Management of dehydration - diarrhea and vomiting.in pediatric patient fluid resuscitation and correction of electrolytes according to Malaysian CPG and NICE Guideline

1. Acute GastroEnteritis,
Fluids And Electrolytes
Presenters:
Voon YW
Meerashini
Supervisor : Dr. Koo HW

2. What is the Acute Gastroenteritis ?
Gastroenteritis
Definition: inflammation of stomach and intestine
Hallmark: increased stool frequency with alteration in
stool consistency
*diagnosis of exclusion
Acute
(< 2weeks)
Chronic
(> 2 weeks)

3. Pathophysiology
v i r u l e n c e of o rg a n i s m > p ro t e c t i v e f a c t o r of g u t
- t h ro u g h i n va s i v e / e n t e ro t ox i n - > m u c o s a l i n j u r y
- i n t e re f e re f l u i d , e l e c t ro l y t e i m b a l a n c e & g u t
a b s o r p t i o n
Clinical symptoms
• d i a r r h e a : usually 5–7 days, resolve within 2 weeks
• vo m i t i n g : usually 1–2 days, resolve within 3 days.
• a b d o m i n a l p a i n a n d d i s t e n t i o n
• f e ve r l e t h a r g y, d i z z i n e s s

4. BRISTOL STOOL CHART

6. Source of infection
way for spreading
Susceptible people
• V i r u s
• B a c t e r i a
• P a r a s i t e
f ecal-oral
T h e p o p u l a t i o n i s
g e n e r a l l y
s u s c e p t i b l e , e s p
y o u n g e r c h i l d r e n
a n d i n f a n t s h a v e
h i g h e r m o r t a l i t y
d u e t o f l u i d a n d
e l e c t r o l y t e s l o s s e s
+ u n a b l e t o d r i n k
o n t h e i r o w n . . .

7. Common Causative Agent
Virus Bacteria Parasite
- Rotavirus- 37%
- Enteric Adenovirus
- Norovirus/Norwalk
- Astrovirus
- Adenovirus
- Campylobacter jejuni
- Shigella spp.
- Salmonella sp.
- Enteropathogenic E.coli
- Enterohemorrhagic/
Enterotoxigenic E. coli
- Vibrio cholerae
- Clostridium perfringens &
difficile
*organism may cause bloody
diarrhea
- Entamoeba histolytica
- Giardia lamblia
- Cryptosporidium spp.

8. HISTORY
• Onset, frequency, quantity and character of
 Vomiting- presence of bile, blood
 Diarrhea- presence of blood or mucous, volume and nature of
stool
• Urine output, last diapers change
• Weight change
• Recent oral intake
• Recent change in formula milk or introduction of new food
• Bottle hygiene/ outside food

9. • History of travelling/ swimming
• Associated symptoms: fever, change in mental status
• History of other recent infections
• Past medical history (underlying medical problems, medications,
immune compromised states)
• Relevant social history
• Sick contact

10. Physical Examination

12. Mild Moderate Severe
Mental status Alert Restless, irritable Lethargic, unconscious
Thirst - ++ Drinks poorly
Tachycardia - + +
Palpable pulses ++ + (weak) Decreased/ Not felt
Blood pressure Normal Orthostatic
hypotension
Hypotension
Respirations Normal Deep, may be rapid Deep and rapid
Eyes and
Fontanelle
Normal sunken Deeply sunken
Tears Present Present or absent Absent
Capillary refill time Normal < 2 seconds Prolonged (>2s)
Mucous membrane Moist Dry Very dry
Extremities Warm Cool Cold, mottled, cyanotic
Urine output Normal Oliguria Anuria/severe oliguria

13. SUNKEN EYES

14. SUNKEN FRONTANELLE

15. SKIN TURGOR

16. MOLTED SKIN

17. • Seizures:
• Febrile convulsion (assess
for possible meningitis)
• Hypoglycaemia
• Hyper/hyponatraemia
• Hypovolemic shock
• electrolyte imbalance
OTHER PROBLEMS ASSOCIATED
WITH DIARRHOEA

