- Passage of 3 or more loose or watery stool in a 24 hour period.
- Loose stool- That would take the shape of a container.
- For practical purpose, the recent change in consistency & character of the stool & its water content.
Types of Diarrhea
- Acute watery diarrhea- lasts < 14 days.
- Dysentery- Diarrhea with visible blood & mucus.
- Persistent Diarrhea- Duration >14 days. Cause- infectious.
- Chronic diarrhea-Duration >14 days. Cause- noninfectious.
- Viruses (e.g., adenovirus, rotavirus, Norwalk virus)
- Escherichia coli, Clostridium difficile and Campylobacter, Salmonella, and Shigella are common bacterial causes
- Bacillus cereus, Clostridium perfringens, Staphylococcus aureus, Salmonella, and others cause food poisoning
- Entamoeba histolytica and Giardia, Cryptosporidium, and Cyclospora are parasitic or protozoal agents that cause diarrhea.
|Causative agent||Incubation period||Duration of illness|
|1.Rotavirus||1-4 days||4-8 days|
|2.Norovirus||12-48 hrs||12-60 hrs|
|4.EHEC||1-8 days||5-10 days|
|5.Salmonella spp.||1-3 days||4-7 days|
|6.Shigella spp.||24-48 hrs||4-7 days|
|7.Bacillus cereus||1-6 hrs||24 hrs|
|8.Clostridium perfringens||8-16hrs||24-48 hrs|
|9.Staph aureus.||1-6hrs||24-48 hrs|
|10.Vibrio cholera||24-72 hrs||3-7 days|
|11.Entamoeba histolytica||2-3d to 1-4 Wks||Several wks to mths|
|12.Giardia lamblia||1-2 Wks||Days to wks|
- Acute renal failure
- Septicemia & septic shock
- Hemolysis, renal failure & hemorrhage
- Hemolytic uremic syndrome
Assessment of hydration status
|Symptom||Minimal/ no dehydration (<3% wt loss)||Mild to moderate dehydration 3-9% wt loss)||Severe dehydration (>9% wt loss)|
|1.Mental status||Well alert||Normal, fatigue or restless, irritable||Apathetic, lethargic, unconsciousness|
|2.Thirst||Drinks normally||Thirsty, eager to drink||Drinks poorly, unable to drink|
|3.Heart Rate||Normal||Normal to increased||Tachycardia, bradycardia.|
|4.Quality of pulses||Normal||Normal to decreased||Weak, thready|
|6.Eyes||Normal||Slightly sunken||Deeply sunken|
|8.Mouth & tongue||Moist||Dry||Parched|
|9.Skinfold||Instant recoil||Recoil in < 2sec||Recoil in >2 sec|
|12.Urine output||Normal to decrease||Decreased||Minimal|
Assessment of hydration status (IMCI Protocol)
|Clinical signs General condition Eyes
Go back quickly
Drinks eagerly, thirsty Goes back slowly
Goes back very slowly
|Decide||No signs of dehydration||If the patient has 2 or more signs, there is “some signs of dehydration”||If the patient has 2 or more signs, there is “severe dehydration”|
|Plan||Plan A||Plan B||Plan C|
* infant < 2mths of age, thirst is not assessed & decision regarding ‘some’ or ‘severe’ dehydration is made if 2 of the 3 signs are present
Guidelines for replacement of Fluid & Electrolytes
- < 6 months- quarter glass or cup( 50ml)
- 7 months- 2 years- quarter to ½ glass or cup(50-100ml)
- 2-5 yrs ½ to 1 glass or cup(100-200ml)
- Older children- as much as the child can take.
- Correction of dehydration- ORS @ 75ml/kg over a period of 4 hours.
- Reassess after 4 hours-if still dehydrated, repeat deficit therapy. If rehydrated, treat as “no dehydration” with Plan A
- If ORT is not successful, treat as “ severe dehydration” with intravenous fluids as in Plan C.
|Infant (<1 year)||Older child (>1 year)|
|Volume of Ringers lactate||30ml/kg body wt within first 1 hour followed by 70 ml/kg body wt over next 5 hours||30ml/kg body wt within ½ hour followed by 70ml/kg body wt over the next 2.5 hours|
Monitoring – Access for improvement every 1-2 hours
If not improving, give iv infusion more rapidly
Encourage oral feeding by giving ORS @ 5ml/kg/hr along with iv fluid as soon as the child is able to drink.
