FLUID AND ELECTROLYTES

SCOPE
1. FLUIDS
> COMPONENTS
> TOTAL BODY WATER
> FLUID COMPARTMENTS
> REGULATION OF BODY WATER
> MECHANISMS OF WATER
DISTRIBUTION
> OSMOLALITY OF BODY FLUIDS

SCOPE
2. ELECTROLYTES
> SODIUM
> POTASSIUM
> CALCIUM
> MAGNESIUM
> CHLORIDE
> PHOSPORUS

SCOPE
3. ACID BASE BALANCE
4. FLUID THERAPY
> MAINTENANCE
> DEFICIT
5. DIARRHEA
> ASSESSMENT OF DHN
> ORS
> IV
> DIARRHEA TREATMENT PLANS

FLUIDS AND ELECTROLYTES

Children are prone to fluid and electrolyte
problems: WHY?
1. Higher metabolic rate relative to weight
( 2x over adult)
2. Larger skin surface area in relation to
body water
3. Tend to loss more proportionate to body
weight
4. Immaturity of kidneys

FLUIDS AND ELECTROLYTES

Gen. Considerations:
total amount of water and electrolytes as
a whole
Water and solutes in various
compartments
Concentration of solutes within its
compartment

FLUIDS AND ELECTROLYTES

Fluid compartments
TBW
Intracellular Extra cellular
Newborn= 75-80%
40%
30-35%
Children= 65%
40%
25%
Intravascular=16%
Insterstitial= 9%
Adults= 60%
40%
20%

FLUID COMPARTMENTS
Intracellular
(30-40%)

Instertitial
(15%)

Plasma
(5%)

Extracellular
( 20-25%)

ELECTROLYTES
Extracellular Fluid
Cations

Na=140

Anions

Intracellular Fluid
Cations

Anions

Phos=107
Cl=104

K= 140

HCO3=24
Prot=40

Prot=14
K=4
Ca=2.5
Mg=1.1

Other=6
Phos=2

Na=13

HCO3

Phos=2

Cl=3

Fluid Balance
2 barriers separate ICF, interstitial fluid and plasma
Plasma membrane separates ICF from surrounding
interstitial fluid
Blood vessel wall divide interstitial fluid from plasma
Body is in fluid balance when required amounts of water
and solutes are present and correctly proportioned
among compartments
An inorganic substance that dissociates into ions in
solution is called an electrolyte
Water is by far the largest single component of the body
making up 45-75% of total body mass
Process of filtration, reabsorption, diffusion, and osmosis
all continual exchange of water and solutes among
Copyright 2009, John Wiley &
compartments
Sons, Inc.

ICF differs considerably from ECF

ECF most abundant cation is Na+, anion is Cl Sodium
Impulse transmission, muscle contraction, fluid and electrolyte balance

Chloride
Regulating osmotic pressure, forming HCl in gastric acid
Controlled indirectly by ADH and processes that affect renal reabsorption of
sodium

ICF most abundant cation is K+, anion are proteins and phosphates
(HPO42-)
Potassium

Resting membrane potential , action potentials of nerves and muscles

Maintain intracellular volume
Regulation of pH
Controlled by aldosterone

Na+ /K+ pumps play major role in keeping K+ high inside cells and
Na+ high outside cell

Copyright 2009, John Wiley &

Sons, Inc.

FLUIDS AND ELECTROLYTES

Intracellular volume is maintained by:
1. Active transport of electrolytes
Na+ (OUT)
ATP-ase pump
K+ (IN)
2. Water by passive diffusion

FLUIDS AND ELECTROLYTES

Intravascular (ECF) volume is maintained
by:
1. Filtration =at the capillary level
2. Oncotic pressure = mainly by ALBUMIN
in the plasma

FLUIDS AND ELECTROLYTES

BODY WATER REGULATION
maintained at PLASMA OSMOLALITY=
285-295 mOSM/ k water
Involved: osmoreceptors
volume receptors
hypothalamus
posterior pituitary
collecting ducts of nephron

FLUIDS AND ELECTROLYTES

BODY WATER REGULATION
Intake regulation: by thirst
Conditions that generate thirst:
Plasma osmolality raised by 1-2 %
Volume depletion
Renin-angiotensin stimulation

FLUIDS AND ELECTROLYTES

BODY WATER REGULATION
Disturbance in thirst mechanism:
1. CNS disorders
2. K+ deficiency
3. malnutrition

FLUIDS AND ELECTROLYTES

BODY WATER REGULATION
Absorption in GIT- HOW? Passive diffusion
1. Na+ K+ pump= requires energy
2. Sodium-glucose co-transport
3. Others

FLUIDS AND ELECTROLYTES

BODY WATER REGULATION
Excretion
lungs: evaporative
skin: evaporative
obligatory losses
urine

Daily Water Gain and Loss

Copyright 2009, John Wiley &

Sons, Inc.

