrin and some cells ) </li></ul><ul><li>which breast milk contains are less or have been </li></ul><ul><li>destroyed in animal milk after heating </li></ul>Predisposing factors Bottle-fed babies are more predisposed to diarrhea
  10. 11. Intraintestinal infections(enteritis) <ul><li>Viruses: (70%) Rotavirus etc. </li></ul><ul><li>Bacteria: Escherichia coli (E.coli), etc. </li></ul><ul><li>Fungi: Candida albicans, etc. </li></ul><ul><li>Protozoa: Entamoeba histolytic, etc. </li></ul>Infectious Factors
  11. 12. <ul><li>The infectious diarrhea dose not include that having legal name such as bacillary dysentery, cholera </li></ul><ul><li>Diarrhea caused by other infectious agents and unknown pathogens may all be named “ enteritis” and should be defined with the name of the specific pathogen. </li></ul><ul><li>Such as enteropathogenic E. Coli. enteritis, rotavirus enteritis. </li></ul>
  12. 13. <ul><li>Viruses Bacteria Parasites fungi </li></ul><ul><li>Rotavirus Salmonella species Giardia lamblia candida </li></ul><ul><li>albicans </li></ul><ul><li>Adenovirus Shigella species Cryptosporidium parvum </li></ul><ul><li>Nowalk agent Escherichia coli Entamoeba histolytica </li></ul><ul><li>Campylobacter jejunis </li></ul><ul><li>torovirus, Yersinia enterocolitica </li></ul><ul><li>Calcivirus Vibrio cholerae </li></ul><ul><li>Astrovirus Aeromonas hydrophilia </li></ul><ul><li>Plegiomonas shigelloides </li></ul>Common infectious etiologic agents of acute gastroenteritis
  13. 14. rotavirus
  14. 15. Infection from E. coli - 5 Groups <ul><li>Enteropathogenic E.coli - (EPEC) </li></ul><ul><li>Enterotoxigenic E. coli - (ETEC) </li></ul><ul><li>Enteroinvasive E. coli - (EIEC) </li></ul><ul><li>Enterohemmorhagic E. coli - (EHEC) </li></ul><ul><li>Enteroadherent aggregative </li></ul><ul><li>E. coli - (EAEC) </li></ul>
  15. 16. Enterohemorrhagic E. coli O157:H7 Blood stool Abdominal cramps fever Transmission electron micrograph
  16. 17. Shigella sonnei
  17. 18. Salmonella
  18. 20. Entamoeba histolytica
  19. 21. Candida albicans
  20. 22. Extraintestinal infections Otitis media Upper respiratory infection Meningitis Pneumonia Urinary infection Cutaneous infection etc . diarrhea vomiting Infectious Factors
  21. 23. Dietary factors <ul><li>Feeding conditions causing diarrhea </li></ul><ul><li>among infants: </li></ul><ul><li>Excess or irregular feeding. </li></ul><ul><li>Sudden alteration of diet. Feeding </li></ul><ul><li>starch or fat too early, changing food </li></ul><ul><li>or weaning suddenly. </li></ul><ul><li>Allergy to cow’s milk or disaccharidase </li></ul><ul><li>deficiency. </li></ul>Non-infectious Factors
  22. 24. Weather factors <ul><li>A cool environment increased </li></ul><ul><li>bowel peristalsis </li></ul><ul><li>A hot environment digestive juices </li></ul><ul><li>drink excess milk </li></ul>Non-infectious Factors
  23. 25. Pathogenesis <ul><li>Osmotic diarrhea </li></ul><ul><li>Secretory diarrhea </li></ul><ul><li>Exudative diarrhea </li></ul><ul><li>Abnormal motility </li></ul>It is important to note that more than one mechanism may coexist. For example, in infectious and inflammatory conditions, malabsorption leading to osmotic diarrhea and active secretion can coexist.
