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Gastroenteritis in Children DR. OSAMA Y. KENTAB,M.D., FAAP, FACEP. CONSULTANT PEDIATRIC EMERGENCY...
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Transcript of Gastroenteritis in Children DR. OSAMA Y. KENTAB,M.D., FAAP, FACEP. CONSULTANT PEDIATRIC EMERGENCY...
Gastroenteritis in Children
DR. OSAMA Y. KENTAB,M.D., FAAP, FACEP.CONSULTANT PEDIATRIC EMERGENCY MEDICINE
KING ABDULAZIZ MEDICAL CITY - RIYADH
Fluid and Electrolytes
Case I 9 month old, 9 kg child with 2
days of vomiting and diarrheaT 38.5C, HR 158, RR 38, BP 90/50crying without tears, capillary refill 3
sec abdomen soft, non-tender, without
HSM
How dry is this child?
How dry is this child?
1. Mild Dehydration
2. Mod Dehydration
3. Severe Dehydration
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33% 33%33%
0% 0 of 0
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Dehydration
Infants are at higher risk for dehydration due to: larger baseline water content higher metabolic rate renal immaturity inability to meet own intake needs
Conventional Clinical Assessment of Dehydration
Gold standard for dehydration fluid deficit as percentage of body weight lost
Pre-illness weight - weight at presentation pre-illness weight
pre-illness weight rarely known, so use clinical findings to estimate
deficit
Infectious Etiologies Identified In Children Admitted For Dehydration
Description Viral enteritis
NOS Rotavirus Salmonella spp Shigella spp Bacterial
enteritis NOS Clostridium spp E. coli
(pathologic/invasive)
(%)
21.9
1.9
1.0
1.0
0.7
0.6
0.5
Assessment of dehydration
Severity Body FluidLost
% WeightLost
Shock State
Mild 50 ml/kg 5% Impending
Moderate 50 – 100 ml/kg 10% Compensated
Severe >100 ml/kg > 10% Uncompensated
Clinical Findings in Dehydration
% Skin Mucosa Pulse BloodPressure
0 Good Turgor Moist Normal Normal
5 Dry Dry, no tears Mildly Orthostatic
10 Tenting Very dry Mod , weak Mildly
15 Poorlyperfused
Parched Marked ,Thready
Markedly
First line of treatment is?
1. ORS in mild/mod with no vomiting
2. IV fluid
3. Anti diarrheal Drugs
4. Anti emetic drugs
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25% 25%25%25%
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Guidelines for Managementof Dehydration
ORT is first line of treatment for mild/moderate dehydration
All medical facilities (office and ED) should have ORT available
Parents of Infants seeking care for diarrhea should be trained in use of ORT and early feeding
Symposium on ORT
Pediatrics , 1997; 100 (5): e10
Treatment of Dehydration in ChildrenOral Rehydrateon
Contraindications for ORT Severe dehydration / uncompensated shock
Preterm infant
Severe ongoing vomiting
High stool output (>20ml/kg/hr)
Poor compliance
Commonest Barriers to ORT in KSA?
1. Physician/staff knowledge/familiarity
2. Convenience
3. Availability of solutions
4. Parent/patient and physician attitudes
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Treatment of Dehydration in ChildrenOral Rehydrateon
Barriers to ORT in KSA Physician/staff knowledge/familiarity Convenience Availability of solutions Parent/patient and physician
attitudes Reimbursement issues
Treatment of Dehydration in ChildrenOral Rehydration
Procedure for oral rehydrationDetermine volume required:
replace entire deficit over 4 hours50 cc/kg for mild dehydration80-100 cc/kg for moderate to severe
ongoing losses5-10 cc/kg for each diarrheal stool 2 cc/kg for each episode of emesis
Essential Steps Of Oral Rehydration Therapy.
Select an appropriate fluid
Estimate the degree to which the child is dehydrated
Estimate the fluid deficit
Example: 10 kg child, estimated at 7% dehydrated, has a weight loss of: 0.07 x 10 = 0.7kg
Acute weight loss with vomiting and diarrhea is due to water loss
Since 1 L water weighs 1kg, 700 ml water weighs 0.7kg.