FLUIDS AND ELECTROLYTES

BODY WATER REGULATION
Volume of urine is regulated by:
1. Plasma osmolality ( thru the neurohypophyseal-renal axis
2. GFR
3. Renal tubular epithelium
4. Plasma adrenal steroids

FLUID THERAPY
1. Maintenance
A. Normal maintenance= replaces normal
losses
B. Active maintenance= replaces ongoing
abnormal losses
2. Deficit = replaces PREVIOUS losses

FLUID THERAPY
MAINTENANCE
GOAL: Maintain normal body water content
HOW?
1. Replace normal obligatory losses
2. Replace ONGOING abnormal losses
3. Prevent dehydration from occurring even
in the presence of ongoing abnormal
losses

Additional goals of maintenance fluids:

1. Prevent electrolyte disorder
2. Prevent ketoacidosis
3. Prevent protein degradation
Composition of a good maintenance fluid:
1 Water
2 Glucose
3 Sodium
4 Potassium
*** Glucose in D5 conc. Provides 17 calories/100 ml and
nearly 20 % of the total daily caloric need; enough to
prevent ketone production and protein degradation.

A patient receiving maintenance intravenous

fluids is receiving inadequate calories and
will lose 0.5 to 1 % of weight each day.

DAILY MAINTENANCE FLUID

VOLUME
Based on body weight
0-10 kg
100 ml/kg/24 hrs
11-20 kg
1000 ml//24 hrs PLUS
50 ml for every extra kg
above 10 kg
>20 kg
1500 ml//24 hrs PLUS
20 ml for every extra kg
above 20 kg
CEILING!!!
2400 ml/24 hrs or 100 ml/hr

MAINTENANCE FLUID
VOLUME HOURLY
Used if 24 hrcalculation is not needed but
HOURLY!!
0-10 kg
4 ml/kg/hr
11-20 kg
40 ml/hr PLUS 2 ml for
every extra kg above 10kg
>20 kg
60 ml/hr PLUS 1 ml for
every kg above 20 kg
Ceiling: 100 ml/hr

MAINTENANCE FLUID
VOLUME HOURLY
> 1ST 10 kg= 4 ml/kg/hr
2nd 10 kg= 2 ml/kg/hr
3rd 10 kg = 1 ml/kg/r

Ceiling: 100 ml/hr

REMINDER!!!!
1 For obese patients there might be an
overestimation of the maintenance
volume.
Instead: Base the calculation on the lean
body weight or on the 50%th percentile or
Median Z score of the weight for height
OR
use the ceiling: 2400 ml/24 hrs

FLUID THERAPY
MAINTENANCE
Based on surface area
1. Determine the surface area using the
weight in kg
SA = kg x 4 + 9
100
2. Multiply SA by 1500 ml/24 hrs

FLUID THERAPY
HOW TO CALCULATE RATES of FLUID
ADMINISTRATION
1. Determine rate/hour= divide total fluid volume (in
ml) by 24 ( ml/hr
2. Determine rate/min = divide no. 1 by 60 (ml/min)
3. Determine rate microdrips/min = multiply no. 2
with 60= (microdrips/min)
Basis: 60 udrips in one ml OR
4. Multiply no. 2 with 15 = drops per minute
Basis: 15 drops in one ml
5. SHORTCUT!!! ML/HOUR = MICRODRIPS/MINUTE
ML/HOUR 4 = DROPS/MIN

FLUID THERAPY
Maintenance
A. Normal maintenance
B. Active maintenance=replacing ONGOING
ABNORMAL LOSSES
HOW?
1. Determine the amount of WATER lost
(volume for volume)
2. Determine the ELECTROLYTE COMPOSITION
of the body fluid lost

DECREASES or INCREASES
to the maintenance fluid
Decreases:
1. Humidified gases
MF x 0.75
2. Paralyzed
MF x 0.7
3. High ADH (IPPV or coma) MF x 0.7
4. Hypothermia
MF -12% per
C core temp below 37
5 High ambient humidity
MF x 0.7
6 Renal failure
MF x 0.3
(+urine output)

