Unit 5 - Treatment of Dehydrated Patients
Medical Education: Teaching Medical Students about Diarrhoeal Diseases

World Health Organization 1992
http://apps.who.int/iris/handle/10665/40343

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INTRODUCTION TREATMENT OF PATIENTS WITH SOME DEHYDRATION - TREATMENT PLAN B Tasks involved in Treatment Plan B How much ORS solution should be given How to give ORS solution Monitoring treatment Reassessing the patient Patients who cannot remain at the treatment centre TREATMENT OF PATIENTS WITH SEVERE DEHYDRATION - TREATMENT PLAN C Tasks involved in Treatment Plan C Deciding how fluid will be given Intravenous replacement Oral replacement Nasogastric replacement Intravenous rehydration Selecting an appropriate fluid Putting up an intravenous drip Deciding how much IV fluid to give Reassessing the patient Alternative methods of rehydration Nasogastric rehydration Oral rehydration Giving breast milk and water Transition to Treatment Plans B and A Treatment of suspected cholera PATIENTS WITH PROBLEMS Electrolyte or acid-base abnormalities Failure of oral rehydration therapy Seizures EXERCISES

UNIT 5 - TREATMENT OF DEHYDRATED PATIENTS

INTRODUCTION

Dehydration occurs when the water and electrolytes lost during diarrhoea are not fully replaced. As dehydration develops, various signs and symptoms appear which can be used to estimate the extent of dehydration and guide therapy. Three categories of dehydration can be recognized, each of which is associated with a specific Treatment Plan (see Unit 3). In increasing order of severity, these are:

• No signs of dehydration - follow Treatment Plan A

  Patients in this category have a fluid deficit equalling less than 5% of their body weight.
  

• Some dehydration - follow Treatment Plan B
  Patients in this category have a fluid deficit equalling 5-10% of their body weight.
  
• Severe dehydration - follow Treatment Plan C
  Patients in this category have a fluid deficit equalling more than 10% of their body weight.

Treatment Plan A (for treatment of diarrhoea at home) is described in Unit 4. The present unit describes the treatment at a health facility of infants and children with some dehydration or severe dehydration, using Treatment Plans B and C, respectively.

TREATMENT OF PATIENTS WITH SOME DEHYDRATION - TREATMENT PLAN B

Children with signs indicating there is some dehydration usually do not need to be admitted to hospital. They can be treated in a special area of the clinic known as the "ORT corner" or the "oral rehydration area". Mothers should stay with their children to help with the treatment and learn how to continue it at home, after the child is rehydrated.

Tasks involved in Treatment Plan B

The main tasks of Treatment Plan B are to:

• continue breast-feeding;
  
• estimate the amount of ORS solution to be given during the first 4 hours, for rehydration;
  
• show the mother how to give ORS solution;
  
• monitor treatment and reassess the child periodically until rehydration is completed;
  
• resume giving foods other than breast milk after 4 hours;
  
• identify patients who cannot be treated satisfactorily with ORS solution by mouth and adopt a more appropriate method of treatment;
  
• give instructions for continuing the treatment at home after rehydration is completed, following Treatment Plan A.
  
• If the child wants more ORS than shown, give more.
  
• Encourage the mother to continue breastfeeding.
  
• For infants under 6 months who are not breastfed, also give 100-200 ml clean water during this period.

OBSERVE THE CHILD CAREFULLY AND HELP THE MOTHER GIVE ORS SOLUTION.

Show her how much solution to give her child.

Show her how to give it - a teaspoonful every 1-2 minutes for a child under 2 years, frequent sips from a cup for an older child.

Check from time to time to see if there are problems.

If the child vomits, wait 10 minutes and then continue giving ORS, but more slowly; for example, a spoonful every 2-3 minutes.

If the child's eyelids become puffy, stop ORS and give plain water or breast milk. Give ORS according to Plan A when the puffiness is gone.

AFTER 4 HOURS, REASSESS THE CHILD USING THE ASSESSMENT CHART. THEN SELECT PLAN A, B OR C TO CONTINUE TREATMENT:

If there are no signs of dehydration, shift to Plan A.
When dehydration has been corrected, the child usually passes urine and may also be tired and fall asleep.

