types of ors,indications.contraindications of ors

1. ORAL REHYDRATION SALTS (ORS)
DR.T.SIVARAMAKRISHNAN
MBBS.DCH.DNB (PAEDS)
CONSULTANT PAEDIATRICIAN
VETRIVEL MATERNITY & CHILDRENS HOSPITAL
AMMAPET MAIN ROAD
SALEM

2.  INTRODUCTION
 PRINCIPLES OF ACTION OF ORS
 COMPOSITION OF ORS
 TYPES OF ORS
 INDICATION
 DOSAGE
 LIMITATIONS
 SUPER ORS
 CONCLUSION

4.  During the 1980s, UNICEF launched the 'child
survival and development revolution',
concentrating its efforts on four potent methods
of saving children's lives -- growth monitoring,
breastfeeding, immunization, and the use of oral
rehydration salts (ORS) -- the best way of
combating the dehydration caused by diarrhoea.
 The British medical journal The Lancet has
described ORS as "potentially the most
important medical advance of this century."

5.  In 1968, researchers in Bangladesh and India
discovered that adding glucose to water and salt in
the right proportions enabled the liquid to be
absorbed through the intestinal wall. So anyone
suffering from diarrhoea could replace the lost fluids
and salts simply by drinking this solution.
 One of the first large-scale field applications of oral
rehydration salts took place in 1971 during the
Bangladesh war of independence when outbreaks of
cholera swept through refugee camps. Of the 3,700
victims treated with ORS, over 96 per cent survived.

6. INTRODUCTION
 The stool output in the adult is < 250ml/day,
this amount varies by age in children
 During diarrheal disease the intestinal output
increases greatly, overwhelming the
reabsorptive capacity of intestinal lumen.
 Multiple studies done among cholera patient
demonstrated an intact Na-couple solute co-
transport mechanism allowing efficient salt
and water reabsorption

7.  This co-transport remains intact even in
infections of E. coli, salmonella, shigella and
rotavirus
 The mechanism essential for the efficacy of
oral rehydration solution (ORS) is the couple
transport of sodium and glucose in the
intestinal brush border

8. PRINCIPLE
 Glucose when given orally enhances the intestinal
absorption of salt & water.
 Thus it can correct electrolyte & water deficit.

10. COMPOSITION OF STANDARD AND REDUCED
OSMOLARITY ORS SOLUTIONS
ORS Standard Reduced Osmolarity
Contents mEq/L mEq/L
Glucose 111 75
Sodium 90 75
Chloride 80 65
Potassium 20 20
Citrate 10 10
Osmolarity 311 245

11. TYPES OF ORS??
 Sodium bicarbonate based
 Trisodium citrate based
 Reduced osmolarity ORS
 Super ORS

12. STANDARD ORS
 In 1975 the WHO and UNICEF decided to
promote a single ORS (WHO-ORS)
 It contained (mmol/L) Na 90, K 20, CL 80, bicarb
10 and Glu 111 with an Osm of 311
 This composition allowed for a single solution to
be use for treatment of diarrhea caused by a
multitude of agents
 Has been proven to be effective and safe for
over 25 year

13. SODIUM BICARBONATE BASED ORS
DISADVANTAGES
 Less stable
 Stool output not reduced

14. TRISODIUM CITRATE BASED ORS
Contents (gm)
NaCl 3.5
Glucose 20.0
KCl 1.5
Trisodium citrate 2.0

15. ADVANTAGES
More stable
Less stool output in high output diarrhoea
Tri Na citrate-increases intestinal absorption of Na &
water

16. POSSIBLE ADVERSE EFFECTS
 Hyper tonicity in net fluid absorption
 To overcome this prob we should
reduce the osmolarity of ors….

17. REDUCED OSMOLARITY ORS
Na+ 75mM
Cl + 65mM
Glucose 75mM
K+ 20mM
Citrate 10mM
TOTAL 245mM

18.  The reduced osmolarity ORS has lower
concentrations of glucose and sodium
chloride than the original ORS, but the
concentrations of potassium and citrate are
unchanged

19. ADVANTAGES
 Increased efficacy of ORS in non cholera diarrhoea
 Need for unscheduled supplement IV therapy in children
fell by 33%.
 Stool output decreased by 20%.
 Vomiting decreased by 30%.
 Safe & effective.

20. DISADVANTAGES
 The reduced osmolarity ORS has been
criticized by some for not providing enough
sodium for adults with cholera.Clinical trials
have, however, shown reduced osmolarity
ORS to be both safe and effective for adults
and children with cholera.

21. Patients who received reduced-osmolarity ORS had an increased
incidence of hyponatremia (serum sodium level <130 mmol/L)
(odds ratio [OR], 2.1; 95% confidence interval [CI], 1.1-4.1). The mean
difference in serum sodium at 24 hours of treatment between the
2 groups was 1.2 mEq/L, and none of the patients with
hyponatremia in either group was symptomatic.
Christopher et al, JAMA, 2004,291:2628-2631

22. WHOM CAN IT BE GIVEN?
IN WHAT CONDITIONS CAN IT BE
GIVEN?
 All age groups
 All aetiologies
 All countries

23. DOSAGE
Mild to Moderate Dehydration
 The fluid losses should be estimated and rapidly
replaced
 Administer 50-100 ml of ORS/kg during 2-4 hr
 Additional ORS should be administer for ongoing
losses
 Smaller volumes should be offered first and increase
as tolerated using (i.e. 5 ml)
 More may be offered if the child wants more, but
larger amounts have been associated with vomiting