INCREASES
1 Full activity and oral feeds MF x1.5 free fluids
2 Fever
MF +12 % per C core
temp above 37
3 Room temp. >31C
MF +30% per C rise
above 31
4 Hyperventilation
MF x 1.2
5 Preterm neonate(<1.5 kg)
MF x 1.2
6 Radiant heater
MF x 1.5
7 Phototherapy
MF x 1.5
8 Burns Day 1
MF + 4% per 1% of
body
surface affected
9 Burns Day 2+
MF + 2% per 1% of
body surface affected

FLUID THERAPY
Electrolytes content of Body Fluids (meq/L)
K+
ClNa+
Gastric
20-80
5-20
100-150
Pancreatic 120-140
5-15
90-120
Small I
100-140
5-15
90-130
Bile
120-140
5-15
80-120
Ileostomy
45-135
3-15
20-115
Diarrhea
10-90
10-80
10-110
Sweat
10-30
3-10
10-35
Burns
140
5
110

IF VOLUMES OF FLUID LOST CAN NOT

BE MEASURED? ESTIMATE!!!
1. DIARRHEA STOOL= 10
ML/KG/EPISODE
2. VOMITING= 2 ML/KG/EPISODE

FLUID THERAPY
Indicators that maintenance fluids are
adequate:
1. Body weight maintained
2. Thirst does not occur
3. Urinary output not less than 1.0-1.5
ml/kg/hr

CASE
A 14 month was admitted for fever, extensive
mouth ulcers and inability to swallow food and
oral fluids. Wt: 8.6 kg. Temp: 40C. IVF
administration was decided
Questions:
1. Calculate the total normal maintenance fluid
for 24 hours including the volume added for
fever (Use Holliday Segar and surface area.
2 What is the IVF rate per minute in microdrips
and macrodrops

Given: 8.6kg, temp: 40.0 degrees

Holliday segar calculation:
8.6kg x 100ml/24hr = 860ml/24hr
Inc for fever
12% mf x MF x 3=
0.12 x 860ml MF x 3= 309
860 + 309 = 1269ml MF/24hr
1170 /24hr = 49ml/hr
49 mic gtt/min
12 gtt/min

Surface area
Wt x 4 + 9/ 100
8.6 x 4 +9 /100 = 0.434 x1500ml/24hr MF/24
=651 ml/24hr
12% of 651ml x 3= 234ml
651ml + 234 ml= 885 ml/24hr
37ml/hr or 37 mic gtt/min
9 gtt/min

FLUID THERAPY
DEFICIT THERAPY
Goals:
1. To correct fluid loss
2. To correct osmolality= Sodium
3. To correct other electrolyte losses
4. To correct acid-base imbalance

FLUID THERAPY
Essential problems!!!
1. How RAPID and how SEVERE the loss
was
2. TYPE of loss-depending on the
electrolyte/acid or base content of the
fluid lost

FLUID THERAPY
THE BEST GUIDE FOR ASSESSMENT OF
FLUID LOSS IS THE ACUTE CHANGE IN
BODY WEIGHT

FLUID THERAPY
Acute change in weight can be calculated:
1.Weight before the loss MINUS weight after
the loss
2. Determine the percent weight loss:
weight loss DIVIDED by weight before
loss then MULTIPLY by 100
3. Determine severity of deficit (dehydration)

FLUID THERAPY
Mild
Moderate
Severe

INFANTS
CHILDREN
3-5
% wt loss
3%
5-10 % wt loss
6%
10
% wt loss
9%

FLUID THERAPY
To determine the amount of DEFICIT FLUID
to administer based on the PERCENT
WEIGHT LOSS:
Infant
Children
Mild
30-50 ml/kg
30 ml/kg
Moderate
60-90 ml/kg
60 ml/kg
Severe
100-150 ml/kg 90 ml/kg

FLUID THERAPY
Clinical Manifestations of Dehydration
1. Weight loss
2. Thirst = 5% or more of wt. loss (1-2% increase
in plasma osmolality)
3. Mucus membranes=dry
4. Skin elasticity = lost
5. Fontanelles depressed
6. Gen. condition= irritable to lethargic, coma