If signs indicating some dehydration are still present, repeat Plan B, but start to offer food, milk and juice as described in Plan A.

If signs indicating severe dehydration have appeared, shift to Plan C.

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT PLAN B:

Show her how much ORS to give to finish the 4-hour treatment at home.

Give her enough ORS packets to complete rehydration, and for 2 more days as shown in Plan A.

Show her how to prepare ORS solution.

Explain to her the three rules in Plan A for treating her child at home:

to give ORS or other fluids until diarrhoea stops

to feed her child

to bring the child back to the health worker, if necessary.

How much ORS solution should be given?

When there is some dehydration the deficit of water is between 50 and 100 ml for each kg of body weight. If the child's weight is known, the amount of ORS solution required for rehydration can be estimated, using 75ml/kg as the approximate deficit. If the child's weight is not known, the estimated deficit can be determined using the child's age, although this approach is less precise. Both methods are shown in the chart in Figure 5.1, which indicates the range of fluid volumes that is appropriate for a child of a given weight or age. Alternatively, the approximate ORS volume (in ml) can be calculated by multiplying the weight (in grams) times 0.075. Thus, a child weighing 8000 grams would require about (8000 x 0.075) 600 ml of ORS solution.

It should be emphasized that the range of fluid volumes shown in the chart is an estimate of what is needed and should be used only as a guide. The actual amount given should be determined by how thirsty the patient is and by monitoring the signs of dehydration, bearing in mind that larger volumes will be required by larger patients, those with more advanced signs of dehydration, and those who continue to pass watery stools during rehydration. The general rule is that patients should be given as much ORS solution as they will drink, and the signs of dehydration should be monitored to confirm that they are improving.

How to give ORS solution

The estimated amount of ORS solution to be given during the first 4 hours should be explained to the mother, using measuring units with which she is familiar, e.g., 4 cups, 2 glasses, etc.

The mother should then learn how to give ORS solution to her child. This is best done by means of a brief demonstration by a nurse or health worker, following which the mother should give her child the solution, under supervision, observing the following guidelines:

Give one teaspoonful every 1-2 minutes to children under 2 years of age, or offer frequent sips from a cup to older children. Adults may drink the solution freely. Try to give the estimated amount in a period of 4 hours.

If the child vomits, wait 10 minutes, then continue giving ORS solution, but more slowly: a spoonful every 2-3 minutes.

If the child will drink more than the estimated amount of ORS solution and is not vomiting, give more; if the child refuses to drink the estimated amount, and the signs of dehydration have disappeared, stop giving ORS solution and shift to Treatment Plan A.

If the child is breast-fed, continue breast-feeding during therapy with ORS solution.

For infants under 6 months of age who are not breast-fed, also give 100-200 ml of clean water during the first 4 hours.

When the mother can administer the fluid comfortably and the child is taking it well, she should be shown how to mix ORS solution using containers of a type available in her home or that she can obtain easily. The health worker should demonstrate the method by mixing a packet. Then the mother should prepare the solution herself to ensure that she understands.

Monitoring treatment

During rehydration with ORS solution the child's treatment and progress should be monitored as follows:

Check periodically to be certain that the mother is giving ORS solution correctly and the child is taking it satisfactorily.

Record the amount of solution taken and the number of diarrhoea stools passed.

Watch for problems, such as signs of worsening dehydration (e.g., further loss of skin elasticity, increasing lethargy) or increasing stool output, which may indicate that ORT will not be successful. The management of such patients is discussed later in this unit.

Watch for puffy eyelids, which are a sign of overhydration; if these are seen, ORS solution should be stopped, although breast-feeding and the provision of plain water should continue. When the puffiness is gone, the child can be considered to be rehydrated and further treatment should follow Plan A.

Reassessing the patient

After 4 hours, carefully reassess the child's hydration status following the assessment chart in Unit 3, Figure 3.1:

If the child has no signs of dehydration, rehydration is complete. The child may be sent home after carefully showing the mother how to continue treatment at home with ORS and feeding following Treatment Plan A, giving her enough ORS packets for two days, and explaining the signs that mean the child should return to the health centre (see Unit 4).

