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Oral rehydration
OVERVIEW: Dehydration and ongoing fluid losses from infectious gastroenteritis (GE) can be effectively treated with oral rehydration solutions (ORS), except in the most severe cases where initial parenteral fluid resuscitation is required. This therapy takes advantage of the coupled transport of sodium and glucose in the small intestine even during course of GE. Water follows osmotically after sodium entry. Potassium is passively absorbed via solvent drag. A glucose concentration of 2% allows maximal sodium absorption.
• ORS for rehydration should have a sodium content of about 75 mEq/L (75 mmol/L). Maintenance ORS, with sodium content of 40-50 mEq/L (40-50 mmol/L), are useful for mild dehydration and treatment of ongoing losses with a relatively low sodium content (e.g., rotavirus). High sodium diarrheal losses as from cholera require higher sodium content ORS (WHO solution = 90 mEq/L [90 mmol/L] Na).
System(s) affected: Gastrointestinal, Endocrine/Metabolic
Genetics: N/A
Incidence/Prevalence in USA: N/A
Predominant age: Primarily infants and children; effective for all ages
Predominant sex: Male = Female
SIGNS AND SYMPTOMS: See Dehydration
CAUSES: N/A
RISK FACTORS: N/A
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: N/A
LABORATORY: N/A
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS: N/A
SPECIAL TESTS: N/A
IMAGING: N/A
DIAGNOSTIC PROCEDURES: N/A
TREATMENT APPROPRIATE HEALTH CARE: Primarily outpatient. Designed to be administered by family members.
GENERAL MEASURES: • Estimate replacement at 60 mL/kg for mild- and 80-100 mL/kg for moderate dehydration over the first 4-8 hours. Very important to replace any ongoing losses and add maintenance fluids.
• Replace ongoing stool losses with ORS. In infant, estimate 5-10 mL/kg per stool or weigh diapers.
• Add maintenance requirements to replacement:
• Estimate:
0-10 kg: 4 mL/kg/hr
Plus 10-20 kg: 2 mL/kg/hr
Plus > 20 kg: 1mL/kg/hr
• Use maintenance ORS. Traditional clear fluids (e.g., fruit juice, soda) are inappropriate for oral rehydration therapy.
• If the patient has hypertonic dehydration, oral rehydration should be planned for 12-24 hours
• If vomiting occurs, small amounts of ORS given frequently is usually effective
• If patient is not vomiting and is alert, patient's thirst is excellent indicator of fluid needs
• ORS is not to be diluted
• Maintenance oral rehydration therapy begins when the deficit is replaced and provides for ongoing losses. Maintenance ORS or a combination of ORS and water or other clear liquids can be used.
• Effective at all ages. If child refuses because of taste, flavor with a commercial artificially sweetened flavoring, such as Nutrasweet flavored Kool-Aid; use approximately 1/4 teaspoon to 4 oz ORS.
• Effective at all ages: prepackaged ORS flavored freeze pops (often well accepted)
• Begin feeding as soon as rehydration achieved
SURGICAL MEASURES: N/A
ACTIVITY: As tolerated
DIET: • For breast feeding infants - mother should continue nursing
• For bottle fed babies - early institution of lactose-free formulas. Delay using milk-based formula for several days.
• Age appropriate - complex carbohydrate rich (eg, rice, bread, potato, cereal), low fat foods should be offered as soon as the dehydration deficit is replaced. Cow's milk can be added to diet after several days.
PATIENT EDUCATION: • Awareness and availability of ORS markedly diminishes morbidity from gastroenteritis
• Travelers concerned with severe diarrhea should carry ORS packets on trips
MEDICATIONS DRUG(S) OF CHOICE: • The prototype ORS is the World Health Organization solution. In developed countries, when GE is unlikely to be caused by cholera, a lower sodium solution is advisable.
WHO ORS:
• 1 liter of clean water
• 1/2 tsp sodium chloride (salt)
• 1/2 tsp trisodium citrate
• 1/4 tsp potassium chloride (salt substitute)
• 2 tbsp glucose
Notes:
• Glucose can be replaced by either sucrose (table sugar) or rice powder which are less expensive. Rice starch-based ORS decreases stool volume in cholera.
• Trisodium citrate can be replaced by sodium bicarbonate (baking soda). (Sodium bicarbonate was used in previous formulation.)
| Comparison of ORS's |
|---|
| Solution | Type † | Na+ | Storage form |
|---|
| WHO ORS | R | 90 | Powder | | Rehydralyte | R | 75 | Liquid | | Pedialyte | M | 45 | Liquid | | Kaolectro | M | 50 | Powder | | Beech-nut-Ped. Electrolyte | M | 50 | Liquid |
† R = rehydration
M = maintenance
Na+ = Sodium (mEq/L or mmol/L)
Contraindications:
• Conditions predisposing to risk of aspiration: Altered consciousness, seizure activity, severe hypotension, shock
• Persistent vomiting (as in pyloric stenosis)
• Absent bowel sounds
Precautions:
• The ingredients should be provided in pre-mixed packets in order to avoid iatrogenic errors in mixing
• If water safety is questionable, it should be boiled or treated for purification
• Discard the solution after 12 hours if held at room temperature, or 24 hours if refrigerated
• After rehydration is complete, ORS's should not be used as the only fluid intake because the high sodium content may lead to hypernatremia
Significant possible interactions: N/A
ALTERNATIVE DRUGS: N/A
FOLLOW UP PATIENT MONITORING: The patient needs to be frequently evaluated to ensure establishment of an improving clinical status and an adequate urine output
PREVENTION/AVOIDANCE: N/A
POSSIBLE COMPLICATIONS: Change to IV hydration if the patient has increasing weight loss (fluid deficit), clinical deterioration, or intractable vomiting.
EXPECTED COURSE AND PROGNOSIS: • Rapid clinical improvement despite continuing diarrhea is the usual course
• The overall complication rate for oral rehydration is the same as that for parenteral rehydration in cases of mild and moderate dehydration.
MISCELLANEOUS ASSOCIATED CONDITIONS: N/A
AGE-RELATED FACTORS: N/A
Pediatric: See Diet
Geriatric: N/A
Others: N/A
PREGNANCY: N/A
SYNONYMS: N/A
ICD-9-CM: N/A
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