18. •Blood: FBC, BUSE, VBG, RBS
•Stool: FEME + ova and cyst,
rotavirus and C&S
Others:
•Blood gases in ill-children
•Blood glucose in infant
•Blood C&S if child is septic
looking
Investigations

19. How to manage ?

20. PLAN A: TREAT DIARRHOEA AT HOME
3 RULES OF HOME TREATMENT:
1. GIVE EXTRA FLUIDS (AS MUCH AS THE CHILD WILL TAKE)
• Breastfeed frequently and longer
• Give ORS or cooled boiled water
• Food-based fluids (soup and rice water) or cooled boiled water.
ORS
• Up to 2 years : 50 to 100ml after each loose stool
• 2 years or more : 100 to 200ml after each loose stool
• (if weight is available, give 10ml/kg of ORS after each loose stool)

21. 2. CONTINUE FEEDING
• Continue nursing on demand/ formula/ semi-solid or solid foods
• Avoid foods high in simple sugar as osmotic load may worsen the
diarrhoea.
3. WHEN TO RETURN (TO CLINIC/HOSPITAL)
When the child:
• Is not able to drink or breastfeed or drinking poorly.
• Becomes sicker.
• Develops a fever.
• Has blood in stool.

22. PLAN B: TREAT SOME DEHYDRATION WITH ORS
• AFTER 4 HOURS, REASSESS AND
CLASSIFY DEHYDRATION.
• SELECT APPROPRIATE PLAN
• BEGIN FEEDING
• IF THE MOTHER MUST LEAVE BEFORE
COMPLETING TREATMENT ->PLAN A

23. PLAN C: TREAT SEVERE DEHYDRATION QUICKLY
• ABCs
• Start IV/IO Drip, ORS while the drip is being set up
• 20 ml/kg of 0.9% NS/ HM as IV bolus.
• Give Maintenance, replace ongoing losses with 0.9% NS (0.45% NS
in neonates) or HM solution
• Fluid deficit: % dehydration x BW in grams (Given over 4-6 H)
• included boluses
• Repeat / Review / Revise

24. OTHER INDICATIONS FOR INTRAVENOUS THERAPY
• Unconscious child.
• Failed ORS treatment
• Abdominal distension with paralytic ileus
• Glucose malabsorption,

25. INDICATIONS FOR ADMISSION TO HOSPITAL
•Shock/ severe dehydration.
•Failed ORS treatment and need for IVD
•Other possible illness or uncertainty of diagnosis.
•Patient factors,
•e.g. Young age, unusual irritability/drowsiness, worsening
symptoms.
•Caregivers not able to provide adequate care at home.
•Social or logistical concerns that may prevent return
evaluation if necessary.

26. What kind of FLUID?

27. Oral Rehydration solution
WHO-UNICEF
RED OSM ORS
risk hypernatremia

28. • the 245 mosm/l solution also appeared to be as safe and at least
as effective as standard ors for use in children with cholera.
previous ORS total osmolarity of 311 mosm/l, had possible
adverse effects of hypertonicity on net fluid absorption.
+ risk of hypernatremia esp in infant
• Thus reducing the solution’s glucose and salt (nacl)
concentrations, help in reducing
stool output by 20% and vomiting by about 30%

29. PREVENTION OF CHILDHOOD AGE
VACCINES
• ROTAVIRUS VACCINES,
• First dose given between the age of 6 and 12 weeks
i) ROTATEQ® - 3 doses, should be completed by age of 8 months
ii) ROTARIX®- 2 doses, completed by 6 months

30. PHARMACOLOGICAL AGENTS
• ANTIDIARRHOEAL MEDICATIONS
• DIOSMECTITE (SMECTA®)
• Reducing stool output and duration of diarrhoea
• PROBIOTICS
• LACTOBACILLUS GG, LACTOBACILLUS ACIDOPHILUS AND
SACCHAROMYCES BOULARDII
• Reduce duration of diarrhoea
• Not generally used

