"The Amrut in Dehydration": Paediatrics Department VMMC & H, Karaikal

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ORS

“THE AMRUT IN DEHYDRATION”

Paediatrics Department
VMMC & H , Karaikal
INTRODUCTION
 Worldwide, diarrhea claims several million lives
annually, mostly those of infants.

 Poverty, crowding, and contaminated water supplies


all contribute.

 Almost all of these deaths could have been


prevented with adequate fluid replacement.

 Incidence is much lower in developed nations but


remains one of the two most common reasons for
visits to pediatric emergency departments
CONT

 More than 5 million children under the age of 5
years die every year due to diarrhoea .

 In India, more than 1 million children get killed by


this miserable disease known as diarrhoea .

 Before the advent of ORT, death from diarrhea was


the leading cause in infants

 Between 1980 and 2006, With the introduction of


ORT, infant deaths, worldwide have decreased the
number of, from 5 to 3 million per year.
WHAT IS
DIARRHOEA?
Increases in volume or fluidity of stools, changes
in consistency, and increased frequency of
defecation.

Blood in stool indicate an acute diarrhoeal


illnesses or dysentery, irrespective of frequency.
“Passage of loose or watery stools at least three times
in a 24 h period”
WHO
Cont….
Diarrhoeal disorders are divided into:

 Acute Diarrhoea
 The most usual form of diarrhoeal illness, have an
abrupt onset, resolve within 14 days and are mostly
caused by infections

 Persistent Diarrhoea
 Diarrhoea which persists for longer than 14 days

 Chronic Diarrhoea
 Duration of symptoms is longer than a month
PATHOPHYSIOLOGY OF
DIARRHEA
 Fluid from the body enters the intestinal lumen (isosmotic i.e
approx.142 mEq/L Na+) during digestion.

 A healthy individual secretes 2000–3000mg of sodium per day


into the intestinal lumen.

 Nearly all of this is reabsorbed so that sodium levels in the body


remain constant.

 In a diarrheal illness, sodium rich intestinal secretions are lost


before they can be reabsorbed.

 This can lead to a life-threatening hyponatraemia within hours.

 This is the motivation for sodium and water replenishment in ORT.


ION EXCHANGE IN
INTESTINE
PHYSIOLOGICAL BASIS OF USING ORT
IN DIARRHOEA
 Sodium passes into epithelial cells by co-transport via the
SGLT1 protein.

 From the intestinal, sodium is pumped by active transport


by the Na+ K + pump through to extracellular space.

 The Na+ K + ATPase pump moves 3 Na+ in exchange for 2


K+

 This creates a “downhill” sodium gradient within the cell.

 SGLT proteins use energy from sodium gradient to


transport glucose into the cell against the glucose
gradient..
Cont….

 The GLUT uniporters then transport glucose across


membrane.

 SGLT1 protein requires 2 Na+ to co-transport one


molecule of glucose (as galactose).

 Without sodium, intestinal glucose is not absorbed.

 This is why oral rehydration salts (ORS) include


both sodium and glucose.

 For each cycle, hundreds of water molecules move


into the epithelial cell, slowly rehydrating the patient.
ORAL REHYDRATION THERAPY
 Most diarrhea-related deaths in children are due to
dehydration……
….loss of large quantities of water and
electrolytes from the body in the liquid stool.

 Many of these deaths can be prevented with the use of


oral rehydration therapy (ORT).

 Oral rehydration therapy (ORT) is a type of fluid


replacement used as a treatment for dehydration.

 It involves drinking water mixed with sugar and salt and


other home available fluids, while continuing to eat.
HISTORY OF ORT
INDIA- THE PIONEER
OV E R 2,500 YEARS AGO, INDIAN PHYSICIAN
SUSHRUTA DESCRIBED THE TREATMENT OF
ACUTE DIARRHEA WITH RICE WATER, COCONUT
JUICE AND CARROT SOUP.
IV FLUIDS IN CHOLERA
IN 1831, WILLIAM BROOKE TREATED
CHOLERA PATIENTS WITH IV
FLUIDS REDUCING MORTALITY
FROM 70 % TO 40 %.

 I V fluid replacement became the standard of care in


moderate/severe dehydration for over a hundred
years.
INDIA AGAIN!!
L AT E 1950’S: DR HEMENDRANATH
CHATTERJEE

1 9 7 1 : Dr. Dilip Mahalanabis


350,000 treated with mortality of 0.36%
Na-glucose co-transport
Inthe early 1960s, Robert k. Crane discovered the
sodium-glucose co-transport as the mechanism for
intestinal glucose absorption.

Around the same time, other scientists showed that


the intestinal mucosa was not disrupted in cholera, as
previously thought.
DISCOVERY OF ORS
• CAPTAIN PHILLIPS 1962
• Combined glucose and sodium, ignorant of co-transport
physiology.

Importance Realized!!!
• 1 9 7 8 – in recognition of the lives saved with ORT, The
Lancet proclaims that
“The discovery that sodium transport and glucose
transport are coupled in the small intestine, so that
glucose accelerates absorption of solute and water, was
potentially the most important medical advance this
century.”
ORAL REHYDRATION
SOLUTION
 So as soon as diarrhoea starts, it is essential to give the
child extra drinks to replace the liquid being lost.
 Oral Rehydration solution (ORS) is the cheap, simple and
effective way to treat dehydration caused by diarrhoea.

