................................................................................................................................

Review of oral rehydration solutions for horses

with diarrhoea
P ECKE', DR H O D G S O N and RJ ROSE
Rural Veterinary Centre, Department of Animal Health, University of Sydney, Rural Veterinary Centre, PMB 4. Camden,
New South Wales 2570

Treatment considerations
Key words: Oral rehydration. horses, diarrhoea, fluid, electrolytes.
The rationale behind oral fluid therapy in horses with acute
diarrhoea is to offset colonic fluid losses through absorption of

A
cute diarrhoea is a recognised cause of life-threatening
the ORS from the small intestine. Depending on how much is
fluid and electrolyte disturbances in horses and other
absorbed (rate of administration and intestinal transit rate may
pecies. Yet when fluid therapy is necessary in these ani-
affect absorption), some ORS may pass through to the large
mals, clinicians mostly opt for intravenous administration,l,'
intestine and contribute to the faecal output. This accounts for
although there may be situations where oral fluids provide an
the common observation of diarrhoea becoming worse follow-
effective and cheap alternative or adjunct to therapy. Oral rehy-
ing ORS administration, despite an improvement in systemic
dration has limitations, and certainly not all fluids are suitable
fluid balance.
ORS.'
Different clinical syndromes of dehydration and/or hypo-
ORS are effective in treatment of human cholera.' and in
volaemia may require different strategies for replacement of
many cases of diarrhoea in neonatal calves and piglets.'." In
fluid and electrolyte losses. To ernphasise this point, three different
humans and calves, the use of oral fluids has been based on the
causes of dehydration in horses are compared in Table
need for a cost-effective treatment of large numbers of cases in
acute diarrhoea, heavy sweating and exhaustion following an
conditions where access to nursing staff and sterile administer-
endurance ride, and feed and water deprivation. For ease of com-
ing equipment is limited.'"-"
parison, horses are compared when suffering a similar degree of
Much of the pioneering work on ORS stems from studies of
water loss. While each suffers a water deficit of about 25 L
human cholera in developing c ~ u n t r i e s . ' ~ ' " ~Fluid
" ~ ' ~losses asso-
(about 5% body weight), the electrolyte losses differ markedly.
ciated with cholera and most cases of neonatal calf diarrhoea are
A single O R S would not be ideal in all three situations.
the result of impaired absorption in the small intestine. Despite
In order to replace a fluid deficit of 5 Yo body weight or more
this, the small intestine is the main site of absorption of ORS.
an initial volume of at least 20 L is required for an adult horse.
MicheP noted that there are several absorptive mechanisms for
When administered orally, this volume must be divided into
sodium operative in the intestine, and if disturbance of one of
smaller 8 to 10 L volumes and given at intervals of at least 15 to
these contributes to diarrhoea, then the remaining intact ones
20 minutes.'' Longer intervals, such as every few hours, may
provide a means for ORS to be absorbed.
prolong small intestinal transit and allow increased time for
While severely dehydrated animals are likely to need intra-
absorption.'" Reflux from the stomach tube is an indication to
venous fluids, oral fluids and intravenous therapy can be com-
stop administration. When the function of the small intestine is
bined. At the Rural Veterinary Centre we treat about 20 horses
compromised, or where administration of an ORS would exacer-
every year that require large volumes of intravenous fluid for the
bate an existing disease state, the intravenous route for fluid and
management of diarrhoea. Anecdotal evidence indicates that
electrolyte therapy should be chosen.
these horses undergo clinical improvement when part of the
Horses with acute diarrhoea suffer a mixed fluid and elec-
fluid and electrolyte deficit is treated through the oral route.
trolyte deficit as the result of several contributing factors:
Presence of disease states, such as proximal enteritis and ileus,
where administration of ORS may be detrimental to the horse, 0 There are increases in faecal sodium and water loss, while
are obvious contraindications. faecal potassium excretion may remain unchanged?",!'