If signs indicating some dehydration are still present, continue rehydration therapy by again giving the volume of ORS solution estimated from Treatment Plan B. Continue this approach until the signs of dehydration have disappeared. Also start to offer food and drink as described in Treatment Plan A.

If the child is having frequent watery stools and the signs of dehydration have worsened, ORT should be temporarily stopped and the child rehydrated intravenously as described in Treatment Plan C (see Figure 5.2).

Patients who cannot remain at the treatment centre

If the mother must leave before completing rehydration therapy:

Show her how much ORS solution to give to complete the initial 4-hour treatment at home. If possible, she should make up some solution under supervision and give it during the journey.

Give her enough ORS packets to complete the initial rehydration and for 2 additional days; show her how to make the fluid.

Explain to her how to continue the treatment of her child at home following Treatment Plan A.

TREATMENT OF PATIENTS WITH SEVERE DEHYDRATION - TREATMENT PLAN C

Children with signs of severe dehydration can die quickly from hypovolaemic shock. They should be treated immediately, following Treatment Plan C (Figure 5.2).

Tasks involved in Treatment Plan C

The main tasks of Treatment Plan C are to:

decide how fluid will be given: (a) by IV drip, (b) by nasogastric infusion, or (c) orally;

decide how much IV fluid to give; then give the fluid and reassess the patient frequently;

shift to Treatment Plan B or A when the child is no longer severely dehydrated;

treat suspected cases of cholera with an appropriate antibiotic.

Deciding how fluid will be given

Intravenous replacement

The treatment of choice for severe dehydration is IV rehydration, because it is the most rapid way to restore the depleted blood volume. Intravenous rehydration is especially important if there are signs of hypovolaemic shock (i.e., the patient has a very rapid and weak, or absent radial pulse, cool and moist extremities; the patient is very lethargic or unconscious). Alternative routes for fluid replacement should only be considered when IV rehydration is not possible or cannot be obtained nearby, within 30 minutes.

Nasogastric replacement

If IV therapy is not possible, a nasogastric (NG) tube can be used to give ORS solution, provided there is a person trained in its use. However, this approach is not as satisfactory as IV infusion because the fluid cannot be given as rapidly and additional time is required for it to be absorbed from the intestine. The maximum rate of fluid infusion is about 20 ml/kg/hour; with higher rates, abdominal distension and repeated vomiting are frequent problems.

Oral replacement

If IV and NG therapy are not possible, or will be delayed, and the child is able to drink, ORS solution should be given by mouth at a rate of 20 ml/kg/hour. This approach has the same disadvantages as NG therapy; moreover, it cannot be used for patients who are very lethargic or unconscious. Children under 2 years should be given ORS solution by spoon, about one teaspoonful per minute; older children and adults may drink the solution from a cup. Patients with abdominal distension caused by paralytic ileus should not be given ORS solution either orally or by NG tube.

If fluid replacement is not possible by any of these routes, refer the child urgently to the nearest centre where IV or NG therapy can be given.

Intravenous rehydration

Selecting an appropriate IV fluid

A variety of different solutions is available for IV infusion (see Unit 2). However, some do not contain appropriate amounts of the electrolytes required to correct the deficits found in dehydration due to diarrhoea. Ringer's Lactate Solution (also called Hartmann's Solution for Injection) is the preferred commercially available solution. If it is not available, normal saline (0.9% NaCl), half-strength Darrow's solution with 2.5% or 5% dextrose or half-normal saline in 5% dextrose may be used. IV solutions containing only dextrose (glucose) should not be used.

Putting up an intravenous drip

IV therapy should be given only by trained persons. Some points to remember are given below (see also Annex 5):

Needles, tubing, bottles, and fluid must be sterile.

IV therapy can be given in any convenient vein. Those most suitable are in front of the elbow (antecubital vein) or, in infants, on the scalp. In cases of hypovolaemic shock, particularly in adults, simultaneous infusion into two veins may help to restore blood volume rapidly.