  24. 26. Osmotic diarrhea <ul><li>unabsorbable or poorly absorbable solute that exerts an osmotic pressure effect across the intestinal mucosa, resulting in excessive water output. </li></ul><ul><li>Causes Dietary factors </li></ul>Viral enteritis Pathogenesis
  25. 27. Secretory diarrhea <ul><li>Abnormal ion transport across the intestinal epithelial cells, which results in increased secretion, decreased absorption, or both. </li></ul><ul><li>A classic example </li></ul><ul><li>enterotoxigenic E coli (ETEC ). </li></ul>Pathogenesis
  26. 28. Exudative diarrhea <ul><li>Pathogens invade and multiply within </li></ul><ul><li>intestinal mucosa with inflammatory changes </li></ul><ul><li>Leak of blood, fluid, pus </li></ul><ul><li>Impairment of absorption </li></ul><ul><li>Causes enteroinvasive E.coli(EIEC), </li></ul><ul><li>Shigella, Salmonella </li></ul>Pathogenesis
  27. 29. Abnormal motility <ul><li>Enhanced motility </li></ul><ul><li>resulting in rapid gut transit and </li></ul><ul><li>decreased contact time between luminal </li></ul><ul><li>contents and absorptive epithelial cells </li></ul><ul><li>Slow motility </li></ul><ul><li>may result in bacterial overgrowth </li></ul>Pathogenesis
  28. 30. <ul><li>Bacterial enteritis </li></ul><ul><li>Enterotoxin Bacteria invasive intestinal </li></ul><ul><li>mucosa </li></ul><ul><li>Heat-intolerant Heat-resistant </li></ul><ul><li>Enterotoxin enterotoxin </li></ul><ul><li>Adenyl cyclase Guanyl cyclase Congestion, dropsy, ulcer </li></ul><ul><li>cAMP↑ cGMP↑ </li></ul><ul><li>Na+ Cl- H 2 O↑ </li></ul><ul><li>Small intestine juice secrete↑ Stool </li></ul><ul><li>(blood, mucus shreds, pus) </li></ul><ul><li>Diarrhea </li></ul>Pathogenesis of Bacterial enteritis
  29. 31. Carbohydrate decomposition & absorption disorder Shedding of epithelial cells on intestine mucous membrane, intestinal villus shortening Intestinal lactic acid ↑ Intestinal Na + & glucose ↑ Disaccharidase activity ↓ Watery diarrhea Na + , glucose coupling transporter disorder Na + , glucose absorption disorder Reabsorbed water-electrolyte ↓ Pathogenesis of Viral Enteritis Virus particles Microvillares epithelial cells on Small intestine mucous membrane Intestines osmotic pressure↑
  30. 32. Pathogenesis of Noninfectious Diarrhea Improper diet Gastric gathered food , less gastric acid, lower intestinal bacteria up-moving & propagation Decomposition producing Amines ↑ Bacteria & toxicity products short chain organic acid Intestinal osmotic Portal vein system pressure↑ Enterokinesia↑ entering blood circulation Osmotic diarrhea Toxicosis symptom (endogenous infection)
  31. 33. <ul><li>Classified by course </li></ul><ul><li>   Acute infantile diarrhea: <2 weeks </li></ul><ul><li>   Persisting infantile diarrhea: </li></ul><ul><li>2 weeks~2 months </li></ul><ul><li>Chronic infantile diarrhea: >2 months </li></ul>Clinical manifestations
  32. 34. Clinical manifestations GI symptoms Systemic toxic symptoms Disturbances in water, electrolyte, and/or acid-base balances Acute Diarrhea
  33. 35. Gastrointestinal symptoms <ul><li>Other GI symptoms </li></ul>Frequent stools: loose, watery, with pus,mucus, blood ,undigested food Microscopic findings: WBC, RBC, fatty particles Anorexia, nausea, vomiting, abdominal pain and distention Clinical Manifestations Diarrhea
  34. 36. Clinical manifestations Systemic toxic symptoms Abnormal temperature Irritability, lethargy, coma Acute Diarrhea
  35. 37. Water and electrolyte disturbances <ul><li>The most important evidences to distinguish severe diarrhea from mild </li></ul><ul><li>The usual causes of death in gastroenteritis </li></ul><ul><li>The correction of them is the fundamental aim of treatment of diarrhea </li></ul><ul><li>They include: </li></ul>Dehydration Metobolic acidosis Hypokalemia Hypocalcemia and Hypomagnesemia Clinical Manifestations