FLUID THERAPY
Clinical manifestations of dehydration
7. Circulation
> cool, mottled
> tachycardic
> thin, thready pulse
> low BP, narrow pulse pressure (less than 20 mm Hg)
> Capillary refill time (CRT)
< 2 sec= loss is less than 50 ml/kg
2-3 sec = loss is 50-90 ml/kg
> 3 sec = loss is 100 ml/kg or more

FLUID THERAPY

Signs of dehydration acc. to severity:

Mild
Moderate
Severe
General alert
irritable
lethargic,coma
Thirst
thirsty
thirsty
not able todrink
Fntanelles normal sunken
sunken
Eyes
normal sunken
very sunken,dry
Tears
normal none
none
Mucosa wet
dry
very dry
Skin pinch GBQ
slowly
very slowly
Vital signs:
RR
normal rapid
rapid,deep
Pulses
normal fast
fast, thready or none
BP
normal normal,low
very low

FLUID THERAPY
To determine DEGREE OF DEHYDRATION using clinical
manifestations:
1. Look at the column of Severe dehydration
2. If there are two or more signs in the column, classify
as SEVERE DHN, if one or none
3. Look at column of Moderate DHN
4. If there are two or more signs in the column, classify
as Moderate DHN, if one or none go to the column of
Mild DHN
5. Classify as Mild DHN, if thirst is present even if the
only sign present
6. Classify as No DHN if the child has diarrhea with no
signs of DHN identified

FLUID THERAPY
To determine deficit fluid therapy based on
clinical manifestations:
Infant
Children
Mild
30-50 ml/kg
30 ml/kg
Moderate
60-90 ml/kg
60 ml/kg
Severe
100-150 ml/kg 90 ml/kg

FLUID THERAPY(Method A)
DURATION OF DEFICIT PHASE (3-6 hrs)
Note: this method is used for dehydration sec. to diarrhea
Two phases
1. Rapid phase
2. Repair
Amount:
Amount:
Mild= no rapid phase
total amount
Moderate= of the total deficit
3/4
Severe = 1/3 of the total deficit
2/3
How fast:
Infants = one hour
5 hrs
Children= 30 minutes
2 or 3 hrs
NOTE: IN SHOCK, AS FAST, AND VOLUMES CAN
BE REPEATED A NUMBER OF TIMES UNTIL OUT
OF SHOCK

DEFICIT(Method B)
24- HR REHYDRATION
Phase 1: Emergency= to one hour
Plasma volume
( may be skipped if no circulation
problems)
Phase 2: Repletion= 6-7 hours
ECF volume
( the 1st hour is usually faster to initiate urination)
Phase 3: Early recovery= 16-18 hours
ICF volume

FLUID MANAGEMENT OF DEHYDRATION (Method B)

Step 1: Restore intravascular (plasma) volume
(20 ml/kg in 20 minutes)
Step 2: Calculate 24-hr water needs
a. calculate maintenance
b. calculate deficit
Step 3: Calculate electrolyte needs
a. calculate maintenance sodium/K
b. calculate deficit sodium/K
Step 4: Select an appropriate fluid based on
water and electrolyte needs
a. administer half the total calculated in Step 2 for
the FIRST 8 HOURS
Note: subtract first the boluses given in Step 1
b. administer the remaining in 16 hours
Step 5: Replace ongoing losses as they occur

CASE EXERCISE:
1. 11-month old child, wt.= 8 kg, assessed to be moderately
dehydrated. No signs of circulation problem.
Calculate: Total deficit fluid volume and the allocation of
volumes per unit time (hr)
Calculate the normal maintenance after rehydration
2. Assume ongoing abnormal losses (one episode of
vomiting, 2 episodes of diarrhea.) How do you replace?

CASE Method A
total deficit:
8 x 90 ml = 720 ml
of 720 for the 1st hour= 180 ml per hour
of 720 for next 5 hrs= 540/5= 108 ml per hour
replacement of ongoing losses NOT DONE
during deficit phase.
Once hydrated if there are losses:

10mlx8x2= 160 ml ( diarrhea)

2x8x1= 16 ml (vomiting)

CASE
HOW TO REPLACE ONGOING LOSSES
1 WHAT FLUID/HOW
A ORS= by sips, teaspoon,
dropper
B IV fluid= fast drip separate
from the deficit fluid volume
2 HOW much: A volume for volume
B Estimate

