Acute diarrhea and fluid therapy

approach to acute diarrhea in pediatrics

1. Acute Diarrhea and Fluid Therapy Presented by: Dr. Monther Alshahrani Saudi Board in Pediatric Medicine

2. Objectives: Introduction Pathophysiology Osmotic vs secretory diarrhea Causes of acute diarrhea Approach and management Definition of dehydration Causes Clinical assessment Types of dehydration Management Complications

3. Introduction Diarrhea Acute diarrhea Persistent diarrhea Dysentery Chronic diarrhea

4. Pathophysiology

5. Pathophysiology Osmotic Secretory Motility disorder Decreased surface area

6. 6

7. Osmotic vs secretory diarrhea

8. Note: stool reducing substance is positive in osmotic diarrhea.

9. Etiology of acute diarrhea

10. Etiology of acute diarrhea Acute non-infectious Dietic Drugs Acute Abdomen Part of systemic disease Acute infectious Acute gastroenteritis Extra intestinal infections

11. Approach and management

12. Approach and management Detailed history Complete physical examination Investigations Treatment

13. Detailed history When did it start? Duration? What is the patient usual bowel habit? Consistency? Frequency? Volume of stool? Are the lose motion interspersed by normal ones? Content: Undigested food? Blood? Mucous? fatty? Foul smelling?

14. Continue Associated symptoms: Fever Vomiting Pain Distention Jaundice Urinary symptoms Concurrent problem: Joint pain and swelling skin rash dysphagia oral ulcer perianal fistula

15. Continue previous similar attack? Contact with sick patient? Antibiotic use? Travelling? Oral intake? Weight loss? Activity? Urine output?

16. Continue Past medical history: Recurrent infections previous hospitalization Past surgical: bowel resection congenital GIT anomalies repaired Medications: laxative or antibiotics Allergy: cow milk

17. Continue Nutritional history in detail amount? And type (fructose, lactose, gluten, carbonated drinks, water source). Family history Consanguinity Similar case in the family Immunodeficiency Celiac disease IBD Social history (any stress at home or school). Antenatal history in detail (prenatal U/S, NICU admission and course, neonatal screening).

18. Complete physical examination General (hydration), start with GIT then other systems Role out Acute abdomen Examine stool

19. Investigations Based on the Data from history and physical examination Stool analysis and culture Stool electrolytes CBC and inflammatory markers Renal function and serum electrolytes Urine analysis and culture Other special tests according to the cause

20. Treatment Frist stabilize the patient (ABCs) Hydration Electrolytes replacement Proper diet Anti-diarrheal meds? Antibiotics? Special treatment for systemic disease

21. What is Dehydration

22. Dehydration   Volume depletion or dehydration occurs when fluid is lost from the extracellular space at a rate that exceeds intake.  

23. Dehydration   Infants w/ diarrhea are at increased risk for dehydration for the following reasons: Higher body surface area-to-volume ratio when compared to older children or adults There is a higher frequency of gastroenteritis Dependent on others for fluid  

24. The most common sites for extracellular fluid loss are: Gastrointestinal tract ( eg , diarrhea, vomiting) Skin ( eg , fever, burns) Urine ( eg , glucosuria , diuretic therapy, diabetes insipidus )

25. Clinical assessment

26. Types of Dehydration

27. Types of dehydration Isonatremic dehydration Hyponatremic dehydration Hypernatremia dehydration

28. Management History and physical to identify the cause

29. LABORATORY TESTING Electrolytes and acid-base Na K HCO3 BUN

30. Repletion therapy in hypovolemia The first step involves emergent correction of moderate to severe hypovolemia . The second step finishes repletion of fluids and electrolyte losses.

31. You should consider the following: Does the child require emergent therapy? By what route (oral or intravenous)? What kind of fluid should be given? What fluid volume should be given initially and then in follow-up? How quickly should the fluid in each step be given?

32. Isonatremia Intravenous therapy would consist of replacement of the fluid deficit with isotonic saline.

33. Hyponatremia Caused by the intake of hypotonic solutions. Some or most of the free water in these solutions cannot be excreted because hypovolemia also enhances the secretion of antidiuretic hormone (ADH), thereby increasing renal water reabsorption . Mild to moderate hyponatremia and can be treated with isotonic saline alone.

34. Symptomatic hyponatremia manifests most commonly with neurologic dysfunction. Nausea and malaise. Headache, lethargy, obtundation , and seizures may occur as the serum sodium continues to fall below 120  mEq /L The primary problem with symptomatic hyponatremia is evolving cerebral edema , and the risk of morbidity from delayed therapy is greater than the risk of complication from too rapid correction and osmotic demyelination .

35. Hypernatremia   Results from the loss of free water due to increased insensible losses because of fever or sweating, urinary concentrating defects as in diabetes insipidus , or relatively dilute diarrheal fluid. Children with a serum sodium concentration above 155  mEq /L who are corrected too rapidly are at greatest risk of such neurologic sequelae , particularly seizures

36. How to calculate fluid deficit and maintenance

37. Fluid Boluses Intravenous: 20 ml/kg over 5 min 10 ml/kg over 10-30 min in cardiac and renal disease. ORS: Repletion phase: 50-100 ml/kg over 4 hours.

38. How to calculate fluid deficit Fluid deficit Percentage of dehydration X weight (Kg) X 10 “half in first 8 hours and the other half in the remaining 16 hours” Note: you should subtract the boluses from the total deficit volume.

39. How to calculate fluid maintenance Maintenance IV fluid over 24 hours For the first 10 Kg X 100 For the second 10 kg X 50 For each Kg above 20 X 20 Maintenance ORS 10ml/kg/bowel motion

40. Example: A 6 year old girl presented by persistent vomiting and diarrhea for 2 days. On examination she is conscious with decreased activity, sunken eyes, dry mucus membrane, cold extremity and delayed capillary refill. Her weight is 21 kg. Her electrolytes within normal with metabolic acidosis and slightly elevated Urea and normal Creatinine . Calculate fluid deficit and maintenance?

41. Does the child require emergent therapy? By what route (oral or intravenous)? What kind of fluid should be given? What fluid volume should be given initially and then in follow-up? How quickly should the fluid in each step be given?

42. Complications

43. Shock Acute renal failure Electrolyte disturbance Acid base disturbance Convulsion DIC Heamoconcentration

44. References Nelson Essential and textbook UpToDate Illustrated

45. Thank you