  36. 38. Characteristics of some specific enteritis <ul><li>Non-infectious diarrhea : </li></ul><ul><li>The patient mainly presents the gastrointestinal symptoms without or with mild systemic symptoms and water-electrolyte disturbances </li></ul><ul><li>The stools may contain mucus, froth, or undigested food, but have no pus or blood . Microscopic findings can be negative or only fatty particles. </li></ul>
  37. 39. <ul><li>Infectious diarrhea </li></ul><ul><li>Often associated with obvious systemic symptoms and water-electrolyte disturbance in addition to gastrointestinal symptoms </li></ul>Characteristics of some specific enteritis
  38. 40. Infectious diarrhea <ul><li>Invasive bacterial enteritis </li></ul><ul><li>dysentery-like symptoms: frequent stools </li></ul><ul><li>with mucus, pus and blood. </li></ul><ul><li>Microscopic findings of stools are a </li></ul><ul><li>number of leukocytes and erythrocytes. </li></ul>Characteristics of some specific enteritis
  39. 41. Infectious diarrhea <ul><li>Enterotoxigenic bacterial diarrhea or viral diarrhea </li></ul>stools are often frequent, profuse and watery. Dehydration, electrolyte disturbances and acidosis can develop rapidly. No cells or a little leukocytes can be found under microscopy of the stool. Characteristics of some specific enteritis
  40. 42. <ul><li>Candida albicans enteritis </li></ul><ul><li>occurs predominantly in infants under 2y and </li></ul><ul><li>with protracted use of antibiotics who have a </li></ul><ul><li>disturbed enteric bacterial flora. </li></ul><ul><li>The patient often has also thrush. </li></ul><ul><li>The stools often have mucus and much froth, </li></ul><ul><li>candidal filament may be seen under microscope. </li></ul>Characteristics of some specific enteritis Infectious diarrhea
  41. 43. muguet (mycotic stomatitis)
  42. 44. Rotavirus enteritis <ul><li>Pathogen: Human rotavirus (HRV). </li></ul><ul><li>Predisposing age: 6 - 24 months. </li></ul><ul><li>Predisposing seasons: autumn and winter. </li></ul><ul><li>Suddenly onset with low-grade fever and </li></ul><ul><li>symptoms of common cold, no obvious toxic </li></ul><ul><li>symptoms. </li></ul>Characteristics of some specific enteritis
  43. 45. <ul><li>Vomiting usually precedes diarrhea. The diarrhea is </li></ul><ul><li>typically acute in onset and generally watery in </li></ul><ul><li>character, frequent and in large amount, odorless. </li></ul><ul><li>It is usually associated with dehydration which is </li></ul><ul><li>usually isotonic and associated with electrolyte, </li></ul><ul><li>acid-base disturbance. </li></ul><ul><li>It is a self-limited disease, the clinical illness </li></ul><ul><li>generally lasts for 3-8 days </li></ul>Rotavirus enteritis Characteristics of some specific enteritis
  44. 46. <ul><li>Organism Incubation Duration Vomiting Fever Abdominal Pain </li></ul><ul><li>Rotavirus 1-7 d 3-8 d Yes Low No </li></ul><ul><li>Adenovirus 8-10 d 5-12 d Delayed Low No </li></ul><ul><li>Norovirus 1-2 d 2 d Yes No No </li></ul><ul><li>Astrovirus 1-2 d 4-8 d +/- +/- No </li></ul><ul><li>Calicivirus 1-4 d 4-8 d Yes +/- No </li></ul><ul><li>Aeromonas </li></ul><ul><li>Species None 0-2 wk +/- +/- No </li></ul><ul><li>Campylobacter </li></ul><ul><li>Species 2-4 d 5-7 d No Yes Yes </li></ul><ul><li>Entamoeba </li></ul><ul><li>species 5-7 d 1-2+ wk No Yes No </li></ul>Organisms and Frequency of Symptoms
  45. 47. <ul><li>Organism Incubation Duration Vomiting Fever Abdominal Pain </li></ul><ul><li>Enterohemorrhagic </li></ul><ul><li>E coli 1-8 d 3-6 d No +/- Yes </li></ul><ul><li>Enterotoxigenic </li></ul><ul><li>E coli 1-3 d 3-5 d Yes Low Yes </li></ul><ul><li>Salmonella </li></ul><ul><li>Species 0-3 d 2-7 d Yes Yes Yes </li></ul><ul><li>Shigella </li></ul><ul><li>Species 0-2 d 2-5 d No High Yes </li></ul><ul><li>Vibrio </li></ul><ul><li>species 0-1 d 5-7 d Yes No Yes </li></ul><ul><li>Giardia </li></ul><ul><li>Species 2 wk 1+wk No No Yes </li></ul><ul><li>Campylobacter </li></ul><ul><li>Species 2-4 d 5-7 d No Yes Yes </li></ul><ul><li>Cryptosporidium </li></ul><ul><li>species 5-21 d Months No Low Yes </li></ul>Organisms and Frequency of Symptoms