Begin oral rehydration at a rate of 5 ml every 5 minutes (use a watch or clock for timing)
Increase the rate of intake as tolerated
Goals include replacing at least 10 ml/kg in the first hour and having the total fluid deficit replaced within 4 hours
Case 1
Moderately dehydrated 10% dehydrated 10kg child
Oral rehydration therapy 50 x l0 = 500cc deficit
(10 x 10)+(2 x 10) = 120 cc for ongoing losses
620 cc over 4 hours
155 cc/hr = one ounce every 15 minutes
= 10cc by syringe every 5 minutes
Appropriate oral rehydration solutions
1. 75-90 mmol/L of Na for Rehydration
2. 45-50 mmol/L for Rehydration
3. Base is 50 mmol/L
4. Glucose is 1.5%
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Treatment of Dehydration in ChildrenOral Rehydration
Appropriate oral rehydration solutions
Na:
75-90 mmol/L for rehydration
45-50 mmol/L for maintenance
base: 20-30 mmol/L
glucose (%): 2-2.5% (optimum glucose-Na cotransport)
Treatment of Dehydration in ChildrenOral Rehydration
Na (mEq/L)
K (mEq/L)
Cl (mEq/L)
Base (mEq/L)
Glu (gm/L)
Osm (mmol/L)
Rehydration WHO
Rehydralyte
90 75
20 20
80 65
10 10
20 25
310 305
Maintenance Pedialyte
45
20
35
10
25
250
Clear Liquid Cola
Apple Juice Chicken Broth
Gatorade
2 3
250 20
0.1 1 8 3
2 2
250 17
13 4 0 3
126 124
0 46
750 540 450 330
Can Oral Rehydration SolutionsBe Safely Flavored at Home
Solution Na K Cl Glu OSM
WHO 90 20 80 111 310
Pedialyte 45 20 35 140 250
Pedialyte (4 oz) plus2.5 cc unsweetened
Jello powder30 cc apple juice
30 cc orange juice
50
3938
20
2126
39
3035
138
141139
315
330312
Treatment of Dehydration in Children Alternative Oral Rehydration Solutions
Homemade ORS 1 liter of water 1/2 tsp. salt 5 tsp. table sugar 50 mEq/L Na, 2.1% CHO
Half-strength apple juice (8 oz) with 8 -10 saltine crackers 60 -70 mEq/L Na
Case 1: Isotonic Dehydration
Child has persistent vomiting and diarrhea. He is refusing PO’s. Na 140, K 4.8, Cl 108, HCO3 10, BUN 25,
Cr1.0, Glu 160
How would you treat him with IV fluids Which fluids? What rate? When to switch to maintenance (and
which fluids with what rate)?
Isotonic Dehydration
First 8 hours Emergency phase: 1/2 - 1 hour Replacement phase: 7-7.5 hrs
Deficit - 1/2 total in1st 8hrs(1/2 in next 16 hr.)
Maintenance - 1/3 daily requirement
Additional 10% for fever
Ongoing losses: determined per hour
Emergency Phase
20 cc/kg normal saline or ringer’s lactate bolus over 20-30 minutes
Re-assess Repeat 10 cc-20 cc/kg as needed 2-4 cc/kg D10 bolus for hypoglycemia
if needed
Goal: Normalized vital signs
Urine output
Replacement Phase
Quick Answer D5 1/2 NS at 2 times maintenance fluid rate
Quick Maintenance Rate Body Wt ml/kg/day ml/kg/hr
1st 10kg l00cc/kg/d 410-20 kg 50 cc/kg/d 2>20 kg 20 cc/kg/d 1
Case 1: Isotonic Dehydration
200cc NS bolus with HR l30 and urine output
Deficit = 100cc/kg = 1000cc Maintenance = 100cc x 10kg =
1000cc/day = 42cc/hr 1000 +1000 - 200 = 1800 = 1.8L in 24 hour.