31. •ANTIMICROBIALS

32. • ANTIMICROBIALS

33. FLUIDS

34. FLUID MAINTENANCE
• VOLUME OF FLUID REQUIRED
TO REPLACE NORMAL DAILY
LOSSES
• NORMAL DAILY LOSSES
INCLUDES:
• URINE
• STOOL
• PERSPIRATION (TRANS-
EPIDERMAL DIFFUSION)
• RESPIRATORY TRACT
(EVAPORATIVE)
Give bolus 10-20cc/kg

35. MAINTENANCE FLUIDS (AGE ≤ 1 YEAR)
• ADD 20CC-30CC/KG/D
AGE TERM IV FLUID
Day 1 60ml / kg / day D10%
Day 2 90ml / kg / day
1/5 NS D10%
Day 3 120ml / kg / day
Day 4- 1m
150ml / kg / day
1m-6m
1/2 NS D5%
6 -12 m 120ml/kg/day

36. MAINTENANCE FLUIDS
CHILD (AGE > 1 YEAR)
• CALCULATION: HOLLIDAY-SEGAR CALCULATOR
WEIGHT (KG) MILILITRES / DAY Infusion rate
First 10 kgs 100 X WEIGHT 4 mls/kg/hour
Subsequent 10kgs 1000 + [50 X each kg above 10 kg]
2 mls/kg/hour
All additional kg 1500 + [20 X each kg above 20kg]
1 mls/kg/hour

37. Example:
A 12-kg child is clinically shocked and 10% dehydrated as a result of gastroenteritis.
Initial therapy: To establish ABCs
20 ml/kg for shock
12× 20 = 240 ml of 0.9% NS IV bolus.
Fluid deficit= Percent of dehydration X Weight in grams (over 6 hours)
10/100 x 12000 = 1200 ml - bolus
Daily maintenance fluid - over 24 hours
1st 10 kg 100 × 10 = 1000 ml
Subsequent 2 kg 2 x 50 = 100 ml
Total = 1100 ml/day
Conclusion
Initial, to give 240 ml of 0.9% NS IV bolus.
To rehydrate (1200cc/ 6 hours - bolus) 0.9%NS or HM’s solution +
Maintenance (1100cc/ 24 hours) with 0.9%NS D5%.
Replace on going diarrhoea/vomiting lossess orally whenever possible:
5- 10ml/kg for each episode.

38. 1. HYPONATREMIA
2. HYPERNATREMIA
3. HYPERKALEMIA
4. HYPOKALEMIA
5. HYPERCALEMIA
6. HYPOCALEMIA
7. HYPOMAGNESEMIA

39. HYPERNATREMIA NA >150MMOL/L
CAUSES
• Water loss in excess of sodium (e.g
Diarrhoea)
• Water deficit (e.g. Diabetes
insipidus)
• Sodium gain Large amount of
NaHCo3 Infusion or salt poisoning
CLINICAL SIGNS OF HYPERNATREMIC
DEHYDRATION
• IRRITABILITY
• SKIN FEELS DOUGHY
• ATAXIA, TREMOR HYPERFERLEXIA
• SEIZURE
• HYPERPNOEA
• MUSCLE WEAKNESS
• A CHARACTERISTIC HIGH-PITCHED
CRY
• INSOMNIA
• LETHARGY
• COMA
• MODERATE: Na 150-160mmol/l
• SEVERE: Na > 160mmol/l

40. MANAGEMENT
Na+> 150mmol/l:
• In shock, Volume resuscitation with 0.9% NS
• Avoid rapid correction-
• May cause cerebral oedema, convulsion and death.
• Aim to correct deficit over 48-72 hours
• Aim fall of serum Na+ ≤ 0.5mmol/l/hr/ < 12 mmol/litre in 24H.
• Repeat Urea and electrolytes every 6H until stable.
• If hypernatraemia worsens or is unchanged after replacing deficit/ no evidence of
dehydration
• Consider change to hypotonic solution (E.G. 0.45% NSD5).