  46. 48. Dehydration <ul><li>Clinical features of dehydration </li></ul><ul><li>Degrees of dehydration </li></ul><ul><li>Types of dehydration </li></ul>Clinical Manifestations Water and electrolyte disturbances
  47. 49. Higher metabolic rates Increased body surface area to mass index Higher body water contents (water comprises approximately 70% of body weight in infants, 65% in children, 60% in adults) Young pediatric patients tend to be more susceptible to fluid losses a quick turnover of fluids and solute
  48. 50. Normal routes of fluid excretion in infants and children. Lungs Skin Urine & feces insensible water losses
  49. 51. <ul><li>Sudden weight loss </li></ul><ul><li>Changes in activity level </li></ul><ul><li>(restless, lassitude, lethargy, coma) </li></ul><ul><li>Thirst and dry mouth </li></ul><ul><li>Sunken eye sockets and tearless </li></ul><ul><li>Sunken anterior fontanel ( infant) </li></ul><ul><li>Dry skin and poor skin turgor </li></ul><ul><li>Decreased urination (Oliguria) </li></ul><ul><li>Severe cases: poor peripheral circulation </li></ul><ul><li>( prolonged capillary refill time) or even shock </li></ul>Dehydration
  50. 52. Clinical features of dehydration in an infant prolonged
  51. 53. Loss of Skin Elasticity
  52. 54. Degrees <ul><li>According to weight loss: </li></ul>Dehydration 100~120 50~100 50 Volume deficit (ml/kg) >10% 5%~10% <5% Weight loss (% of BW) severe moderate mild Extent
  53. 55. Degrees According to the severity of the symptoms and signs The key point to distinguish severe cases from mild and moderate ones is poor peripheral circulation and even shock. Dehydration
  54. 56. Dehydration 5-10% Slight sunken
  55. 57. Types of dehydration Hypertonic Isotonic Hypotonic The type is defined according to the change of serum osmolality (serum Na+ concentration) Dehydration
  56. 58. Isotonic dehydration <ul><li>The commonest type of dehydration in acute infantile diarrhea(acute dehydration) </li></ul><ul><li>The volume of ECF , but no shift of water between ECF and ICF. </li></ul>Loss of equal amounts of water and sodium with normal serum Na concentration (130~150mmol/L). Types of dehydration Definition:
  57. 59. Hypotonic dehydration <ul><li>A shift of water from ECF to ICF </li></ul><ul><li>1. More obvious signs of dehydration and a greater </li></ul><ul><li>degree of shock per unit of water loss. </li></ul><ul><li>2. The increase in the volume of ICF leads to an </li></ul><ul><li>increase in brain volume, sometimes resulting in </li></ul><ul><li>convulsions. </li></ul><ul><li>More common in poorly nourished infants or with </li></ul><ul><li>prolonged diarrhea in developing countries . </li></ul>Loss of more sodium than water with low serum Na concentration (<130mmol/L) Types of dehydration <ul><ul><ul><ul><ul><li>Definition: </li></ul></ul></ul></ul></ul>
  58. 60. Hypertonic dehydration Loss of more water than sodium with high serum Na concentration (>150mmol/L) 1. Less obvious signs of dehydration 2. Particularly dangerous : Water is drawn out of the brain and cerebral shrinkage within a rigid skull may lead to multiple, small cerebral haemorrhages and convulsions. A shift of water from ICF to ECF The least common, usually results from high insensible water losses or from profuse, low-sodium diarrhea Types of dehydration Definition:
  59. 61. Hypertonic dehydration Isotonic dehydration Hypotonic dehydration humour distribute Interstitial fluid plasma ICF
  60. 62. Property of dehydration ICF: severely decrease, Milder dehydrant sign than the other two kinds >150 mmol / L High grade fever, Infection Hypertonic ECF: severely decrease, Easily shock , Severer dehydrant sign than the other two kinds <130 mmol / L Chronic gastrointestinal fluid lose Hypotonic ECF: decrease, Osmotic pressure (intracellular = extracellular) Dehydrant volume accord with dehydrant physical sign 130 ~ 150 mmol / L Acute gastrointe-stinal fluid lose Isotonic Pathophysiology & clinical characteristic Serum sodium Pathogeny Type of dehydration
  61. 63. Metabolic acidosis <ul><li>Degrees of acidosis </li></ul><ul><li>Clinical manifestations </li></ul>
