FocusonDiarrhoea,DehydrationandRehydration

Home>Diarrhoea>MedicalEducation:TeachingMedicalStudentsaboutDiarrhoealDiseases

share
Unit1TheEpidemiologyandEtiologyofDiarrhoea
Unit2PathopysiologyofWateryDiarrhoea:DehydrationandRehydration
Unit3AssessingtheDiarrhoeaPatient
Unit4TreatmentofDiarrhoeaatHome
Unit5TreatmentofDehydratedPatients
Unit6Dysentery,PersistentDiarrhoea,andDiarrhoeaAssociatedwithOtherIllnesses
connect Unit7DiarrhoeaandNutrition
Unit8PreventionofDiarrhoea

Unit2PathopysiologyofWateryDiarrhoea:DehydrationandRehydration
MedicalEducation:TeachingMedicalStudentsaboutDiarrhoealDiseases

http://www.who.int/childadolescenthealth/New_Publications/CHILD_HEALTH/Meded/2med.htm

INTESTINALPHYSIOLOGY
Normalintestinalfluidbalance
Intestinalabsorptionofwaterandelectrolytes
Intestinalsecretionofwaterandelectrolytes

MECHANISMSOFWATERYDIARRHOEA
Secretorydiarrhoea
Osmoticdiarrhoea

CONSEQUENCESOFWATERYDIARRHOEA
Isotonicdehydration
Hypertonic(hypernatraemic)dehydration
Hypotonic(hyponatraemic)dehydration
Basedeficitacidosis(metabolicacidosis)
Potassiumdepletion

REHYDRATIONTHERAPY
Oralrehydrationtherapy(ORT)
Oralrehydrationsalts(ORS)
CompositionofORS
Sodiumconcentration
Homefluids
LimitationsofORT
Intravenoustherapy
Preferredsolution
HealthPhone
Acceptablesolutions
Unacceptablesolution
FactsforLife EXERCISES

7PointPlan
Diarrhoea UNIT2PATHOPHYSIOLOGYOFWATERYDIARRHOEA:DEHYDRATIONANDREHYDRATION
preventionand
treatment
INTESTINALPHYSIOLOGY

Health Waterydiarrhoearesultsfromdisorderedwaterandelectrolytetransportinthesmallintestine.Intestinaltransport
EducationTo mechanismsarealsothebasisforthemanagementofdiarrhoea,throughoralfluidtherapyandfeeding.Itistherefore
Villages importanttounderstandsomeofthenormalmechanismsofintestinaltransportandhowtheyarealteredduringdiarrhoea.

Normalintestinalfluidbalance
Motherand
ChildNutrition Normally,absorptionandsecretionofwaterandelectrolytesoccurthroughouttheintestine.Forexample,ahealthyadult
&Malnutrition takesinlessthantwolitresoffluideachday.Salivaandsecretionsfromthestomach,pancreas,andliveraddaboutseven
litres,makingatotalofaboutninelitresthatenterthesmallintestineeveryday.There,waterandelectrolytesare
simultaneouslyabsorbedbythevilliandsecretedbythecryptsofthebowelepithelium.Thiscausesatwodirectionalflowof
TenStepsto waterandelectrolytesbetweentheintestinallumenandtheblood.Sincefluidabsorptionnormallyisgreaterthanfluid
Successful secretion,thenetresultisfluidabsorption.
Breastfeeding
Usually,morethan90%ofthefluidenteringthesmallintestineisabsorbed,sothataboutonelitrereachesthelarge
intestine.There,furtherabsorptionoccurs,only100to200millilitresofwaterbeingexcretedeachdayinformedstools.Any
BreastCrawl changeinthetwodirectionalflowofwaterandelectrolytesinthesmallintestine(i.e.,increasedsecretion,decreased
absorption,orboth)resultsineitherreducednetabsorptionornetsecretionandcausesanincreasedvolumeoffluidto
enterthelargeintestine.Whenthisexceedsitslimitedabsorptivecapacity,diarrhoeaoccurs.
Guideto
ChildCare Intestinalabsorptionofwaterandelectrolytes
Absorptionofwaterfromthesmallintestineiscausedbyosmoticgradientsthatarecreatedwhensolutes(particularly
sodium)areactivelyabsorbedfromthebowellumenbythevillousepithelialcells.Thereareseveralmechanismswhereby
FollowUs
sodiumisabsorbedinthesmallintestine.Toentertheepithelialcells,sodiumislinkedtotheabsorptionofchloride,or
absorbeddirectlyassodiumion,orexchangedforhydrogenion,orlinkedtotheabsorptionoforganicmaterialssuchas
glucoseorcertainaminoacids.Theadditionofglucosetoanelectrolytesolutioncanincreasesodiumabsorptioninthe
intestineasmuchasthreefold.