41. HYPONATREMIA
SODIUM: <135MMOL/L
• Hyponatremic encephalopathy is a medical emergency that requires rapid
recognition and treatment to prevent poor outcome.
• Asymptomatic when na+ > 125 mmol/L
• Symptoms : Headache, nausea, vomiting, confusion, disorientation, irritability,
lethargy, reduced consciousness, convulsions, coma, apnoea.
 Complications: seizures, coma, permanent brain damage, respiratory arrest, brain-
stem herniation, death

42. Hyponatremia
Asymptomatic
hyponatraemia with
normal/raised volume
status
Asymptomatic
hyponatraemia with
dehydration
Symptomatic
hyponatraemia
Bolus of 2cc/kg of NaCl 3 %
over 10-15 min
oral fluid/ IV drip 0.9
NaCl
fluid restriction
Repeat Bolus
Symptoms
persist
check plasma sodium
level and consider a 3rd bolus
Symptoms
persist

43. • Rate of correction: ≤12mmol/L/24 hours
• Measure Na at least hourly initially, reduce freq based on response to
treatment
• Higher rate may lead to fatal cerebral edema or osmotic
demyelination syndrome

44. POTASSIUM
MAIN INTRACELLULAR CATION
INTRACELLULAR K+ : 150 MMOL/L
EXTRACELLULAR K+ : 4 MMOL/L
DAILY POTASSIUM REQUIREMENT: 1-
2MMOL/KG/DAY
NORMAL K:
AT BIRTH : 3.7-6
AT 2 WEEKS-3MONTHS : 3.7-5.7
BEYOND 3 MONTHS : 3.5-50

45. 3. HYPERKALEMIA (K >5.5)
CAUSES
1. Dehydration
2. Acute renal failure
3. Diabetic ketoacidosis
4. Adrenal insufficiency
5. Acute tissue breakdown
- Burn
- tumor lysis syndrome
- Trauma
- major surgery
6. Drugs: oral K supplement, K
sparing diuretics, ACE
inhibitors, Beta blocker
CLINICAL FEATURES OF HYPERKALEMIA
• HIGH K LEVELS INTERFERE WITH
REPOLARIZATION OF THE CELLULAR
MEMBRANE FOLLOWING COMPLETION OF THE
ACTION POTENTIAL
• NAUSEA
• VOMITING
• PARESTHESIAS (EG, TINGLING)
• MUSCLE WEAKNESS
• FATIGUE
• CONFUSION
• MOSTLY ASYMPTOMATIC, WITH FIRST
MANIFESTATION OF ECG CHANGES OR SUDDEN
CARDIAC ARREST
• MAY PRESENT WITH CARDIAC ARREST DUE TO
WIDE-COMPLEX TACHYCARDIA OR
VENTRICULAR FIBRILLATION

46. ECG changes
• Tall, tented T waves
• Prolonged PR interval
• Prolonged QRS complex
• Loss of P wave, wide biphasic QRS
• Ventricular fibrillation
• Asystole

48. HYPOKALEMIA K<3.5MMOL/L
Causes
Extra-renal losses:
• vomiting, diarrhea
• profuse sweating
• surgical drainage
Renal losses:
• diuretics
• steroid
• drugs (amphotericin, diuretic, salbutamol, laxative drugs)
• renal tubular acidosis
• DKA
• endocrinopathies: Cushing’s syndrome, primary aldosteronism, thyrotoxicosis
Others:
• low muscular mass (muscular dystrophy)
• beta agonist therapy
•Sepsis

49. SIGN AND SYMPTOMS
• MUSCLE WEAKNESS AND CRAMPS, PARALYSIS
• NAUSEA, VOMITING
ECG CHANGES (SEEN WHEN K<2.5MMOL/L)
• PROMINENT U WAVE
• ST DEPRESSION
• FLAT, LOW OR BIPHASIC T WAVES
• PROLONGED PR INTERVAL (SEVERE HYPOK+)
• SINOARTERIAL BLOCK (SEVERE HYPOK+)