  62. 64. Degrees <ul><li>According to the serum HCO 3 - or CO 2 CP </li></ul>Metabolic acidosis <20 <9 Severe acidosis 20-30 9-13 Moderate cidosis 30-40 13-18 Mild acidosis 40-60 18-27 Normal CO 2 CP(vol%) HCO 3 - ( mEq/L)
  63. 65. Clinical manifestations <ul><li>Lassitude, lethargy, coma or irritability </li></ul><ul><li>Deep, rapid respiration and cool expiratory air </li></ul><ul><li>The expiratory air smells like ‘acetone’ </li></ul><ul><li>Cherry lips </li></ul><ul><li>Nausea, vomiting </li></ul>Metabolic acidosis
  64. 66. Hypokalemia <ul><li>Definition </li></ul><ul><li>Features of the body potassium before and after rehydration </li></ul><ul><li>Clinical manifestations </li></ul>Hypokalemia is a condition of below normal levels of potassium in the blood serum(<3.5 mmol/L) .
  65. 67. <ul><li>Heart symptoms </li></ul><ul><li>Renal symptoms </li></ul><ul><li>Neuromuscular symptoms </li></ul>Hypokalemia
  66. 68. Clinical manifestations <ul><li>tachycardia, arrhythmia, dull heart sounds </li></ul><ul><li>ECG T wave depression, the appearance of a U wave, S-T segments depression, prolonged Q-T intervals. </li></ul>Heart symptoms: Increased myocardial irritability: Hypokalemia
  67. 69. Hypokalemia: K+ < 3.5 meq/L
  68. 70. Clinical manifestations Hypokalemia Renal symptoms: <ul><li>Lassitude, weakness, hypotonia, diminished reflexes and even paralysis </li></ul><ul><li>Abdominal distention with diminished or absent peristalsis </li></ul><ul><li>Hypokalemic and hypochloremic alkalosis </li></ul><ul><li>Neuromuscular symptoms Depressed irritability: </li></ul><ul><li>Polyuria Impaired concentrating ability </li></ul>
  69. 71. <ul><li>Serum K usually remains normal prior to rehydration </li></ul><ul><li>1. hemoconcentration </li></ul><ul><li>2. During acidosis potassium moves from ICF into ECF </li></ul><ul><li>3. Oliguria reduces the excretion of potassium </li></ul>Along with rehydration serum K will gradually fall, because: 1. Hemodilution 2. Acidosis is being corrected, potassium returns from ECF to ICF 3. Potassium excretion is increased along with urine discharge 4. Synthesis of glycogen with infused glucose needs potassium 5. Ongoing loss of potassium due to diarrhea Features of the body K before and after rehydration <ul><li>In the presence of a body </li></ul><ul><li>potassium deficit </li></ul>
  70. 72. Hypocalcemia and Hypomagnesemia <ul><li>Definition </li></ul><ul><li>Features before and after rehydration </li></ul><ul><li>Manifestations : Tetany and convulsion </li></ul>If the tetany or convulsion is not relieved after the patient has been given calcium, hypomagnesemia should be considered. A condition of below normal levels of Ca (<1.75 mmol ) or Mg (<0.6 mmol ) in the blood serum
  71. 73. Features before and after rehydration
  72. 74. Diagnosis <ul><li>Clinical diagnosis </li></ul><ul><li>history (including feeding history and epidemical data), manifestations, physical examination and routine examination of stool. </li></ul><ul><li>Dehydration (degree and type), electrolyte disturbances and acidosis should be assessed for moderate and severe cases. </li></ul><ul><li>Ancillary data : </li></ul><ul><li>WBC counts of peripheral blood to assess risk of bacterial infection </li></ul><ul><li>Serum electrolyte and blood gas analysis </li></ul><ul><li>Etiological diagnosis for enteritis depends on stool bacteria culture or virus identification which are not always available. </li></ul>
  73. 75. Differential Diagnosis <ul><li>Physiologic diarrhea </li></ul>It occurs in infants apparently fatty, younger than six months, usually breast feeding. Accompanied by eczema. Besides diarrhea the infants have no other symptoms and have good appetite and normal weight gain. After solid foods (supplemental food) were added the stools turn to normal
  74. 76. <ul><li>Bacillary dysentery </li></ul><ul><li>Epidemic data (contact history) </li></ul><ul><li>Stool bacteria culture. </li></ul>Differential Diagnosis