Afterbeingabsorbed,sodiumistransportedoutoftheepithelialcellsbyanionpumpreferredtoasNa+K+ATPase.This
transferssodiumintotheextracellularfluid(ECF),whichelevatesitsosmolalityandcauseswaterandotherelectrolytesto
flowpassivelyfromthebowellumenthroughintercellularchannelsandintotheECF(seeFigure2.2,part1).Thisprocess
maintainsanosmoticbalancebetweenfluidinthebowelandECFintheintestinaltissue.

Intestinalsecretionofwaterandelectrolytes

SecretionofwaterandelectrolytesnormallyoccursinthecryptsofthesmallbowelepitheliumwhereNaClistransported
fromECFintotheepithelialcellacrossitsbasolateralmembrane(seeFigure2.2,exampleE).Thesodiumisthenpumped
backintotheECFbyNa+K+ATPase.Atthesametime,secretorystimuliincreasetheabilityofchloridetopassthroughthe
luminalmembraneofthecryptcells,allowingthationtoenterthebowellumen.Thismovementofchlorideioncreatesan
osmoticgradientthatcauseswaterandotherelectrolytestoflowpassivelyfromtheECFintothebowellumenthroughthe
intercellularchannels.
MECHANISMSOFWATERYDIARRHOEA

Therearetwoprincipalmechanismsbywhichwaterydiarrhoeaoccurs:(i)secretion,and(ii)osmoticimbalance.Intestinal
infectionscancausediarrhoeabybothmechanisms,secretorydiarrhoeabeingmorecommon,andbothmayoccurina
singleindividual.

Secretorydiarrhoea

Secretorydiarrhoeaiscausedbytheabnormalsecretionoffluid(waterandsalts)intothesmallbowel.Thisoccurswhen
theabsorptionofsodiumbythevilliisimpairedwhilethesecretionofchlorideinthecryptscontinuesorisincreased(see
Figure2.1,part2).Netfluidsecretionresultsandleadstothelossofwaterandsaltsfromthebodyaswaterystoolsthis
causesdehydration.Ininfectiousdiarrhoea,thesechangesmayresultfromtheactiononthebowelmucosaofbacterial
toxins,suchasthoseofEscherichiacoliandVibriocholerae01,orofviruses,suchasrotavirusothermechanismsmayalso
beimportant.

Osmoticdiarrhoea

Thesmallbowelmucosaisaporousepitheliumwaterandsaltsmoveacrossitrapidlytomaintainosmoticbalancebetween
thebowelcontentsandtheblood.Undertheseconditions,diarrhoeacanoccurwhenapoorlyabsorbed,osmoticallyactive
substanceisingested.Ifthesubstanceistakenasanisotonicsolution,thewaterandsolutewillsimplypassthroughthegut
unabsorbed,causingdiarrhoea.Purgatives,suchasmagnesiumsulfate,workbythisprinciple.Thesameprocessmayoccur
whenthesoluteislactose(inchildrenwithlactasedeficiency)orglucose(inchildrenwithglucosemalabsorption)both
conditionsareoccasionalcomplicationsofentericinfections.Ifthepoorlyabsorbedsubstanceistakenasahypertonic
solution,water(andsomeelectrolytes)willmovefromtheECFintothegutlumen,untiltheosmolalityoftheintestinal
contentsequalsthatofECFandblood.Thisincreasesthevolumeofthestooland,moreimportantly,causesdehydration
owingtothelossofbodywater.Becausethelossofbodywaterisgreaterthanthelossofsodiumchloride,hypernatraemia
alsodevelops(seebelow).

