Ors 2016

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

3. 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."

4. 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.

5. 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

6. 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

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

8. 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

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

10. 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

11. Sodium bicarbonate based ORS DISADVANTAGES Less stable Stool output not reduced

12. Trisodium citrate based ORS Contents (gm) NaCl 3.5 Glucose 20.0 KCl 1.5 Trisodium citrate 2.0

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

14. Possible adverse effects Hyper tonicity in net fluid absorption To overcome this prob we should reduce the osmolarity of ors….

15. Reduced osmolarity ORS Na + 75mM Cl + 65mM Glucose 75mM K + 20mM Citrate 10mM TOTAL 245mM

16.  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

17. 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 .

18. 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.

19. 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

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

21. 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

22. 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

23. 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

24. 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

25. 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.

26. How to prepare it ? Dissolve the entire contents of the packet in 1l of drinking water It should be used within 24 hours

27. If ORS packets are not available ? Table salt (5gm) + sugar (20gm) in 1l of drinking water

28. 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

29. 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 .

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

31. 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

32. 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 ( Re hydration  So lution for  Mal nutrition) is recommended for such children. It contains less sodium (45  mmol /l) and more potassium (40  mmol /l) than reduced osmolarity ORS.

33. CONCLUSION

34. 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

35. 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

36. 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 .

37. THANK YOU.

38. 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

39. 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

40. 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.

41. 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.

42. 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

43. 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 .