  75. 77. <ul><li>Acute necrotizing enterocolitis </li></ul><ul><li>Severe systemic toxic symptoms </li></ul><ul><li>Obvious bloody diarrhea </li></ul>Differential Diagnosis
  76. 78. Treatment <ul><li>Principles </li></ul><ul><li>regulating and continue feeding </li></ul><ul><li>correcting water and electrolyte disturbances </li></ul><ul><li>controlling intestinal and extraintestinal infection </li></ul><ul><li>good care and symptomatic treatment </li></ul>
  77. 79. Treatment Fasting severe vomiting Regulating and limiting the diet Antibiotic : bacterial infection Microecological drug : lactobacilli GI tract mucosa protector : smecta Drug therapy Fluid therapy Mainstay of treatment Dietary therapy
  78. 80. Fluid therapy <ul><li>Purpose : Correction of dehydration, </li></ul><ul><li>electrolyte and acid-base imbalances </li></ul><ul><li>Common solutions used in fluid therapy </li></ul><ul><li>Oral fluid therapy </li></ul><ul><li>Intravenous fluid therapy </li></ul>
  79. 81. Common solutions <ul><li>Non-electrolyte solution </li></ul><ul><li>Electrolyte solutions </li></ul><ul><li>Mixed solution </li></ul><ul><li>Oral rehydration salt(ORS) </li></ul>Fluid therapy
  80. 82. Non-electrolyte solution <ul><li>5%(isosmotic ) </li></ul><ul><li>10% (hyperosmotic ) </li></ul><ul><li>Because the glucose is used for energy supply after it enters the body, the solutions are known as no tonic solutions only used in providing water and calories. </li></ul>Fluid therapy Glucose solution (GS)
  81. 83. <ul><li>Tonicity or effective osmolality is the ability </li></ul><ul><li>of a solution to cause water movement . </li></ul><ul><li>solution osmotic pressure </li></ul><ul><li>plasma osmotic pressure </li></ul><ul><li>solution osmotic pressure = </li></ul><ul><li>%concentration×10×1000×each molecule dissociable ion </li></ul><ul><li>molecule weight </li></ul>It’s a ratio =
  82. 84. <ul><li>0.9%NaCl osmotic pressure = </li></ul><ul><li>0.9×10×1000×2 </li></ul><ul><li>58.5 </li></ul><ul><li>Tonicity = </li></ul><ul><li>308 mOsm / L </li></ul><ul><li>300 mOsm / L </li></ul>= 308 mOsm / L solution osmotic pressure = %concentration×10×1000×each molecule dissociable ion molecule weight solution osmotic pressure plasma osmotic pressure = =1
  83. 85. tonicity include <ul><ul><ul><li>isotonic : An extracellular solution that has </li></ul></ul></ul><ul><ul><ul><li>effectively the same concentration of </li></ul></ul></ul><ul><ul><ul><li>solution as that found within a cell </li></ul></ul></ul><ul><ul><ul><li>hypertonic : A hypertonic solution has higher </li></ul></ul></ul><ul><ul><ul><li>solution concentrations on the outside. in a </li></ul></ul></ul><ul><ul><ul><li>net movement of water out of cells. </li></ul></ul></ul><ul><ul><ul><ul><li>hypotonic : A hypotonic (hypoosmotic) solution has </li></ul></ul></ul></ul><ul><ul><ul><ul><li>a lower concentration on the outside , </li></ul></ul></ul></ul><ul><ul><ul><ul><li>in a net movement of water into cells. </li></ul></ul></ul></ul>
  84. 86. Fluid therapy Electrolyte solutions Sodium chloride solution (NaCl) Isotonic (0.9%, Normal saline, NS): Replenish volume. Maintain plasma osmolality Hypertonic(3%) Correct hyponatremia Sodium bicarbonate (SB)(NaHCO 3 ) Isotonic(1.4%) Maintain plasma osmolality, correct acidosis Hypertonic(5% , 3.6 tonic) Correct acidosis Potassium chloride (KCl) Isotonic(1.2%) Hypertonic(10% ,8.9 tonic ) Replenish K+
  85. 87. Mixed solution <ul><li>Components of mixed solution </li></ul><ul><ul><ul><li>solution component ratio </li></ul></ul></ul><ul><ul><ul><li>NS 5%/10%GS 1.4%SB </li></ul></ul></ul><ul><ul><ul><li>2:1 isotonic sol 2 1 </li></ul></ul></ul><ul><ul><ul><li>1:1 sol (1/2tonicity) 1 1 </li></ul></ul></ul><ul><ul><ul><li>2:3:1 sol (1/2tonicity) 2 3 1 </li></ul></ul></ul><ul><ul><ul><li>4:3:2 sol (2/3tonicity) 4 3 2 </li></ul></ul></ul><ul><ul><ul><li>1:2 sol (1/3tonicity) 1 2 </li></ul></ul></ul><ul><ul><ul><li>1:4 sol (1/5tonicity) 1 4 </li></ul></ul></ul>Prepared with different portions of various isotonic electrolyte solutions and glucose solution.