CONSEQUENCESOFWATERYDIARRHOEA

Diarrhoeastoolcontainslargeamountsofsodium,chloride,potassium,andbicarbonate(seeTable2.1).

Alltheacuteeffectsofwaterydiarrhoearesultfromthelossofwaterandelectrolytesfromthebodyinliquidstool.
Additionalamountsofwaterandelectrolytesarelostwhenthereisvomiting,andwaterlossesarealsoincreasedbyfever.
Theselossescausedehydration(duetothelossofwaterandsodiumchloride),metabolicacidosis(duetothelossof
bicarbonate),andpotassiumdepletion.Amongthese,dehydrationisthemostdangerousbecauseitcancausedecreased
bloodvolume(hypovolaemia),cardiovascularcollapse,anddeathifnottreatedpromptly.Threetypesofdehydrationare
consideredbelow.

Isotonicdehydration

Thisisthetypeofdehydrationmostfrequentlycausedbydiarrhoea.Itoccurswhenthenetlossesofwaterandsodiumare
inthesameproportionasnormallyfoundintheECF.Theprincipalfeaturesofisotonicdehydrationare:

thereisabalanceddeficitofwaterandsodium
serumsodiumconcentrationisnormal(130150mmol/l)
serumosmolalityisnormal(275295mOsmol/l)
hypovolaemiaoccursasaresultofasubstantiallossofextracellularfluid.

Isotonicdehydrationismanifestedfirstbythirst,andsubsequentlybydecreasedskinturgor,tachycardia,drymucous
membranes,sunkeneyes,lackoftears,asunkenanteriorfontanelleininfants,andoliguria.Thephysicalsignsofisotonic
dehydrationbegintoappearwhenthefluiddeficitapproaches5%ofbodyweightandworsenasthedeficitincreases.Asthe
fluiddeficitapproaches10%ofbodyweight,dehydrationbecomessevereandanuria,hypotension,afeebleandveryrapid
radialpulse,coolandmoistextremities,diminishedconsciousness,andothersignsofhypovolaemicshockappear.Afluid
deficitthatexceeds10%ofbodyweightleadsrapidlytodeathfromcirculatorycollapse.

Hypertonic(hypernatraemic)dehydration
Somechildrenwithdiarrhoea,especiallyyounginfants,develophypernatraemicdehydration.Thisreflectsanetlossof
waterinexcessofsodium,whencomparedwiththeproportionnormallyfoundinECFandblood.Itusuallyresultsfromthe
ingestionduringdiarrhoeaoffluidsthatarehypertonic(owingtotheircontentofsodium,sugar,orotherosmoticallyactive
solutes,suchaslactoseinwholecow'smilk)andnotefficientlyabsorbed,andaninsufficientintakeofwaterorotherlow
solutedrinks.ThehypertonicfluidscreateanosmoticgradientthatcausesaflowofwaterfromECFintotheintestine,
leadingtoadecreaseintheECFvolumeandanincreaseinsodiumconcentrationwithintheECF(seeFigure2.3,B).The
principalfeaturesofhypernatraemicdehydrationare:

thereisadeficitofwaterandsodium,butthedeficitofwaterisgreater
serumsodiumconcentrationiselevated(>150mmol/l)
serumosmolalityiselevated(>295mOsmol/l)
thirstissevereandoutofproportiontotheapparentdegreeofdehydrationthechildisveryirritable
seizuresmayoccur,especiallywhentheserumsodiumconcentrationexceeds165mmol/l.

Hypotonic(hyponatraemic)dehydration

Childrenwithdiarrhoeawhodrinklargeamountsofwaterorotherhypotonicfluidscontainingverylowconcentrationsofsalt
andothersolutes,orwhoreceiveintravenousinfusionsof50%glucoseinwater,maydevelophyponatraemia.Thisoccurs
becausewaterisabsorbedfromthegutwhilethelossofsalt(NaCl)continues,causingnetlossesofsodiuminexcessof
water.Theprincipalfeaturesofhyponatraemicdehydrationare:

thereisadeficitofwaterandsodium,butthedeficitofsodiumisgreater
serumsodiumconcentrationislow(<130mmol/l)
serumosmolalityislow(<275mOsmol/l)
thechildislethargicinfrequently,thereareseizures.