When a peripheral vein cannot be found because of severe hypovolaemia, a needle may be introduced into the femoral vein where it must be held firmly in place. (The femoral vein is located just medial to the femoral artery, which can be easily identified by its pulsation.) A large amount of fluid can then be infused very rapidly. The IV site should be changed to a peripheral vein as soon as one becomes evident. A venous incision ("cut-down") should not be necessary; this takes longer to perform and is liable to become infected.

If IV therapy will be delayed and the patient is able to drink, start giving ORS solution by mouth until the drip is running.

Deciding how much IV fluid to give

If possible, patients with severe dehydration should be weighed so that their fluid requirements can be determined accurately. The fluid deficit in severe dehydration equals about 10% of body weight (i.e., 100 ml/kg).

Infants should be given IV fluid at a rate of 30 ml/kg in the first hour, followed by 70 ml/kg in the next 5 hours, thus providing a total of 100 ml/kg in 6 hours. Older children and adults should be given IV fluid at a rate of 30 ml/kg within 30 minutes, followed by 70 ml/kg in the next 2.5 hours, thus providing a total of 100 ml/kg in 3 hours. For all patients it is useful to mark the IV fluid bottles, indicating the level the fluid should reach after each hour of infusion.

After the first 30 ml/kg have been given, a strong radial pulse should be easily felt. If it is still very weak and rapid, a second infusion of 30 ml/kg should be given at the same rate; however this is rarely necessary. Small amounts of ORS solution should also be given by mouth (about 5 ml/kg/hour) as soon as the patient is able to drink, in order to provide additional potassium and base; this is usually possible after 3-4 hours (infants) or 1-2 hours (older patients).

Reassessing the patient

During rehydration, the patient's progress should be assessed at least hourly until there is a definite improvement. Particular attention should be paid to:

the signs of dehydration (see Unit 3, Figure 3.1);

the number and nature of the stools passed;

any difficulty in giving fluids.

Signs of a satisfactory response to rehydration are: return of a strong radial pulse, improved level of consciousness, increased ability to drink, much improved skin turgor, and passage of urine. When these are seen, the interval between reassessments can be lengthened.

If the signs of dehydration remain unchanged or become worse, and especially if the patient has also passed several watery stools, the rate of fluid administration and the total amount of fluid given for rehydration should be increased.

Alternative methods of rehydration

Nasogastric rehydration

An NG tube (size 6-8 French for a child, 12-18 for an adult) should be placed by a person trained in its use (see Annex 6). While the tube is in place, the head should be kept slightly raised to reduce the risk of regurgitated fluid entering the lungs.

Patients with severe dehydration should receive about 120 ml of ORS solution per kg of body weight over 6 hours, administered at a steady rate of 20 ml per kg per hour. This rate should be reduced only if there is repeated vomiting or increasing abdominal distension.

Patients should be reassessed every 1-2 hours until a satisfactory response to treatment is seen. If the signs of dehydration fail to improve or become worse after 3 hours of attempted NG rehydration, this approach is not likely to be successful and the patient should be sent urgently to a facility where IV treatment is possible.

Oral rehydration

The amount of fluid to be given orally and the monitoring of patients during oral rehydration are the same as described above for NG rehydration. It is helpful to measure out the amount of fluid required each hour into a glass or other container, even though it may be given by spoon. If a patient cannot drink the required amount of fluid or vomits frequently, the rate of administration should be slowed and the rehydration period lengthened. If signs of dehydration fail to improve or become worse after 3 hours of attempted oral rehydration, the patient should be sent urgently to a facility where IV treatment is possible.

Giving breast milk and water

In addition to rehydration therapy, the patient's normal need for water must be met. Breast-feeding should be resumed as soon as an infant can suck. Infants less than 6 months of age who are not breast-fed should be given 100-200 ml of plain water during the first 6 hours, once they are able to drink; older children and adults should be given water to drink as soon as they desire it, provided that vomiting has subsided. (This is in addition to any ORS solution being given.)

