Management of Acute Diarrhea: Nestle

Speaker: Dr. S. K. Mittal Presented at:  Nestlé Nutrition Institute, Delhi

Summary

In second of the series, Dr. S Mittal focuses on Inpatient management emphasizing on careful evaluation before treatment being subscribed. The video advises medical officers on how to create an input output chart with calculating total fluids, sodium and potassium. It covers maintenance and deficit requirements of intravenous fluids and presents an outline of deficit therapy and using intravenous fluids for deficit correction. He further goes on to describe what solutions medical practitioners have while offering solutions for correcting ‘hyponatremia’ by gradually increasing potassium levels in the body of an infant. The talk highlights clinical markers and possible resolutions to measure and raise bi-carbonate levels in the body.

Diarrhoea is a symptom and not a disease. Initial Evaluation is by taking a detailed history. Detailed history types are severity, duration of diarrhoea and change if any. Associated symptoms like vomiting, fever, lethargy, refusal to feed, any other should also be noted. Symptoms of any associated infection like ear ache/discharge, respiratory distress, and deranged sensorium/convulsion. Symptoms of dehydration-increased thirst, irritability, lethargy, refusal to drink, time since passage of urine. Treatment received particularly the reconstitution and amounts of ORS, anti-emetics, antibiotics, feeds during diarrhoea, reasons for admission and similar episodes in past. Following investigations must be asked for in all children admitted with acute diarrhoea. Stool R/E, pH, red substances, hemogram, Serum Electrolytes. BUN, ABG and routine urine are some other check-ups. CRP/Blood Culture/Urine Culture as warranted. Other investigations like x-ray Chest, LP as and when required.

The management of fluids is done in two ways .ORS ad lib emphasises on proper reconstitution, dissolve all in 1L, and keep in fridge. Adequate a mounts (100-200m1/loose stool) Small sips with cup and spoon helps stop vomiting. Antiemetic if required 1-2 doses Domstal/Perinorm preferable. Avoid odenendostrome and round the clock or even SOS. Ideally child needs reassessment if vomiting continues or recurs.

An assessment about the intake and output should be made. All fluids-oral/lv, all losses recorded hourly. Every 24 hours (or earlier if the child is dehydrated) make an assessment of intake total fluids, sodium, Potassium given. Also assess the losses in terms of fluids/electrolytes. Also assess dehydration by physical signs, urine Output

The maintenance of intravenous fluids can be done by body weight, by surface area, by calorie consumption. Fluid requirement based on calorie consumption is difficult to apply in clinical practice especially in moribund children not consuming orally and in malnourished children (Cal on expected weight fluid on present weight). Surface area more accurate 2L/sq.m at all ages except in 1st week (1 L/sq.m). However surface area nomograms are not readily available. Commonest method applied in clinical practice is by age and body weight as these parameters are easily available. Fluids are always calculated on the basis of present weight

The theory of deficit therapy makes us want to remember that body has lots of compensatory mechanisms for correcting deficits of fluids and electrolytes but very poor mechanisms for handling excess of fluids/electrolytes. Except in very dire situations like severe dehydration with shock, symptomatic hypo natremia, life threatening acidosis etc. corrections should always be done slowly and that too for only half of the calculated deficits.