CASE METHOD B
Step 2: Calculate 24-hr water needs
a. calculate maintenance
b. calculate deficit
Ans 8 X 100 = 800 ml/24 hrs
8 X 90 = 720 ml
2 Step 4: Select an appropriate fluid based on
water and electrolyte needs
a. administer half the total calculated in Step 2 for
the FIRST 8 HOURS
Note: subtract first the boluses given in Step 1
b. administer the remaining in 16 hours
Ans: 800+ 720= 1520 ml
1520/ 2= 760
760/8 = 95 ml per hour 1st 8 hours
760/16= 48 ml per hour next 16 hours

CASE
TO REPLACE LOSSES USING METHOD
B
1 Replace the losses as soon as lost AT
ANYTIME DURING THE 24 HR FLUID
PLAN
2 VOLUME FOR VOLUME OR ESTIMATE
3 ORS OR IVFLUID

ELECTROLYTE
Calculation of electrolyte maintenance and
deficit:
1. Maintenance
Sodium: 2-3 meq/kg/24 hrs
Potassium: 1-2 meq/kg/24 hrs
2. Deficit
Sodium: Water deficit x 80 meq/L
Potassium: Water deficit x 30 meq/L

CASE 11 month old, 8 kg

Step 3: Calculate electrolyte needs
a. calculate maintenance sodium/K
b. calculate deficit sodium/K
Maintenance
Na:3meq x 8= 24 meq
K: 2 meq x 8= 16 meq
Deficit
Na: 0.720 L x 80meq/L= 57 meq (56.6)
K: 0.720 Lx 30 meq/L= 22 meq (21.6)

IONIC COMPOSITION OF INTRAVENOUS INFUSION

SOLUTIONS
Solution

Cation- mmol/L
Na+

Anion- mmol/L

K+

Cl-

Lactate

Glucose

Ringers
Lactate

130

109

28

D5 LR

130

109

28

278

Dhaka soln

133

13

98

48

140

Half-strength
Darrow soln
In D5W

61

17

51

27

278

Normal saline
(0.9% Nacl)

154

154

278

Normosol M
In D5W

40

13

40

16 (acetate)

234

FLUID THERAPY
Osmolality disturbance
1. Isotonic dehydration
a. serum sodium = 135-140 meq/L
b. water and sodium proportionately lost
2. Hypotonic dehydration
a. serum sodium = < 130 meq/L
b. Na+ is lost MORE than water
3. Hypertonic dehydration
a. serum sodium = 150 meq/L
b. Na+ is lost LESS than water

FLUID THERAPY
Signs of Iso, Hypo, Hypertonic DHN
Isotonic
SerumNa+ 135-140
Serum Os 280
Skin
dry
poor elasticity
Lips
dry
CNS

lethargic

BP
Temp

normal to low
normal to low

Hypotonic
< 130
<260
clammy, cold
very poor
clammy, moist
extreme
comatose
convulsions

very low
low

Hypertonic
150
300
warm, doughy
normal to poor
parched
thirst
lethargic
hyperirritable
convulsions
hyperreflexia
normal BP
febrile

ELECTROLYTES
SODIUM
1. Hypernatremia ( 145 meq/L)
Causes: Excessive sodium
Water deficit
Both water and sodium deficits
Ref. Box 45 p 197 17th edition
Clin. Manifestations:
Dehydration
CNS symptoms= brain hemorrhage,stroke
Hyperglycemia
Hypocalcemia
Rapid overcorrection= cerebral edema

ELECTROLYTES
SODIUM
Hyponatremia(< 135 meq/L)
Causes: Pseudohyponatremia
Hyperosmolality
Hypovolemic
Euvolemic
Hypervolemic
Ref. Box 45-2 p 199
Clin. Manifestations:
Brain sweling
Rapid overcorrection: seizures

ELECTROLYTES
POTASSIUM
Hyperkalemia
Causes: Box 45-4 p 204
Clini. Manifestations:
Ecg changes= peak T wave, prolonged PR interval, flat P, widen QRS
Renal failure
Acidosis
Hypokalemia
Causes: Box 45-5 p 206
Ecg= flattened T wave, depressed ST segment, ventricular fib, muscle
weakness and cramps, polyuria, polydipsia, metabolic
acidosis/alkalosis,

ELECTROLYTES
CALCIUM
HYPOCALCEMIA
Causes: Box 45-6 p 210
Clin. Manifestations:
neuromuscular irritability
paresthesias
tetany=carpopedal spasm, laryngospasm,
seizures, Chvostek, Trosseau
Ecg= prolonged QT,prolonged ST, peaked
T waves, arrythmia, impaired cardiac contractility