Transition to Treatment Plans B and A

At the end of the planned rehydration period (usually 3-6 hours), the patient's hydration status should be carefully reassessed. If signs of severe dehydration are still present, rehydration therapy must be continued following Treatment Plan C. Otherwise, further treatment should follow Plan B or Plan A, depending, respectively, on whether some signs of dehydration remain or there are no signs of dehydration. In either case, ORS solution should be used. Before removing the IV line, however, it is wise to give ORS solution for at least one hour to be certain ORT is feasible. If possible, patients presenting with severe dehydration should be hospitalized until the diarrhoea subsides. Otherwise, they should be observed for at least 6 hours after rehydration before returning home, to make sure that the mother can maintain their hydration using ORS solution.

Treatment of suspected cholera

Children over 2 years of age and adults with severe dehydration caused by acute watery diarrhoea who live in an area where cholera occurs, should be given an appropriate oral antibiotic after vomiting subsides. This would usually be tetracycline or doxycycline (see Annex 7). If V. cholerae 01 in the area are known to be resistant to tetracycline, furazolidone, cotrimoxazole or chloramphenicol may be used. Treatment of cholera with an appropriate antibiotic helps to shorten the duration of diarrhoea, but does not diminish the need for careful fluid replacement.

PATIENTS WITH PROBLEMS

A number of problems may arise during rehydration therapy, some of which require specific treatment. In general, these fall into the three categories discussed below.

Electrolyte and acid-base abnormalities

These include hypernatraemia, hyponatraemia, hyperkalaemia, hypokalaemia, and base-deficit acidosis. The pathogenesis and clinical features of these disorders are described in Unit 2. Usually they arise as dehydration is developing or when the fluids used for rehydration do not have an appropriate composition. Although certain clinical features may suggest a particular diagnosis, for example, seizures suggest hypernatraemia or hyponatraemia, and paralytic ileus suggests hypokalaemia, these signs are not specific and a diagnosis can be made with certainty only by measuring serum electrolytes, bicarbonate, or pH. It is more important to understand, however, that these disorders are all corrected when ORS solution is used to treat dehydration as described in this unit and kidney function is satisfactory.

Failure of oral rehydration therapy

A small number of patients with some dehydration cannot be treated adequately with ORS solution by mouth and require IV (or NG) therapy. They should receive Ringer's Lactate Solution (70 ml/kg intravenously over 3-4 hours) and then be reassessed to determine whether ORT is possible or IV treatment should be continued. Patients that fall in this category may have:

High rates of purging (frequent passage of voluminous liquid stools):
Patients with watery diarrhoea who purge at very high rates (e.g., exceeding 15-20 ml/kg/hour) may be unable to drink sufficient ORS solution to replace their continuing stool losses, so that their signs of dehydration worsen. Such patients should be treated for several hours with IV fluid, until the rate of purging decreases.

Persistent vomiting:
Vomiting does not usually prevent successful ORT because most of the fluid taken is actually retained and absorbed, despite the obvious losses. When vomiting is frequent, the first step is to stop giving ORS solution for 10 minutes, and then to resume giving it, but more slowly; most patients can be managed successfully in this way. Occasionally, however, severe and repeated vomiting prevents effective oral rehydration. If the clinical signs of dehydration do not improve, or become worse, fluids should be given intravenously until the vomiting subsides. Remember that vomiting is often most severe during dehydration and usually disappears as water and electrolytes are replaced. Drugs should never be given to control vomiting because they are not very effective and often cause the child to become sleepy, making ORT more difficult.

Inability to drink:
Patients who cannot drink because of stomatitis (due, for example, to measles, thrush, or herpes), fatigue, or central nervous system depression induced by drugs (such as antiemetics or antimotility drugs) should be given IV fluid or ORS solution by NG tube. If the patient is comatose, fluid should be given intravenously, if possible, or by NG tube.

Abdominal distension and ileus:
If the abdomen starts to become distended, ORS solution should be given more slowly. If abdominal distension continues to increase or is already well developed, and especially if there is paralytic ileus with absent bowel sounds, ORT or nasogastric therapy should be stopped and fluid given intravenously. Paralytic ileus may be caused by opiate drugs (e.g., codeine, paregoric), hypokalaemia, or, more frequently, by both acting together.