Basedeficitacidosis(metabolicacidosis)
Duringdiarrhoea,alargeamountofbicarbonatemaybelostinthestool.Ifthekidneyscontinuetofunctionnormally,much
ofthelostbicarbonateisreplacedbythekidneysandaseriousbasedeficitdoesnotdevelop.However,thiscompensating
mechanismfailswhenrenalfunctiondeteriorates,ashappenswhenthereispoorrenalbloodflowduetohypovolaemia.
Then,basedeficitandacidosisdeveloprapidly.Acidosisalsoresultsfromexcessiveproductionoflacticacidwhenpatients
havehypovolaemicshock.Thefeaturesofbasedeficitacidosisinclude:

theserumbicarbonateconcentrationisreduceditmaybelessthan10mmol/l
arterialpHisreduceditmaybelessthan7.10
breathingbecomesdeepandrapid,whichhelpstoraisearterialpHbycausingacompensatingrespiratoryalkalosis
thereisincreasedvomiting.
Potassiumdepletion
Patientswithdiarrhoeaoftendeveloppotassiumdepletionowingtolargefaecallossesofthisiontheselossesaregreatest
ininfantsandcanbeespeciallydangerousinmalnourishedchildren,whoarefrequentlypotassiumdeficientbefore
diarrhoeastarts.Whenpotassiumandbicarbonatearelosttogether,hypokalaemiadoesnotusuallydevelop.Thisis
becausethemetabolicacidosisthatresultsfromthelossofbicarbonatecausespotassiumtomovefromICFtoECFin
exchangeforhydrogenion,thuskeepingtheserumpotassiumlevelinanormalorevenelevatedrange.However,when
metabolicacidosisiscorrectedbygivingbicarbonate,thisshiftisrapidlyreversed,andserioushypokalaemiacandevelop.
Thiscanbepreventedbyreplacingpotassiumandcorrectingthebasedeficitatthesametime.Thesignsofhypokalaemia
mayinclude:

generalmuscularweakness
cardiacarrhythmias
paralyticileus,especiallywhendrugsaretakenthatalsoaffectperistalsis(suchasopiates).

REHYDRATIONTHERAPY
Thegoalinmanagingdiarrhoealdehydrationisrapidlytocorrectfluidandelectrolytedeficits(termed"rehydrationtherapy")
andthentoreplacefurtherfluidandelectrolytelossesastheyoccuruntildiarrhoeastops(termed"maintenancetherapy").
Fluidlossescanbereplacedeitherorallyorintravenouslythelatterrouteisusuallyneededonlyforinitialrehydrationof
patientswithseveredehydration.

Oralrehydrationtherapy(ORT)

ORTisbasedontheprinciplethatintestinalabsorptionofsodium(andthusofotherelectrolytesandwater)isenhancedby
theactiveabsorptionofcertainfoodmoleculessuchasglucose(whichisderivedfromthebreakdownofsucroseorcooked
starches)orlaminoacids(whicharederivedfromthebreakdownofproteinsandpeptides).Fortunately,thisprocess
continuestofunctionduringsecretorydiarrhoea,whereasmostotherpathwaysofintestinalabsorptionofsodiumare
impaired.Thus,ifpatientswithsecretorydiarrhoeadrinkanisotonicsaltsolutionthatcontainsnosourceofglucoseor
aminoacids,sodiumisnotabsorbedandthefluidremainsinthegut,ultimatelyaddingtothevolumeofstoolpassedbythe
patient.However,whenanisotonicsolutionofglucoseandsaltisgiven,glucoselinkedsodiumabsorptionoccursandthisis
accompaniedbytheabsorptionofwaterandotherelectrolytes.Thisprocesscancorrectexistingdeficitsofwaterand
electrolytesandreplacefurtherfaecallossesinmostpatientswithsecretorydiarrhoea,irrespectiveofthecauseof
diarrhoeaortheageofthepatient.