ELECTROLYTE
CALCIUM
Hypercalcemia
Causes: Box 45-7 214
Clin. Manifestations: poor feed, emesis,
failure to thrive, psychiatric manif.
pancreatitis

ELECTROLYTES
MAGNESIUM
Hypomagnesemia (hypocalcemia)
Causes: Box 45-9 p 218
Clin. manifestations=tetany, Chvostek,
Trosseau, seizures
Hypermagnesemia
Clin. Manifestations= hypotonia,
hyporeflexia, paralysis, CNS depression,

ELECTROLYTES
PHOSPORUS
Hypophosphatemia
Causes: Box 45-10 p 221
Clin. manifestations= acute and chronic,
rickets, poor mineralization, hemolysis of
RBC, muscle weakness and atrophy,
rhabdomyolysis, cardiac dysfunction, CNs

ELECTROLYTES
HYPERPHOSPHATEMIA
Causes: Box 45-11 p 223
Clin. Manifestations= hypocalcemia

ACID-BASE
For further readings
CAUSES:
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis

DIARRHEA

DIARRHEA
Def. increase in fluid loss in stool
(> 100-200 ml/24 hrs)
:increase in frequency of stools
:blood in the stool

DIARRHEA
Fluid Balance in the GIT:

ABSORPTION = SECRETION

DIARRHEA
ABNORMAL FLUID BALANCE:
1. Decreased absorption
2. Increased secretion
3. Combination of both 1 and 2

DIARRHEA
Intestinal absorption of water
Oral intake (1- 1 1/2 liters/day)
+
Saliva (11/2 liters
+
Gastric, pancreatic secretions (5 to 6 liters)
TOTAL: 9 liters enters the small I/day

Normal fluid balance

Jejunum

9 liters
Water with Na+, Cl-,K+ are absorbed
(8 liters/day)
HC03 is secreted

Ileum
1 to 11/2 liters enters colon/day

Colon

Na+ and Cl- are absorbed

K+ and HC03 are secreted

100-200 ml of fluid excreted in stool

DIARRHEA
Mechanisms of diarrhea
1. Invasion of the mucosa
a. Virus= at the jejunum
b. Invasive bacteria (Shigella) = at the
terminal ileum (dysentery)
2. Toxin-mediated (Cholera, ETEC)
a. site: jejunum

brush borders

v
i
l
l
u
s

villus cells

crypt cells

NORMAL GUT

DESTROYED GUT

START OF REGENERATION

CRYPT CELLS AT VILLUS TIPS

brush borders

v
i
l
l
u
s

villus cells

crypt cells

NORMAL GUT

CAMP

brush borders
villus cells

NA+
v
i
l
l
u
s
crypt cells

NORMAL GUT

X
Cl-

DIARRHEA
Gen. principles of fluid treatment
As soon as diarrhea starts:
1. Maintain hydration or prevent dehydration
HOW? A.Give Normal Maintenance= normal fluids
B. Active replacement
> home fluids
> oral maintenance solutions (OMS)
OMS= 30-60 Na+ meq/L
= 20 K+ meq/L
= glucose
ORS= 60-90 Na+ meq/L
2. Treat dehydration, if No.1 fails

SODIUM GLUCOSE CO-TRANSPORT

DIARRHEA
Oral Fluids for Active Replacement in
Diarrhea
1. Home fluids
OMS
>soups
>Glucolyte
> fruit juice
>Hydrite
>water
>Pedialyte
>breast milk
>Glucost
>am (rice water)
3. ORS = Na+ is 75-90 meq/L

ORT-RECENT DEVELOPMENTS
1. REDUCED ORMOLARITY ORS
2. ZINC SUPPLEMENTATION

WHO GUIDELINES FOR A SAFE AND

EFFECTIVE ORS (1992)
1. Total osmolarity: 200-311
2. Glucose: equal to sodium but not exceed
111
3. Sodium: 60-90 mmol/L
4. Potassium: 15-25 mmol/L
5. Citrate: 8-12 mmol/L
6. Chloride: 50-80 mmol/L

COMPOSITION OF STANDARD ORS:

GLUCOSE

111 MMOLE/L

SODIUM

90

CHLORIDE
POTASSIUM
CITRATE

80 MMOLE/L
20 MMOLE/L
10 MMOLE/L

MMOLE/L

TOTAL OSMOLARITY

311 MMOLE/L

Standard ORS:
1. WHO/UNICEF recommended
2. Glucose-based
3. Prevent/treat dehydration from diarrhea
4. Any age
CONCERNS:
1. Slightly hyperosmolar to plasma
2. Does not reduce stool output
3. Does not shorten the diarrheal episode