50. • Identify and treat the underlying condition.
• Unless symptomatic, a potassium level of 3.0 and 3.4 mmol/l is generally not
supplemented but rather monitored.
• Mild hypokalemia – give oral k supplement (mist KCl)
• Max : 1mmol/kg/dose (<5yo)
0.5 mmol/kg/dose (>5yo)
• Iv infusion supplementation 1g kcl = 13.3mmol/L, never give bolus
• Maximum concentration via a peripheral vein is 40 mmol/l
• Max infusion rate of 0.2mmol/kg/hr
• Monitor K closely
K requirement(g): K deficit + K maintenance
13.3
: (4-serum K)(0.4)(weight) + 2(weight)
13.3
K infusion rate : K in each pint(g) x 13.3 x drip rate (cc/H)
500 x weight

51. HYPOCALCEMIA
AVERAGE TOTAL PLASMA CA: 2.2 -2.6 MMOL/L
1. ASYMPTOMATIC BIOCHEMICAL HYPOCA :
• ORAL / IVI CALCIUM GLUCONATE 1MMOL/KG/DAY, OVER 24HRS
• ECG MONITOR TO DETECT BRADYCARDIA & CARDIAC ARRYTHMIA
• AVOID SCALP VEIN AS ‘TISSUING’ LEADS TO PITTING & SCARRING
• MAINTENANCE : 45-90 MG/KG/DAY ELEMENTAL CA ORALLY.
• USE LOW PHOSPHATE MILK
2. SYMPTOMATIC HYPOCA (CA2+ ALWAYS < 1.5 MMOL/L) :
• IV 10 % CALCIUM GLUCONATE 0.5ML/KG, SLOWLY OVER 20 MIN
• CONTINUOUS ECG MONITOR FOR CARDIAC ARREST IN SYSTOLE
• MONITOR CA2+ LEVEL REGULARLY

52. HYPERCALCEMIA
• LIFE THREATENING CONDITION, MAY BE
ASSOCIATED WITH MENTAL
RETARDATION
• CAUSES
• PRIMARY (HYPERPLASIA OR TUMOR)
• SECONDARY HYPERPARATHYROIDISM
• VITAMIN D POISONING
• THIAZIDE THERAPY
• ADRENAL INSUFFICIENCY
• MALIGNANCY SECONDARY TO BONE
• WILLIAM SYNDROME
• SYMPTOMS : ANOREXIA, VOMITING,
CONSTIPATION, IRRITABILITY,
HYPOTONIA
MANAGEMENT
1.REHYDRATE WITH IV DEXTROSE-
SALINE; CORRECT HYPOKALEMIA WITH
KCL
2.IF ON DIGOXIN, REDUCE DOSE OR
DISCONTINUE
3.IV FRUSEMIDE 1 MG/KG 2-3X/DAY WITH
HIGH FLUID INTAKE (200 ML/KG) OF
DEXTROSE-SALINE
4.DIALYSIS MAY BE NECESSARY
5.PREDNISOLONE MAY BE USED FOR A
FEW WEEKS, BUT SLOW ACTION.
6. ELIMINATE VITAMIN D INTAKE,
RESTRICT SUNLIGHT EXPOSURE

53. MAGNESIUM
• NORMAL MAGNESIUM
CONCENTRATION:
- NEWBORN (<6D) – 0.48-1.05 MMOL/L
- INFANT – 0.65-1.05 MMOL/L
7. HYPOMAGNESIUMIA
CAUSES
- MALABSORPTION
- HYPOPARATHYROIDISM
- DIURETIC
- HYPERCALCEMIA
- RENAL TUBULAR ACIDOSIS
- PROLONGED IV FLUID THERAPY
MANAGEMENT:
- IF MG <0.4MMOL/L, GIVE ORAL MG
0.6MMOL/KG/DAY IN 4 DIVIDED DOSES
- IF IV THERAPY IS INDICATED, GIVE 50%
MGSO4 0.1-0.2ML/KG, SLOW IV BOLUS

54. THANK YOU
1. Paediatric protocols for
malaysian hospitals 4th edition
2. Guidelines on the management
of acute diarrhoea in children
2011 by college of paediatrics,
academy of medicine of
malaysia
3. Nice guideline – diarrhea and
vomiting in children, 2008
4. Medscape
REFERENCES