  86. 88. Oral fluid therapy Mild or moderate dehydration. No severe vomiting or abdominal distention Indications ORS may be used with unlimited water intake. The fluid is best given in small amounts frequently . Fluid therapy
  87. 89. Ingredient amount (grams) NaCl 3.5 NaHCO 3 2.5 KCl 1.5 Glucose 20 Water 1000ml Oral rehydration salt (ORS) It has been advocated by the WHO Formula of rehydration salt: 2/3 tonicity and the potassium concentration is 0.15%
  88. 90. 40℃ warm water or cooled boiled water Oral rehydration salt (ORS)
  89. 91. <ul><li>Indications </li></ul><ul><li>Principles </li></ul><ul><li>Methods </li></ul><ul><li>The first day </li></ul><ul><li>The second day </li></ul>Fluid therapy Intravenous fluid therapy
  90. 92. Indications <ul><li>Moderate or severe dehydration </li></ul><ul><li>The illness is not relieved by oral </li></ul><ul><li>fluid therapy or complicated with </li></ul><ul><li>severe vomiting. </li></ul>Intravenous fluid therapy
  91. 93. Principles <ul><li>Correcting volume and electrolyte deficits </li></ul><ul><li>and correcting acid-base imbalances </li></ul><ul><li>Supplying maintenance requirements </li></ul><ul><li>Replenishing ongoing abnormal losses </li></ul>Intravenous fluid therapy
  92. 94. The therapy for the first day <ul><li>Volume supplement </li></ul><ul><li>Correcting acidosis </li></ul><ul><li>Replacement of potassium </li></ul><ul><li>Replacement of calcium and magnesium </li></ul>Intravenous fluid therapy
  93. 95. Volume supplement <ul><li>To determine the amount of fluid to be infused </li></ul><ul><li>To determine the kind of fluid to be infused </li></ul><ul><li>To determine the infusion rate (speed) </li></ul>Three “determination”
  94. 96. The amount of fluid 60-80 ml/kg /day Maintenance requirements 10-30ml/kg/day Ongoing abnormal losses 100-120 50-100 50 Preexisting losses (ml/kg) 150-180 120-150 90-120 Total amount (ml/kg) Severe Moderate Mild Degrees of dehydration
  95. 97. losing continuing 1/2 ~ 1/3 tonic Sodic solution physiological need 1/3 ~ 1/5 tonic Sodic solution The Quality of fluid 1/3 ~ 1 / 5 Tonic Sodic solution Hypertonic dehydration 2:3:1 Isotonic dehydration 4:3:2 Hypotonic dehydration Cumulated losing volume Dehydrant category
  96. 98. Shock volume expansion <ul><li>Volume Solution Speed </li></ul><ul><li>20ml/kg 2:1 30 ~ 60min </li></ul><ul><li>1.4%NaHCO 3 </li></ul><ul><li>Total volume ≤ 300ml </li></ul>Speed
  97. 99. Speed 5ml / kg / h 8 ~ 10ml / kg / h 12 ~ 16h 8 ~ 12h 24h Keep transfusing period ( physiological need, losing continuing ) Cumulated losing volume Total volume
  98. 100. Correcting acidosis <ul><li>Mild acidosis is easily corrected with volume restoration </li></ul><ul><li>As the fluid infused contains certain amounts of </li></ul><ul><li>alkaline solutions and increased renal perfusion permits </li></ul><ul><li>excretion of excess H + ions in the urine </li></ul><ul><li>For severe acidosis 1.4%SB (20ml/kg) may be used </li></ul><ul><li>instead of 2:1 solution for volume expanding therapy. </li></ul><ul><li>1ml/kg of 5%SB, can elevate 1mEq/L of HCO 3 - </li></ul><ul><li>Usually give half of the amount calculated and further </li></ul><ul><li>regulation is based on further HCO 3 - or blood gas </li></ul><ul><li>analysis. </li></ul>Intravenous fluid therapy