Improved ORS
1. Safe and effective to treat dehydration or
prevent dehydration in all types of
diarrhea
2. Reduced stool output
3. Other benefits

IMPROVED ORS
2 APPROACHES:
1. Reducing the osmolarity of ORS
2. Modifying the amount and type of organic
carriers to promote intestinal absorption
How?
1. Replacing glucose with complex carbohydrate
2. Reducing the concentration of glucose and salt

Composition of standard and reduced osmolarity ORS solutions

Reduced Osmolarity ORS
solutions
Standard
ORS
solution
(meq/L

(mEq or
mmol/L
21

mEq or
mmol/L
6, 14, 2227

(mEq or
mmol/L
13, 15-18,
28-29

111

111

75-90

75

Sodium

90

50

60-70

75

Chloride

80

40

60-70

65

Potassium

20

20

20

20

Citrate

10

30

10

10

Osmolarity

311

251

210-260

245

Glucose

Reduced Osmolarity ORS

1. Reduction in the need for unscheduled
IVF therapy= by 35%
2. Reduction of stool output= by 20 %
3. Reduction in incidence of vomiting=
by 30%
4. Incidence of hyponatremia is higher

REDUCED OSMOLARITY ORS

MMOL/LITER
SODIUM
75
CHLORIDE
65
GLUCOSE
75
POTASSIUM
20
CITRATE
10
TOTAL

245

ZINC SUPPLEMENTATION
What happened to zinc during diarrhea:
1. Increased stool zinc loss
2. Negative zinc balance
3. Reduced tissue levels of zinc
Role of zinc in body function?
1. Cellular growth
2. Positive effect on the immune system
3. Others

 Although the theoretical basis of the

potential role of zinc has been postulated
for some time, convincing evidence of its
importance in child health just recently has
come after randomized control trials

ZINC SUPPLEMENTATION
BENEFITS
1. If given as soon as diarrhea starts:
= reduce the duration, severity, risk of
dehydration
2. If continued for 14 days:
= reduce the occurrence of new
episodes of diarrhea in the next 2-3
months

ZINC SUPPLEMENTATION
DOSAGE: for 14 days
< 6 MONTHS: 10 MG/DAY
6 MONTHS: 20 MG/DAY

ACUTE DIARRHEA
TREATMENT OF DIARRHEA
OBJECTIVES
: to prevent dehydration if there are no signs
: to treat dehydration if it is present
: to prevent nutritional damage
: to reduce the duration and severity of diarrhea,
and the occurrence of future episodes by giving
supplemental zinc

DIARRHEA
Fluids often used for active replacement of diarrhea loss
Sodium
Potassium Osmolality
Soups 114-251
2.2-17
290-507
Juices 0.1-10
24-65
542-1190
(Gatorade)
Sodas 1.7-5.5
0.1-1.5
523-601
Water 1
0.5
48-50
Coconut 5.4
32-53
255-333
Tea
0
5
B milk
7
13

ACUTE DIARRHEAS
ASSESS FOR DEHYDRATION
SIGNS
1.General condition=lethargy, stupor,
irritability
2. Eyes= sunken, without tears
3. Mouth and tongue= dry
4. RR=rapid, maybe deep
5. Ability to drink= not able to drink, poorly, thirsty
6. Skin turgor= lost
7. Fontanelles = sunken
8. Circulation= signs of shock

ACUTE DIARRHEAS
ASSESSMENT OF DEHYDRATION
FF SIGNS ARE RELIABLE SIGNS TO ASSESS
DHN:
1. General condition=drowsy,lethargic,
irritable
2. Eyes=sunken
3. Offer water= not able to drink, drinking poorly,
thirsty
4. Skin pinch= goes back very slowly, slowly

Assessment of diarrhea patients for dehydration

A
Look at:Condition
Eyes

Thirst

Well, alert

Restless,irritable

Normal

Sunken

Lethargic,
unconscious
Sunken

Thirsty, drinks
eagerly

Drinks poorly, or
Not able to drink

Drinks

normally

Feel: Skin pinch

Goes back
quickly

Goes back slowly

Goes back very

slowly

Decide:

No signs of
dehydration

Two or more
signs:
Some
Dehydration

Two or more signs:

Severe
Dehydration

ACUTE DIARRHEAS
SKIN PINCH

1.
2.

pt. lying flat= mothers lap or crib

Pinch a fold of skin
where: area of the abdomen between the umbilicus and side of
abdomen
how: >use forefinger and thumb, not fingertips
>pinch along longitudinal/vertical
axis
>pinch the skin to INCLUDE the subcutaneous
tissue
> release the fingers THEN observe the TIME the fold returns to
place
= within 2 secs.(slowly)
= more than 2 secs (very slowly)

ACUTE DIARRHEAS

ASSESSMENT OF DEHYDRATION
1. Two of the ff. signs:
Drowsy, lethargic
Sunken eyes
Not able to drink, drinking poorly
Skin pinch goes back very slowly

SEVERE DEHYDRATION

ACUTE DIARRHEAS
ASSESSMENT OF DEHYDRATION
2. Two of the ff signs:
Restless, irritable
Sunken eyes
Thirsty, drinks eagerly
Skin pinch goes back slowly

SOME DEHYDRATION

ACUTE DIARRHEAS
ASSESS DEHYDRATION
3. Not enough signs to classify as severe or
some dehydration

NO DEHYDRATION

ACUTE DIARRHEAS
HOME TREATMENT- PRINCIPLES
GOALS:to prevent dehydration
:to prevent malnutrition/promote gut
recovery
1. FLUIDS
2. Zinc
3. Food
4. ReFerral

ACUTE DIARRHEAS
HOME TREATMENT- PLAN A
1. FLUIDS
WHAT? home fluids, breastmilk, rice
water, soups, unsweetened
juices, coconut water, water
OMS= oral maintenance salts
ORS= oral rehydration salts

ACUTE DIARRHEAS
HOME TREATMENT- PLAN A
1. FLUIDS
WHAT?
HOW MUCH?
> as much, as tolerated OR
> 50-100 ml for < 2 yrs
> 100-200 ml for 2 -10 yrs

ACUTE DIARRHEAS
HOME TREATMENT- PLAN A

1.FLUIDS
2.FOOD
0-6 MONTHS= breastfeeding, usual milk if
not breastfed, try relactation
6mos.-59 mos= follow feeding
recommendation for age

ACUTE DIARRHEAS
HOME TREATMENT-PLAN A
1. FLUIDS
2. FOOD
3. reFERRAL
when to seek help:
- many watery stools, fever, uncontrolled
vomiting, blood in stool, seem sicker, drinking
poorly, marked thirst
4. Zinc

ACUTE DIARRHEAS
REHYDRATION TREATMENT PLAN B
for SOME DEHYDRATION

GOAL: to correct deficit fluid loss using ORS

1.
DETERMINE AMOUNT of ORS TO GIVE IN 4 HOURS
= using a table or 75 ml/k
= < 6 months old, formula fed: 100-200ml of
water in addition to ORS
= SHOW the mother the amount to give in 4 hrs.
2.
SHOW mother: how to give ORS slowly, by dropper or teaspoon,
when the child vomits; to stop ORS temporarily for 10 minutes,
then resume more slowly.
3.
MONITOR hydration status
4.
REASSESS after 4 hours
= select the appropriate Treatment Plan
= feed the child

ACUTE DIARRHEAS
REHYDRATION TREATMENT PLAN B
Indication for IV therapy:
1. Persistent vomiting
DEHYDRATION
WORSENS
Dehydration
worsens
2. Fast purging
may give ORS by NGT
3. Prolonged oliguria/anuria
IV therapy
4. Abdominal distention
5. Glucose intolerance

ACUTE DIARRHEAS
REHYDRATION TREATMENT PLAN C
1. Determine amount of IVF(Lactated Ringers) to give
immediately:

Age

Infants under 12
mos.
Children
(12 mos up)

First give
Then give
30 ml/kg in 70ml/k in
1 hour

5 hours

30 min

2 1/2 hours

CASE EXERCISE
An 11 month old infant, breastfed, had diarrhea
for 2 days. No other complaints. P.E.: sunken
eyes, irritable, drinks normally, skin pinch goes
back quickly. Other organ systems ok.
1 What is the degree of dehydration.
2 What is the diarrhea treatment plan. Describe
the details of the plan
3 After 4 hours the infant was reassessed:
no longer irritable, eyes still slightly sunken.
a What is the degree of dehydration now
b What is the treatment plan. Describe.