The effectiveness of ORS for treatment of diarrhoea may vary. 0 Lack of feed intake, which predominantly affects the
In calves the success of ORS was shown to be adversely affected potassium uptake, can result in losses of 2500 to 3000
by the severity of dehydration, metabolic acidosis, as well as the mmol of potassium per day?",-3
type of ORS used.',X~il~ii-'HIn addition, composition of the oral 0 Reduced but continuing urinary losses of potassium; this
fluid appears to have a marked effect on outcome. In one ion is not conserved by horses as well as odium^".!^
study," calves receiving an ORS containing either sodium bicar-
0 Reduced, but continuing urinary water losses'"
bonate or sodium acetate had much higher recovery rates from
diarrhoea than calves receiving an ORS that lacked these con- 0 Insensible losses of metabolic water.
stituents. A higher survival rate was also associated with an elec- The resulting decrease in plasma volume stimulates thirst, an
trolyte solution when compared to pure water.' These types of about 3% decrease being required to exert this effect.li Affected
studies have not been conducted in horses. horses initially will often continue to drink water, without con-
comitant intake of electrolytes. When absorbed, the water
dilutes the extracellular sodium, resulting in hyponatraemia, a
'Present address: School of Agriculture. Charles Sturt University, PO Box 588, state of relative water excess,?f3
despite continuing hypovolaemia
Wagga Wagga, New South Wales 2678 in many horses.
Presented at Australian Veterinary Association, Annual Conference, Canberra,
March 1994. ORS Oral rehydration solutions

Aurt Vet/ Vol75, No 6, June 1997 417

................................................................................................................................
Table 1. Estimated daily losses of water, sodium and potassium in hors-
es with feed and water deprivation, heavy sweating and exhaustion and
acute diarrhoea?
Feed and water Heavy sweating Acute
deprivati~n'~ and exha~stion'~ diarrhoea2'
Water (L) 25 25 20b
Sodium (mmol) 500 2500 2169
Potassium (mmol) 3000 1000 2864
aValues found in the authors' study.
bThis water loss was not reflected by a reduction of body weight and is believed
to represent fluid sequestered in the large intestine. The value was calculated
using the Edelman equation."
Metabolic acidosis is often mild in the early stages of diar-
rhoea, but may become more severe with persistent diarrhoea
and signs of hypovolaemia.' How much bicarbonate loss and
lactate accumulation contribute to this metabolic acidosis has
not been established. In an experimental model of acute colitis
induced by castor oil we found that the resultant acidosis was
not associated with increased plasma lactate concentrations, but
rather the administration of Vytrate@(Pfizer Agricare) prior to
its onset. Vytrate@contains equal concentrations of sodium and
chloride ions at concentrations which differ from plasma. We
therefore suggest that the relative concentrations of sodium and
chloride (strong ions) in an ORS have a significant effect on the
acid-base balance of h o r ~ e s . ~ ~Because
~ * ~ . * mixed
~ fluid and elec-
trolyte deficits occur in association with diarrhoea, both fluid
and electrolytes must be replaced, preferably in the appropriate
proportions. Most horses with diarrhoea do not replenish elec-
trolyte losses by voluntary oral intake, so substantial net deficits
of these ions develop q~ickly.*"~*~ In studies of castor oil induced
diarrhoea in our laboratory,20the lack of oral potassium intake
(with feed) coupled with the observed increased urinary losses of
potassium contributed to the measured potassium deficit of
2900 mmol over approximately 24 hours of acute diarrhoea.
These losses do not differ from those in normal horses,13 indi-
cating that the major cause of the potassium deficit in horses
with diarrhoea is the lack of oral intake. The proportion of sodi-
um to potassium loss (combined urinary and faecal) in our
study was 44 Na : 56 K (2169 mmol Na to 2864 mmol K over
about 24 hours). The latter ratio is at variance with the data
from Carlson,' who refers to the cumulative net deficit of these
ions in his interpretation of Tasker's data, where a 7 0 Na : 30 K
proportion of losses was proposed. This ratio is commonly used
to calculate combined fluid and electrolyte losses in horses with
acute diarrhoea. The difference between studies may result from
the fact that we did not take into account the intake of sodium
or potassium, as horses with acute diarrhoea are usually inap-
petant, especially in the early stages of the disease. If values for
intake in Tasker's data are disregarded for the purpose of com-
parison, resultant ionic losses occur in a ratio (of daily combined
urinary and faecal sodium and potassium losses) of 30 Na : 7 0
K, which is the reverse of Carlson's, by mere exclusion of oral
intake. Therefore we suggest that oral intake appears to have a
major effect on potassium balance in horses and should be con-
sidered when planning therapy. For the purpose of formulating
fluid and electrolyte replacement strategies in horses with acute
diarrhoea, using the equation established by Edelman et al,?'
because it considers the exchangeable ionic pools, a ratio o f 4 0
Na : 60K may match actual deficits more closely.