Oralrehydrationsalts(ORS)
CompositionofORS.TheprinciplesunderlyingORThavebeenappliedtothedevelopmentofabalancedmixtureof
glucoseandelectrolytesforuseintreatingandpreventingdehydration,potassiumdepletion,andbasedeficitdueto
diarrhoea.Toattainthelattertwoobjectives,saltsofpotassiumandcitrate(orbicarbonate)havebeenincluded,inaddition
tosodiumchloride.Thismixtureofsaltsandglucoseistermedoralrehydrationsalts(ORS)whenORSisdissolvedinwater,
themixtureiscalledORSsolution.ThefollowingguidelineswereusedindevelopingtheWHO/UNICEFrecommendedORS
solution:

thesolutionshouldhaveanosmolaritysimilarto,orlessthanthatofplasma,i.e.,about300mOsmol/lorless
theconcentrationofsodiumshouldbesufficienttoreplaceefficientlythesodiumdeficitinchildrenoradultswith
clinicallysignificantdehydration
theratioofglucosetosodium(inmmol/l)shouldbeatleast1:1toachievemaximumsodiumabsorption
theconcentrationofpotassiumshouldbeabout20mmol/linorderadequatelytoreplacepotassiumlosses
theconcentrationofbaseshouldbe10mmol/lforcitrateor30mmol/lforbicarbonate,whichissatisfactoryfor
correctingbasedeficitacidosisduetodiarrhoea.Theuseoftrisodiumcitrate,dihydrate,ispreferred,sincethisgives
ORSpacketsalongershelflife.

Sodiumconcentration:ORSsolutionhasbeenusedtotreatmillionsofdiarrhoeacasesofdifferentetiologiesinallages,
andhasprovedtoberemarkablysafeandeffective.Nevertheless,becausestoolelectrolyteconcentrationsvaryindifferent
typesofdiarrhoeaandinpatientsofdifferentages,doctorsaresometimesconcernedaboutusingasingleORSsolutionin
allclinicalsituations.Inthisregard,Table2.1comparesthecompositionofORSsolutionwiththeaverageelectrolyte
compositionofstoolindifferentkindsofacutewaterydiarrhoea.Thestoolsofpatientswithcholeracontainrelativelylarge
amountsofbicarbonateandpotassium.Inchildrenwithacutenoncholeradiarrhoea,theconcentrationsofsodium,
bicarbonate,andchlorideinthestoolarelower,althoughtheyvaryconsiderably.Achildwithdehydrationduetodiarrhoea
hasdeficitsofsodiumandwater.Incasesofseveredehydration,thesodiumdeficithasbeenestimatedtobe70110mmol
foreach1000mlofwater.Thesodiumconcentrationof90mmol/linORSsolutioniswithinthisrangeandhenceitissuitable
forthetreatmentofdehydration.Duringthemaintenancephase,however,whenORSisusedtoreplacecontinuingstool
losses,theconcentrationofsodiumexcretedinthestoolaverages50mmol/l.Althoughthiscouldbereplacedwitha
separatesolutioncontaining50mmolofsodium,thesameresultcanbeobtainedbygivingthestandardORSwithwateror
breastmilk.Thisapproachreducestheaverageconcentrationofsodiumingestedtoarangethatisbothsafeandeffective,
andanymodestexcessofsodiumorwatercanbeexcretedintheurinethisisespeciallyimportantinyounginfants,in
whomrenalfunctionisnotfullydeveloped.Amajoradvantageofthisapproachisthatitavoidsconfusingmothers,nurses,
andevendoctors,whomightotherwisehavetousedifferentORSsolutionsfortherehydrationandmaintenancephasesof
treatment.

Homefluids

AlthoughtheircompositionisnotasappropriateasthatofORSsolutionfortreatingdehydration,otherfluidssuchassoups,
cerealgruels,cerealsaltsolutions,orhomemadesugarandsaltsolutionsmaybemorepracticalandnearlyaseffective
forpreventingdehydration.Homefluidsshouldbegiventochildrentodrinkassoonasdiarrhoeastartsandfeedingshould
becontinued.Suchearlyhometherapycanpreventmanycasesfrombecomingdehydratedanditalsofacilitatescontinued
feedingbyrestoringappetite.