First 8 hours500 cc (1/2 1000cc deficit)
+ 333cc (1/3 of 1000 cc/day maintenance)
- 200cc (emergency phase bolus)
633 cc over 8 hours
80 cc/hr for 8 hours
Acute Dehydration (< 3 Days)Total Body Water Losses
ICF20%
ECF80%
ICFECF
ICF 20%
ECF 80%
Acute Dehydration (> 3 Days)Total Body Water Losses
ICF40%
ECF60%
ICFECF
ICF 40%
ECF 60%
Electrolytes
Na = % ECF x 140 mEq/LCl = % ECF x 110 mEq/L
K = % ICF x 150 mEq/L
ICFECF
K= %ICF x 150 mEq/L
Na= %ECF x 140 mEq/L
CL = %ECF x 110 mEq/L
Electrolytes
MaintenanceSodium 2-3 mEq/kg/dayChloride 2 mEq/kg/dayPotassium1-2 mEq/kg/day
Deficit Sodium %ECF x fluid deficit x 140 mEq/L Chloride %ECF x fluid deficit x 110 mEq/L Potassium %ICF x fluid deficit x 150 mEq/L
(replace only 1/2 of K deficit in 1st 24 hrs)
Case 2
3 month old infant with seizures. Full term infant with 2 day history of
watery stools. T 33.9C, HR 90, RR 20, BP 70/palp,
Wt 5kg Fontanelle sunken, dry mucus
membranes, cool extremities
What is your initial management?
Signs and Symptoms ofHyponatremia
Related to level and rate of fall of serum sodium
Anorexia
Nausea
Lethargy/ disorientation
Hypothermia
Cheyne - Stokes respirations
Seizures
Symptomatic Hyponatremia
Goal to increase Na to 125 mEq/L 3% NS = 0.5 mEq/cc Transient serum increase of 5-10
mEq/L 0.2 (plasma is 20% of TBW) x Wt x 5
- 10 mEq 1-2 mEq x kg 2-4 cc/kg 3% NS to raise serum Na 5-
10 mEq
Hyponatremic Dehydration
Emergency phase Treat CNS manifestations with 3% NS
Fluid resuscitation with 20 cc/kg NS
Replacement phase Replace fluid deficit
Replace Na deficit with goal of 135 mEq/I = ( l35mEq/l - actual Na) x 0.6 x kg
Increase Na 10 mEq/l per day
(risk of osmotic demylination syndrome)
Case 2: Hyponatremic Dehydration
Emergency phase 2cc x 5kg = 10 cc 3%NS 20cc/kg NS bolus x 2 = 200cc NS
Replacement phase (repeat serum Na = 125mEq/L) Na deficit = (135-125) x 0.6 x 5 = 30 mEq Add to “standard” Na deficit
=0.8 x 0.5 L x 140 = 56 mEq
Add to maintenance Na = 2 x 5 kg =10 mEq Total = 96 mEq/L = D5 1/2NS with 20mEq/L
KCL
Case 3
3 year old 15 kg child with profuse watery diarrhea increasing irritability T 38.70C, HR 150, RR 40, BP 95/55 doughy skin Na 160, K 3.5, Cl 120, CO2 10
What is your initial management?
Hypernatremic Dehydration
Emergency phase Fluid resuscitation with 20 cc/kg NS
Replacement phase Calculate free water deficit
4cc/kg for each l mEq/L of Na > l45mEq/l Replace free water deficit over 48 hours Lower serum Na 0.5-1 mEq/hr or 15
mEq/day Monitor for hypocalcemia and
hyperglycemia
Hypernatremic Dehydration
Hypertonic state causes free water movement from cells to ECF to decrease osmolality
Brain responds by making idiogenic osmoles to prevent intracellular dehydration
Rapid decline of osmolality will not allow time to “inactivate” idiogenic osmoles and may lead to cerebral edema
Case 3: Hypernatremic Dehydration
Emergency phase 20cc/kg NS bolus = 300cc NS
Replacement phase (to be given over 2 days) Total fluid deficit = 10% dehydrated
= 100cc/kg = 1500cc Free water deficit =
(160-l45mEq/L) x 4ml/kg x l5 kg = 900 ml
Solute containing solution = 1500 - 900 = 600cc
Case 3: Hypernatremic Dehydration
Fluid rate (calculated for 48 hours period) 1500cc deficit + 2500cc maintenance -
300cc emergency phase = 3700/48 hr = 77cc/hr
Na Na deficit = 0.8 x 0.6 L x 140 = 67mEq Add maintenance Na = 3 x l5 kg x 2
days = 90 mEq Less emergency NS bolus Na = 0.3 x 154
= 46 = 111 mEq/4.4L= 25 mEq/L D5 1/4NS with 20 mEq/Kcl at 77cc/hr Monitor serum Na, Ca, Glucose.