 ORS drink contains the main elements that are lost from
the body during diarrhoea.
 effective in treating dehydration resulting from all types of
acute diarrhoeal diseases.

 ORS drinks should be given to the child every time a


watery stool is passed.
TYPES OF ORS
• WHO ORS- conventional and low osmolar
• ORS with micro-nutrients: Zn fortified and A.A
fortified
• Cereal based and rice based ORS
• RESOMAL ( rehydration solution for malnutrition):
290-345 m.mol/Lt
• Home made ORS
LIMITATION OF HIGH
OSMOLARITY ORS
 D o e s not lower volume, frequency and durationof
diarrhoea.
 Induces vomiting due to taste, so acceptabilitypoor.
 M o r e chances of dehydration, more chancesof
requiring iv fluid.
 Hypernatremia.
 G o o d to correct fluid deficit, not good for
maintenance fluid.
ADVANTAGES OF LOW
OSMOLARITY ORS
Increased efficacy of ORS in non cholera diarrhoea

Need for unscheduled supplement IV therapy in children


fell by 33%.

Stool output decreased by 20%.

Vomiting decreased by 30%.

Safe & effective.


CLINICAL RELEVANCE - LOW
OSMOLARITY ORS
Reduction in need of IV therapy results in reduced
hospitalization and in turn results:

 Reduced risk of hospital acquired infections.


 Reduced disruption of breastfeeding.
 Reduced use of needles and interventions
 Reduced therapy cost.
 Reduced risk of diarrheal deaths in areas whereIV
therapy is not readily available.
PRINCIPLE OF ORS
 Glucose when given orally enhances the intestinal
absorption of salt & water.
 Thus it can correct electrolyte & water deficit.

WHOM CAN IT BE GIVEN?


 All age groups

IN WHAT CONDITIONS CAN IT BE GIVEN?


 All aetiologies
 All countries
DOSAGE & REQUIREMENT?
If the child’s weight is known…..
….. the amount of ORS soln.for rehydration
during the first 4hrs may be calculated as 75ml/kg
• NO DEHYDRATION: The role of ORS here is to
prevent dehydration when a child presents with
AGE.

• SOME DEHYDRATION: In this case dehydration is


treated with iv fluids and ORS.

I.V fluids is to correct the fluid loss and ORS is

to prevent the progression into severe

dehydration and maintain the hydration.


• SEVERE DEHYDRATION: Treated with i.v fluids

Age <12 months- 30ml/kg in 1hr and 70ml/kg in the


next 5hrs.

Age>12 months- 30ml/kg in 30mins and 70ml/kg in


the next 2.5 hrs.

• I.V Fluids used: Normal saline

Ringer lactate

Isolyte P
• 70-100ml/kg/day of ORS is recommended by
WHO in dehydration.

• Replacement of ongoing losses:

for each episode of vomiting- 20ml/episode

for each episode of diarrhoea-30ml/episode


SUBSTITUTES FOR ORS

• Breast milk

• Rice porridge

• Carrot juice

• Orange juice, banana and coconut


water maybe added for potassium
HOW TO
ADMINISTER???
 Wash your hands with soap and water before preparing solution.

 Prepare a solution, in a clean pot, by mixing 1 packet of Oral


Rehydration Salts (ORS) with one litre of clean drinking water.

 Stir the mixture till all the contents dissolve.

 Wash your hands and the baby's hands with soap and water
before feeding solution.

 Give the sick child as much of the solution as it needs, in small


amounts frequently.
Cont…..

Give child alternately other fluids - such as breast milk and juices.

Continue to give solids if child is four months or older.

If the child still needs ORS after 24 hours, make a fresh solution.

ORS does not stop diarrhoea. It prevents the body from drying up.

The diarrhoea will stop by itself.

If child vomits, wait ten minutes and give ORS again. Usually
vomiting will stop.
HOW TO PREPARE ORAL
REHYDRATION SOLUTION
RULES
 <2yrs :- give 1-2 teaspoon every 2-3 minutes

 Older children :- offer frequent sips out of a cup

 Adults:- drink as much as they can

 Give the estimated amount within 4hrs

If the child vomits??

 Wait for 10 minutes


 Give a teaspoonful every 2-3 minutes
Cont…..
 If the child wants to drink more than the estimated
amount ?

No harm , give more

 If the child refuses to drink ?


 See whether the signs of dehydration has disappeared
 If yes
 Treat similar to a non dehydrated diarrheal child.

 If the child is breast fed ?

Nursing + treatment with ORS solution

 Non breast fed infants less than 6 months


Along with ORS solution give 100-200 ml of clean water for
first 4 hrs
ORT PROGRAMME

 First started in 1986-1987

 Implemented through RCH programme

 ORS packets are supplied by the central govt.

 Twice a year 150 packets of ORS are provided as apart of


drug kit supplied to all sub centers in the country
ACHIEVEMENTS &
BENEFITS
 Low cost treatment

 Treatment of the patient in their own homes

 Ingredients are inexpensive and readily available

 Drinking water is sufficient (no need for boiling or other


means of sterilization)

 Breakthrough in the fight against cholera and other


diarrheal diseases

 Mortality rate in cholera has been reduced to 0.11% from


49.3%
THANK
YOU

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