Table2.3givestheWHOrecommendedcompositionofhometherapyfluids.Homefluidsshouldhaveanosmolalitybelow
thatofbloodplasma(i.e.,lessthan300mOsm/l)andtheconcentrationofsodiumshouldpreferablybeintherangeof30
80mmol/l.Thisconcentrationisobtainedbydissolving2.04.5gofcommonsaltinonelitreofwatersolutionsthat
containlittleornosaltmaybeeffectiveifsaltispresentinthechild'sfood.Thesourceofglucosemaybeafoodstarch,
suchasacookedcereal,orsucrose.

Table2.3:WHOrecommendedcompositionofhometherapyfluids

1.Osmolalitylessthan300mOsm/l
2.Sodium3080mmol/l

3.Starch*usually5080g/l
OR
Sucrose **30140mmol/l
*Usuallyacookedcereal,e.g.,ricegruel,orastarchyvegetable.**Themolarratioofsucrosetosodiumshouldbeatleast
1:1.

Whenthefluidcontainsstarch,asinacookedcereal,itwillhavealowerosmolalitythanafluidcontaininganequalamount
ofsucrose,ingrams/litre.Moreover,withintheintestine,starchbreaksdowngraduallyintoglucose,whichisrapidly
absorbed.Thus,theosmolalityofthefluidintheintestineremainsatasafelevel.Asapracticalguide,theamountofstarch
usedshouldbesuchthatthefluidisthick,butcanstillbedrunkeasily(usuallynotmorethan80g/litre).Asimilarsituation
existswhenafluidcontainsproteins,e.g.,soupscontaininglegumes.Theproteinsbreakdownslowlyintoaminoacids,
whichareabsorbedquickly,sothattheosmolalityofthefluidintheintestineremainswithinasaferange.Foroptimal
absorptionofsodium,themolarratioofsucrose:sodiuminasugarandsaltsolutionshouldbeatleast1:1e.g.,50mmol/l
ofsodiumrequiresasucroseconcentrationofatleast50mmol/l.Theratiomayexceed1:1,butshouldnotcausetotal
osmolalitytoexceed300mOsm/l,andthetotalsucroseshouldnotbegreaterthan50g/l.Ifsolutionscontainingsaltand
carbohydratearenotavailable,orcannotbeaccuratelyprepared,saltfreefluidssuchaswatershouldbegivenintheir
place.However,thesearelesseffectiveinpreventingdehydrationwhendiarrhoeaissevereifgiveninlargeamounts,they
mightalsocausehyponatraemia.Infantswithdiarrhoeashouldalwayscontinuetobreastfeed.Breastfeedingduring
diarrhoeaisanimportantsourceofwaterandnutrients,andcanactuallydecreasestoolvolumeandthedurationofillness.
Younginfantswhoarenotbreastfedshouldbegivenoccasionaldrinksofwater.Therearealsosomefluidsthatmaybe
availableinthehomewhichshouldnotbegiventochildrenwithdiarrhoea.Theseincludecommercialsoups,whichmay
containdangerouslyhighconcentrationsofsalt,andsweetenedcommercialfruitdrinksorsoftdrinks,whichareusually
hyperosmolarowingtotheirhighconcentrationsofsucrose.Thesefluidscancausehypernatraemiaasaresultofan
excessivesaltintake,osmoticdiarrhoea,orboth.

LimitationsofORT
Inatleast95%ofepisodesofsecretorydiarrhoeadehydrationcanbecorrectedorpreventedusingonlyORSsolution(or
ORT).However,ORTiseitherinappropriateorunsuccessfulinthefollowingsituations:

ORTisinappropriatefor:

initialtreatmentofsevere(lifethreatening)dehydration,becausefluidmustbereplacedveryrapidly(this
requiresintravenousinfusionofwaterandelectrolytes)
patientswithparalyticileusormarkedabdominaldistension
patientswhoareunabletodrink(however,ORSsolutioncanbegiventosuchpatientsthroughanasogastrictube
ifintravenoustreatmentisnotpossible).