418
Table 2. Comparison of reported deficitsn of water, sodium and potassium
in a horse with acute diarrhoea to the concentration of sodium and potas-
sium in 20 L of Vytrate@(Pfizer Agricare).
Deficits in response Vytrates
to diarrhoea
Water 20 L 20 L
Sodium 2169 mmol 1457 mmol
Potassium 2864 mmol 249 mmol
What constitutes an effective oral rehydration
solution?
Most ORS contain water, electrolytes and agents designed to
promote absorption. Glucose and glycine are included to
enhance sodium absorption in the small intestine, while water
diffuses Potassium, sodium and chloride are
included for the replacement of ionic losses, while citrate and
acetate are involved in the process of delayed alkalisation and
also are believed to enhance electrolyte transport across intesti-
nal mucosa.6 Bicarbonate is included for its more rapid alka-
lising effects. T h e alkalising effect obtained by adding sodium
bicarbonate to a solution is due mainly to addition of the sodi-
u m ions (without additional chloride ions), not the bicarbon-
ate ions, as was traditionally believed. Currently there is no
ORS available that would be specifically formulated for treat-
ment of acute diarrhoea in horses. T h e estimated water, sodi-
u m and potassium deficits of a horse with acute diarrhoea are
compared to an equivalent volume of VytrateB (ORS formu-
lated for calf and piglet diarrhoea) in Table 2. Replacing the
existing water deficit with the same volume of VytrateB, may
not replace electrolyte losses in horses with acute diarrhoea,
particularly potassium deficits. As losses continue in the course
of diarrhoea, water and electrolyte balance of affected horses
needs to be continuously monitored, as adjustments to exist-
ing fluid therapy may be necessary. A single ORS administra-
tion is unlikely to correct existing deficits and repeat O R S
administrations may be necessary.
Volume to be administered
Dehydration in horses becomes clinically apparent when
about 5% of body weight has been lost.' This implies a weight
loss of about 25 kg in a 500 kg horse. It can be assumed that
90% of this is lost as water, resulting in a fluid deficit of about
22.5 L. The small stomach of a horse could not accommodate a
bolus administration of such a volume. However, volumes of 6
to 8 L can be given as often as every 15 to 20 minutes."
Carlson2*expected about 30 Yo of orally administered fluid to be
retained by horses. A study by Sosa Leon et al", found that fluid
tonicity was a key element in the uprake and elimination or
orally administered fluid. Administering ORS by gravity flow
through a nasogastric tube, rather than by a pump may allow
more accurate determination of when the horse first shows signs
of abdominal discomfort. We found that 24 to 30 L given via
nasogastric tube over 1 h (that is 8 to 10 L administered at half-
hourly intervals by pump) caused mild signs of colic in most
horses.*"A slower rate of administration, such as 8 to 10 L given
every few hours, may be better tolerated by horses and result in
enhanced absorption, by slowing intestinal transit of the admin-
istered fluid. In a pilot study we noted a more marked decrease
in total plasma protein concentration (a reflection of extracellu-
~ w Vet/
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................................................................................................................................
Table 3. Concentrations of selected ions (mmol/L)' in four oral rehydration solutions and Hartmann's solution.
Product Vytrate' Recharge'b
Manufacturer Pfizer Agricare Vetsearch International
Na 73 70
CI 73 72
K 13 10
HCOJ ' 3 -
%oncentrations were rounded to the nearest mmoliL.
bWhen reconstituted as recommended for heavy work, 80 mL per 6 L water.
When reconstituted as recommended for heavy work, 80 mL per 2 L water.
dMay be administered intravenously or orally.
eAdministeredintravenously.
'When HCOJ. represents the bicarbonate ion or its equivalent.
Table 4. Cost of some oral rehydration solutions and an intravenous
peparation, Hartmann's solution, per 20 L of ready-to-administer fluid.