  99. 101. Replacement of potassium <ul><li>The amount of potassium to be replaced </li></ul><ul><li>Mild hypokalemia: 200-300mg/kg/day </li></ul><ul><li>or 3- 4mEq/kg/d (KCl) </li></ul><ul><li>Severe hypokalemia: 300-450 mg/kg/day </li></ul><ul><li>or 4-6 mEq/kg/d </li></ul><ul><li>Some key points should be paid attention to: </li></ul>Intravenous fluid therapy
  100. 102. key points about K + replacement <ul><li>Potassium should not be administered unless the patient has passed urine during 6 hours before admission </li></ul><ul><li>The concentration of KCl in the infusion should be 0.15-0.3%, not to exceed 0.3% </li></ul><ul><li>( 27 mEq/L or 0.2% of KCl is the best) </li></ul><ul><li>The solution containing potassium can not be injected intravenously quickly. The duration of infusion should be beyond 6-8 hrs. </li></ul><ul><li>In order to balance the amount of potassium between ECF and ICF, potassium losses are usually replaced over a 4-6 day period </li></ul>
  101. 103. Replacement of calcium and magnesium <ul><li>If patients show the symptoms of hypocalcemia (tetany or convulsion) calcium should be administered </li></ul><ul><li>10% Calcium gluconate 10ml + 10% glucose 10ml intravenous injection slowly </li></ul><ul><li>If the symptoms are not improved, magnesium should be given. </li></ul>Intravenous fluid therapy
  102. 104. The therapy for the second day <ul><li>The fluid therapy on the second day is mainly composed of replacement of ongoing normal and abnormal losses with 1/2 or 1/3 sodium-containing solutions. </li></ul><ul><li>The volumes of ongoing abnormal losses are dependent on the amount of diarrhea stools. </li></ul><ul><li>Correcting acidosis and hypokalemia if necessary </li></ul>Intravenous fluid therapy
  103. 105. <ul><li>If we could prevent rotavirus: </li></ul><ul><li>We would save the lives of 1,400 children a day. </li></ul><ul><li>We would save countries’ precious human and financial resources. </li></ul><ul><li>We would make a difference. </li></ul>2006, USA. oral, vaccine for use in preventing rotavirus gastroenteritis in infants. This vaccine gives health care providers an important new tool that can effectively prevent an illness that affects almost all children within the first few years of life vaccine
  104. 107. Definition: Dehydration Isotonic dehydration Hypotonic dehydration Hypertonic dehydration Hypokalemia Key Points
  105. 108. Etiology of infantile diarrhea To evaluate the severity of dehydration caused by infantile diarrhea, you should pay attention to some signs For fluid therapy, the commonly used non-electrolyte solution and the electrolyte solutions 2:1 isotonic solution ,2:3:1 solution component and usage key points about K + replacement the main distinction between severe and mild infantile diarrhea Key Points
  106. 109. <ul><li>How to expand the plasma volume </li></ul><ul><li>Which sodium-containing solution (tonicity) is choice in </li></ul><ul><li>different types of dehydration </li></ul><ul><ul><ul><li>Clinical signs and symptoms of moderate dehydration </li></ul></ul></ul><ul><ul><ul><li>The total amount of fluid to be supplemented in different </li></ul></ul></ul><ul><ul><ul><li>degrees of dehydration </li></ul></ul></ul><ul><ul><ul><li>The treatment principle of infantile diarrhea </li></ul></ul></ul><ul><ul><ul><li>Features of the body K before and after rehydration, why? </li></ul></ul></ul><ul><ul><ul><li>The features of physiologic diarrhea </li></ul></ul></ul>Key Points
  107. 110. Thanks !