Case 4
5yo child 2nd and 3rd degree bums from car radiator
T 37.9C, HR 150, RR 36, BP 105/65 bums on face, chest, arms, and abdomen
Case 4: Pediatric BurnsBurn Management
Stop Burning Process
ABC’s Obtain access Evaluate for
major trauma Maintain body
temperature (dry blankets)
Full H&P Prevent ileus
(NPO,NO tube) Relieve pain Treat burn Tetanus Transfer to
burn center as needed
Case 4: Pediatric Burns
Face 6.5%
Chest 6.5%
Arms 10%
Abdomen 6.5%
Total 29.5%
Case 4: Pediatric Burns
Parkland Formula Accounts for deficits and ongoing losses Does not account for maintenance in
children under 5 yrs For bums > 20% BSA
2-4 cc/kg/%BSA over 24 hours 1/2in first 8hours from burn; 1/2 in next l6
hrs Objective - At least 0.5 to 1 cc/kg/hr urine
output Follow vital signs and I/O’s very
closely
Case 4: Pediatric Burns
Back to our patient (4 cc/kg ) (20 kg) (29.5% BSA) over 24 hours
2380 cc Ringer’s lactate over 24 hours
1180 cc in 8hours (150cc/hour)
Add maintenance fluids
Do not add potassium during early phase
Case 5
6 week old male History
projectile vomiting poor weight gain abnormal breathing pattern
Physical periodic breathing with 15 sec pauses HR 190, HP 90/44 sunken fontanelle; tenting of skin CR 3 sec
Case 5
Further examination
RUQ mass
Laboratory
Na 127, K 2.5 , Cl 70, Co2 34
7.58/48/307/38/+16
Case 5 : Pyloric Stenosis
Initial resuscitation with 20cc/kg of NS Patient with HR 190, BP 89/40 Repeat 20cc/kg NS (40cc/kg total) HR 180, BP 85/40 Repeat 20cc/kg NS bolus (80cc/kg total) Reassess
Case 5 : Pyloric Stenosis
Narrowing of the pyloric canal due to hypertrophy
First born male Age at onset: 2 to 5weeks Clinically well for the first weeks of life Vomiting becomes more prominent and forceful
Case 5 : Pyloric Stenosis
An olive may be felt Gastric peristaltic waves may be
seen Profound hypochloremic
metabolic alkalosis gastric losses high serum bicarb Chloride often 65 -75 Acidosis develops when critically ill
Case 5 : Pyloric Stenosis
Treatment D5 NS
avoid hypotonic fluids
high risk of hyponatremia
add K when urine output adequate
Surgical pyloromyotomy
Intravenous Rehydration
Rapid rehydration approach Found to be both safe and effective rapid oral and IV rehydration
reduction in admissions for moderately dehydrated children — from 96.3% to 55.8%
discharged in 8 hours or less improved from 4% to 44%
Holliday MA,etal Pediatr Nephrol 1999
Sunoto.Paediatr Indones 1990
Phin SJ etal, J Paediatr Child Health 2003
Nasogastric Rehydration
Rapid nasogastric VS IV rehydration 50 mL/kg over a 3-hour period Both were safe Cost-effective alternatives to the
standard treatment for moderate dehydration
Nager AL etal,Pediatrics 2002
Realimentation
Improves gastrointestinal structure and function
Reduced duration of illness and improved weight gain
The same foods or formula or breast milk the child had been taking prior to the illness
Removing milk or routine dilution of milk is not necessary
Duggan C etal,J Pediatr 1997
Brown KH etal, Pediatrics 1994
Antidiarrheal agents
Not recommended Serious side effects (e.g. paralytic
ileus, sedation, worsening diarrhea)
Murphy MS.Arch Dis Child 1998