Fluid cost ($)a
Vytrate@ 14
Recharge" 3 that Vytrate", which contains equal amounts of sodium and
Horsport6 10
P 54H 45
Hartmann's* 72
aThe cheapest formulation was used and prices, as at February 1997. were
rounded to the nearest dollar.
lar fluid volume) in a horse suffering diarrhoea induced with
castor oil, when two doses of 8 L of Vytrate" were administered
4 h apart rather than 30 min apart.'"
Examples of oral rehydration solutions
The concentrations of certain ions (sodium, potassium, chlo-
ride and bicarbonate or its equivalent) contained in a number of
commercial ORS are listed in Table 3. They are compared with
constituents of a common intravenous crystalloid, Hartmann's
solution. None of the oral preparations listed would be ideal for
treating horses with acute diarrhoea; concentrations of sodium
and potassium are too low to adequately replace losses and the
ratio of sodium to chloride is about 1: 1, instead of the physio-
logical ideal of 1.4 : 1. More efficient correction of an existing
metabolic acidosis in calves with diarrhoea was found when the
Na : CI ratio was 1.4 : 1 rather than 1 : 1.8. The relative quan-
tities of sodium and chloride in the administered fluid are quite
important when considering effects on acid-base balance. This
concept is based on the 'strong ion difference' and its influence
on acid-base balance,'-'' where it is proposed that the strong
ions Na', K , and Cl- primarily affect acid base balance. Using
this principle, it is evident that hydrogen ion gain or bicarbon-
ate loss is not responsible for inducing metabolic acidosis in
horses with acute diarrhoea, but the relative change in the plas-
ma concentrations of sodium and chloride. Normal saline (0.9
% NaCI) should be used with care to treat hyponatraemia o r
hypovolaemia, because if used to excess the disproportionate
concentration of chloride in saline may result in acidosis.
Similarly, any ORS containing a relatively high concentration of
chloride ions may precipitate or worsen a metabolic acidosis in
Auct Vet/ Vol75, N o 6 , June 1997
Horsport" Electrolyte P54" Hartmann's solutione
International Animal Health Parneli Animal Health Baxter Healthcare
Products Laboratories
36 155 129
36 99 109
7.8 5 5
1 45 29
horses with acute diarrhoea. Rose et al' reported a mild, tran-
sient metabolic acidosis in Standardbred horses with diuretic-
induced dehydration following administration of an oral glu-
cose-glycine-electrolyte solution. This appeared to be of little
clinical significance in normal horses. In our studies, we noted
chloride, precipitated a moderate degree of metabolic acidosis
within 1 to 2 h of administration in horses with castor oil
induced acute diarrhoea. This metabolic acidosis was associated
with deterioration of clinical signs."'
We recommend that when treating horses with acute diar-
rhoea, the ratio of sodium to chloride ions in ORS should be
1.4: 1 . This is the normal physiological ratio found in equine
plasma, where "a] = 140 mmol/L, and [CI] = 100 mmol/L.
The addition of 5 g NaHCOA (= 60 mmol Na) to every 2 L of
Vytrate" would restore the Na to CI ratio to the physiological
ideal of 1.4:1 while maintaining near isotonicity of the fluid.
Table 4 compares costs for several commonly used ORS.
When to use ORS
It is not clear how much of the information gathered on oral
rehydration in other species can be extrapolated to the horse.
However, clinical and experimental evidence indicates
that horses with mild dehydration show good clinical response
to oral fluid therapy.
In horses with acute colitis, much of the small intestinal
absorptive function is probably intact. As rapid clinical deterio-
ration is a common feature in such cases, oral rehydration prior
to transport to a centre for intensive therapy may delay onset of
more serious sequelae. This may allow more time for assessment
and appropriate therapy.
Monitoring progress
A single treatment with an ORS is unlikely to replace all exist-
ing fluid and electrolyte losses. To monitor progress in clinical
cases, measurement of haematocrit, plasma total protein and
plasma electrolyte concentrations, as well as assessment of
venous acid-base status are important. Horses with acute diar-
rhoea often suffer enteric protein loss, so in these cases haemat-
ocrit is probably a more reliable indicator of hydration status
than plasma total protein.'" With respect to plasma electrolyte
measurements, it must be noted that plasma sodium and potas-
sium concentrations do not reflect the total body stores of these
419
..................................................................................................................................
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