ORTisunsuccessfulin:

patientswithveryrapidstoolloss,i.e.,greaterthan15ml/kgbodyweightperhoursuchpatientsmaybeunable
todrinkfluidatasufficientratetoreplacetheirlosses
patientswithsevere,repeatedvomiting(thisisunusual)generally,mostoftheoralfluidisabsorbeddespite
vomiting,andvomitingstopsasdehydrationandelectrolyteimbalancearecorrected
patientswithglucosemalabsorption(alsounusual)insuchcasesORSsolutioncausesstoolvolumetoincrease
markedlyandthestoolcontainslargeamountsofglucosedehydrationmayalsoworsen.

Intravenoustherapy
Intravenousfluidsarerequiredonlyforpatientswithseveredehydration,andthenonlytorestorerapidlytheirblood
volumeandcorrectshock.Althoughanumberofintravenoussolutionsareavailable,theyarealldeficientinatleastsome
oftheelectrolytesrequiredtocorrectthedeficitsfoundinpatientsdehydratedbyacutediarrhoea.Toensureadequate
electrolytereplacement,someORSsolutionshouldbegivenassoonasthepatientisabletodrink,evenwhiletheinitial
fluidrequirementisbeingprovidedbyintravenoustherapy.Thefollowingisabriefdiscussionoftherelativemeritsofthe
mostwidelyavailablesolutions.ThecompositionofeachisshowninTable2.4.

Preferredsolution

Ringer'sLactateSolution(alsocalledHartmann'sSolutionforInjection)isthebestcommerciallyavailablesolution.It
suppliesanadequateconcentrationofsodiumandsufficientlactate,whichismetabolisedtobicarbonate,forthecorrection
ofacidosistheconcentratationofpotassium,however,islow,andthesolutionprovidesnoglucosetoprevent
hypoglycaemia.Ringer'sLactateSolutioncanbeusedinallagegroupstocorrectdehydrationduetoacutediarrhoeaofany
cause.EarlyprovisionofORSsolutionandearlyresumptionoffeedingwillprovidetherequiredamountsofpotassiumand
glucose.

Acceptablesolutions

WhenRinger'sLactateSolutionisnotavailable,normalsaline,halfstrengthDarrow'sSolution,orhalfnormalsalinesolution
maybeusedhowever,thesearelessappropriateasregardscontentofsodium,potassium,orabaseprecursor(seeTable
2.4).

Normalsaline(alsocalledisotonicorphysiologicalsaline)isoftenavailable.Itdoesnotcontainabasetocorrect
acidosisanddoesnotreplacepotassiumlosses.Sodiumbicarbonateorsodiumlactate(2030mmol/l)andpotassium
chloride(515mmol/l)canbeaddedtothesolution,butthisrequiresasupplyoftheappropriatesterilesolutions.
HalfstrengthDarrow'sSolution(alsocalledlactatedpotassicsaline)containslesssodiumchloridethanisneeded
tocorrectefficientlythesodiumdeficitincaseswithseveredehydration.Thisispreparedbydilutingfullstrength
Darrow'sSolutionwithanequalvolumeof5%or10%glucosesolution.
Halfnormalsalinewith5%or10%glucose,likenormalsaline,doesnotcorrectacidosis,nordoesitreplace
potassiumlosses.Italsocontainslesssodiumchloridethanisneededforoptimalcorrectionofdehydration.

Unacceptablesolution

Plainglucose(dextrose)solutionshouldnotbeusedbecauseitprovidesonlywaterandglucose.Itdoesnotcontain
electrolytesandthusdoesnotreplacetheelectrolytelossesorcorrectacidosis.Itdoesnoteffectivelycorrect
hypovolaemia.

EXERCISES

1.Indicatewhetherthefollowingfeaturesaremostcharacteristicofsecretoryorosmoticdiarrhoea.PlaceanS(for
secretory)oranO(forosmotic)againsteach,asappropriate.

A.Hypernatraemicdehydration
B.Isotonicdehydration
C.Nonabsorbedsolute
D.Impairedsodiumabsorption
E.E.SuccessfullytreatedwithORT

2.Whichofthefollowingcanincreasetheefficacyofsodiumabsorptionintheintestine?(Theremaybemorethanone
correctanswer.)