24. Mild to Moderate Dehydration CONTD…
 Clinical trials support the use of NG feeding for those
patients with persistent vomiting
 When compared to IV, NG feedings were found to be
more cost effective and associated with fewer
complications
 Hydration status should be assess on a regular basis
 Those children who do not improve with ORT or with
high output should be held for observation

25. DOSAGE & REQUIREMENT?
Age <4mths 4-11mths 1-2yrs 2-4yrs 5-14yrs 15yrs<
Wt.(kg) <5 5-7.9 8-10.9 11-15.9 16-29.9 30<
Soln.(ml) 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

26. HOW TO ADMINISTER???
 Teach the mother
 <2yrs :- give 1-2 teaspoon every 2-3 minutes
 Older children :- offer frequent sips out of a cup
 Adults:- drink as much as they can
 Give the estimated amount within 4hrs

27. IF THE CHILD VOMITS??
 Wait for 10 minutes
 Give a teaspoonful every 2-3 minutes
If the child wants to drink more than the
estimated amount ?
NO HARM……..GIVE MORE.

28. HOW TO PREPARE IT ?
 Dissolve the entire contents of the packet in 1l of
drinking water
 It should be used within 24 hours

29. IF ORS PACKETS ARE NOT AVAILABLE ?
 Table salt (5gm) + sugar (20gm) in 1l of drinking water

30. LIMITATIONS OF ORS
 In children with abdominal ileus or signs of
intestinal obstruction ORT should be held
until surgical evaluation
 1% of infants will have carbohydrate
malabsorption, were diarrhea may be worsen
by ORS or solutions with simple sugars

31. LIMITATIONS CONTD….
 ORT should be discontinued and fluids
replaced intravenously when vomiting is
protracted despite proper administration of
ORS, signs of dehydration worsen despite
giving ORT, the person is unable to drink due
to a decreased level of consciousness. ORT
might also be contraindicated in people who
are in hemodynamic shock due to impaired
airway protective reflexes.

32. DRAWBACKS OF ORS
 DOES NOT DECREASE FREQUENCY
 DOES NOT STOP DIARRHOEA
 DOES NOT DECREASE SEVERITY
 POOR ACCEPTANCE
 POOR TASTE

33. SUPER ORS
 TO REDUCE AMOUNT & RATE OF PURGING
 TO STOP DIARRHOEA
 ADDITIONAL NUTRITIONAL SUPPORT
TRIAL OF
 AMINO ACID GLYCINE OR L-ALANINE OR L-
GLUTAMINE BASED ORS
 COMBINING GLUCOSE POLYMERS &
AMINOACIDS TO REPLACE GLUCOSE
 COOKED STARCH BASED ORS

34. RESOMAL
 The original ORS (90 mmol sodium/L) and
the current standard reduced-osmolarity
ORS (75 mmol sodium/L) both contain too
much sodium and too little potassium for
severely malnourished children with
dehydration due to diarrhea. ReSoMal
(Rehydration Solution for Malnutrition) is
recommended for such children. It contains
less sodium (45 mmol/l) and more potassium
(40 mmol/l) than reduced osmolarity ORS.

35. CONCLUSION

36. WHO AND UNICEF JOINT MEET 2001
Among adults with cholera, clinical outcomes were
not different among those treated with reduced-
osmolarity ORS compared with standard ORS,
although the risk of transient asymptomatic
hyponatremia was noted
Christopher et al, JAMA, 2004,291:2628-2631

37.  Under 5 Diarrhea- 1.5 Billion Episodes & 1.5 to 2.5 Million
deaths
 Widespread use of standard ORS in past 3 decades is with
promising results.
 Most diarrhea deaths are caused by dehydration, which can
be treated by replacing fluid loss with ORS in over 90% of
cases. BMJ 2001;323:59-60

38.  Mortality rate in cholera has been reduced
to 0.11% from 49.3%
 Astudy in kolkatta showed 90-95% of all cases of
cholera & acute diarrhoea can be treated with ors alone .

41. THANK YOU.

42.  New multiple controlled trials has supported
the adoption of a lower osmolarity solution
 Lower osmolarity as been associated to less
stool output, less vomiting and reduced need
of IV among infants and children with non-
cholera diarrhea

43.  In 2002 the WHO announced a new ORS
formulation with a lower osmolarity
 2002 WHO-ORS contains 75mEq/L of Na, 75
mmol/L of Glu and an Osm of 245

44. None of the amino acid/ maltodextrin/
rice based ORS have been found
superior to standard ORS
Bhan MK, et al. Clinical trials of improved ORS
formulation: a review. WHO Bull.1994; 72: 945-55.

45.  A no. of RCTs have been conducted
comparing the standard (1975 WHO) and
reduced-osmolarity (2002 WHO) solutions. In
a trial of 300 adult patients with cholera,
those who received low osm. ORS had no
differences in stool output, duration of
diarrhea, or need for unscheduled
intravenous therapy compared with those
treated with the standard WHO ORS.

47. DOSAGE & REQUIREMENT?
 If the child’s weight is known, the amount of ORS
soln.for rehydration during the first 4hrs may be
calculated as 75ml/kg

48.  A basic oral rehydration therapy solution can
also be prepared when packets of oral
rehydration salts are not available. It can be
made using 6 level teaspoons (25.2 grams)
of sugar and 0.5 teaspoon (2.1 grams) of salt
in 1 litre of water.[17][18] The molar ratio of
sugar to salt should be 1:1 and the solution
should not be hyperosmolar.