Reassess hydration status- After 6 hrs/3 hrs assess hydration status & choose an appropriate plan(A, B or C)
Clinical evaluation of dehydration
- Mild dehydration (<5% in infant,<3% in an older child or adult)- normal or increased pulse, decreased urine output, thirsty, normal physical finding
- Moderate dehydration (5-10% in an infant, 3-6% in older child or adult)- tachycardia, little or no urine output, irritable/lethargic, sunken eyes & fontanelle, decreased tears, dry mucus membranes, mild delay in elasticity (skin turgor), delayed capillary refill (>1.5 sec) cool & pale
Clinical evaluation of dehydration
- Severe dehydration (>10% in an infant; >6% in older child or adult)- rapid & weak or absent peripheral pulses, decreased blood pressure, no urine output, very sunken eyes & fontanelle, no tears, parched mucus membrane, delayed elasticity (poor skin turgor), very delayed CRT (>3 sec), cold & mottled, limp, depressed consciousness
Fluid management of dehydration
- Restore intravascular volume- 20ml/kg NS over 20 min. Repeat as needed.
- Calculate 24 hrs fluid needs- maintenance + deficit volume
- Subtract isotonic fluid already
administered from 24 hrs fluid needs
Fluid management of dehydration
- Administer remaining volume over 24 hrs using ½ NS + 5% Dextrose & 20meq/l KCl
- Replace ongoing loss as they occur
- In a child with a known or probable metabolic alkalosis (child with isolated vomiting), RL should not be used as lactate will worsen the alkalosis.
- Because dehydration can be associated with acute renal failure & hyperkalemia, potassium is
withheld from IV fluid until the patient has voided.
Summary of treatment
|Degree of dehydration||Rehydration therapy||Replacement of losses||Nutrition|
|Minimal or no dehydration||Not applicable||<10 kg: 60-120 ml >10 kg:120-240 ml ORS for each diarrheal episode/vomiting||Breast feeding + age appropriate normal diet with adequate calorie intake|
|Mild to moderate dehydration||ORS, 50-100 ml/kg body wt over 3-4 hrs||Same||Same|
|Severe dehydration||RL or NS in 20ml/kg body wt IV until perfusion & mental status improve, then 100ml/kg body wt ORS over 4 hr, or ½ NS & 5% D IV at 2* maintenance dose||Same, if unable to drink, administer through NG tube or administer 5% Dextrose with1/2 NS with 20 meq/l KCL IV||Same|
Oral rehydration salts (ORS) solutions
- Preservation of the facilitated glucose-sodium cotransport system in the small-bowel mucosa is the rationale of oral rehydration therapy.
- Greater net absorption of an isotonic salt solution with glucose than of one without it.
- Potassium replacement during acute diarrhea prevents below-normal serum concentrations of potassium
- Bicarbonate and citrate are equally effective in correcting the metabolic acidosis caused by diarrhea and dehydration
Oral Rehydration Salt
|Potassium chloride||1.5||Glucose, anhydrous||75|
|Trisodium citrate dihydrate||2.9||Potassium||20|
Advantages of this new reduced osmolarity ORS solution
- It reduces stool output or stool volume by about 25% when compared to the original WHO-UNICEF ORS solution
- It reduces vomiting by almost 30%
- It reduces the need for unscheduled IV therapy by more than 30%.
- According to the MOHP and 2001 NDHS, nearly all mothers of children under 5 years old in Nepal know about ORS packets (97.8 percent); however, only 32 percent of mothers administered ORS during a recent bout of diarrhea
Fluids to avoid
- Fluids causing hypernatremia -most soft drinks
-sweetened fruit drinks
- Fluids with stimulant, diuretic or purgative effect -coffee
-some medicinal teas
Clinical approach to diagnosis
- Access in the examination- physical signs of dehydration, nutritional status of a child, presence of other infections & signs of shock.
- Rotavirus diarrhea- vomiting is early feature & diarrhea is more severe.
- Large & watery stool in secretory diarrhea- ETEC or Vibrio cholerae (rice watery)
- Fever, abdominal cramps & tenesmus with the passing of blood & mucus in dysentery (colitis)
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