A.Cookedricestarch
B.Palmoil
C.Plainsugar
D.Someaminoacids
E.Glucose

3.Whichoneofthefollowingeffectsofseverediarrhoeaismostdangerous?

A.Potassiumdepletion
B.Anorexia
C.Metabolicacidosis
 D.Fever
E.Hypovolaemia

4.Whichofthefollowingarefeaturesofhypertonicdehydration?(Theremaybemorethanonecorrectanswer.)

A.Extremethirst
B.Serumsodiumconcentration:140mmol/l
C.Veryirritablechild
D.Serumpotassiumconcentration:3.8mmol/l
E.Lethargicchild

5.ForwhichofthefollowingsituationsisORTusingORSsolutionnotsatisfactory?(Theremaybemorethanonecorrect
answer.)

A.Maintenancetherapyforaninfantwithrotavirusdiarrhoea
B.Rehydrationofachildwithnonseveredehydrationduetocholera
C.RehydrationofachildwithnonseveredehydrationduetoenterotoxigenicE.coli
D.Rehydrationofacomatosechildwithseveredehydrationandshockduetorotavirusdiarrhoea
E.Maintenancetherapyofachildwithcholera

6.WhichofthefollowingmighthappenifORSwasmixedwithonlyhalfoftherequiredamountofwaterandusedtotreata
childwithrotavirusdiarrhoeaanddehydration?(Theremaybemorethanonecorrectanswer.)

A.Thesolutionwouldbean"improvedORS"andcausethestoolvolumetobereducedandthedurationofdiarrhoeato
beshortened
B.Thechildwoulddevelophypernatraemia
C.Thechildwouldrefusetodrinkthesolution
D.Thechildwoulddevelopparalyticileusandabdominaldistension
E.Thechildwouldbecomeextremelythirsty

7.Whichofthefollowing"homefluids"canbesafelyusedtopreventdehydrationinchildrenwithdiarrhoea?(Theremaybe
morethanonecorrectanswer.)

A.Ricewater
B.Cerealgruelwithasmallamountofsaltadded
C.Coladrink
D.Soupmadefromcookedlegumes
E.Commercialfruitdrink

Answers

1.A.0

B.S

C.0

D.S

E.S

2.A,C,D,E.

3.E.Hypovolaemiacausesshockandcardiovascularcollapse.Thisisthecauseofdeathfromseveredehydrationdueto
diarrhoea.

4.A,C.

5.D.Patientswithseverehypovolaemiarequireveryrapidreplacementofwaterandsalttorestorethebloodvolumeand
preventdeath.ORTisnotsufficientlyrapid.Suchpatientsneedintravenousfluidreplacement,ifitisavailable.

6.B,E.Thechildwouldprobablybecomehypernatraemicbecauseofthehighconcentrationsofsaltandglucoseinthe
solution.Extremethirstisasignofhypernatraemia.

7.A,B,D.Softdrinksandcommercialfruitdrinksareoftenveryhypertonicowingtoahighsugarcontent.Suchfluidscan
causeosmoticdiarrhoeaandhypernatraemicdehydration.Theyalsocontainverylittlesodiumtoreplacewhathasbeen
lost.

updated:23April,2014

previous|home|diarrhoea|dehydration|rehydration|solutions|nutrition|breastfeeding|ors|rotavirus|zinc
hygiene|water|resources|facts|faqs|links|professional|aboutus|supportus|contactus|sitemap

Onlinesince1996

TheMotherandChildHealthandEducationTrustaU.S.501(c)(3)nonprofit
organizationourportalsandsites

Anotherchildwilldiein MotherandChild
RehydrationProject HealthEducationto
.... Nutrition
Successful Villages
HealthPhone MotherandChild
Breastfeeding BreastCrawl
GuidetoChildCare Health
DisasterRelief EducationforGirls
imagine FactsforLife
CommunityRadio ASimpleSolution
CommunityVideo EducationforBoys
AIDSaction Diarrhoea:7PointPlan
HealthRadio ChildProtector
PolioFree HIVandBreastfeeding
KyunkiJeenaIssiKa HealthTube
Untouchability RightsoftheChild
NaamHai EbolaResources

YourFeedback