Glucose malabsorption:
Clinically significant glucose malabsorption is unusual during acute diarrhoea. However, when it does occur, the use of ORS solution may cause a marked increase in watery diarrhoea with large amounts of unabsorbed glucose in the stool and worsening signs of dehydration (see Unit 2, Figure 2.4). The child may also become hypernatraemic and very thirsty. Special tapes or test sticks can be used to detect glucose in the stool. Tests for reducing substances, such as Benedict's solution or Clinitest (R) tablets, can also be used (see Unit 7). When glucose malabsorption prevents successful ORT, fluids should be given intravenously until diarrhoea subsides. Water may also be given to drink until thirst is satisfied.

Seizures

Dehydrated children occasionally develop convulsions either before or during rehydration therapy. Some possible causes of seizures and their appropriate treatment are as follows:

Hypoglycaemia:
This occurs mostly in undernourished infants and young children. A therapeutic test for hypoglycaemia in a comatose child involves giving sterile 20% glucose solution intravenously; if hypoglycaemia is the cause, giving 2.5 ml/kg of the solution over 5 minutes should cause a rapid improvement in consciousness. After waking up, the child should be fed, given ORS solution, or both, to prevent a recurrence.

Hyperthermia:
Some young children (especially infants) develop seizures when they have a fever; the risk is greatest when the fever is high, e.g. exceeds 40° C. Treatment involves giving paracetamol or cooling by sponging with tepid water and fanning.

Hypernatraemia or hyponatraemia:
See Unit 2 for a discussion of these conditions. The preferred treatment is with ORS solution, unless there is also glucose malabsorption (see above). When sufficient amounts are given to correct dehydration and restore normal kidney function, serum sodium levels will become normal.

Central nervous system conditions unrelated to diarrhoea, such as epilepsy or meningitis. Appropriate anticonvulsant and antimicrobial therapy should be given.

EXERCISES

1. Ahmed has diarrhoea and some signs of dehydration. He is 8 months old and weighs 6kg. Approximately how much ORS solution should he receive during the first 4 hours? (Use the chart in Figure 5.1 to determine your answer.)

1. 200-400 ml
   
2. 400-600 ml
   
3. 600-800 ml
   
4. 300-400 ml

2. A mother has brought her 2½ year old daughter, Maria, to the health facility. Maria has been assessed and found to have some signs of dehydration. She weighs 12 kg. While at the facility, her mother has given her 700 ml of ORS solution within 4 hours. After 4 hours, Maria still has some signs of dehydration, but is improving. Assuming that the mother can stay at the facility, what should be done next? (There may be more than one correct answer.)

1. Stop ORT and give 500 ml Ringer's Lactate Solution intravenously during the next 3 hours.
   
2. Repeat Plan B, giving 800-1000 ml of ORS solution in the next 4 hours.
   
3. Pass an NG tube and give 900-1200 ml ORS solution by this route in the next 4 hours.
   
4. Start to feed the child as described in Plan A.

3. John, an 18-month-old baby with diarrhoea, has been brought to the health centre by his grandmother. He weighs 9 kg. He has been assessed and found to have some signs of dehydration. The grandmother must leave soon to catch the last bus; it is too far for her to walk home. What should the health worker do? (There may be more than one correct answer.)

1. Give the child an antibiotic to treat his infection.
   
2. Give the grandmother 700 ml of ORS solution and show her how to give it to John during the next 4 hours.
   
3. Explain to the grandmother how John should be fed when they return home.
   
4. Give the grandmother two 1-litre packets of ORS for use in treating John at home during the next 2 days, after he has been rehydrated.

4. Balaji is a 9 kg boy with signs of severe dehydration who is very drowsy and cannot drink. He is brought to a small health centre. There is no IV equipment at the health centre, but the health worker knows how to use an NG tube. How much ORS solution should be given through the NG tube in the first hour?

1. 30 ml/kg, i.e., 270 ml
   
2. 20 ml/kg, i.e., 180 ml
   
3. 10 ml/kg, i.e., 90 ml
   
4. As much as possible, until abdominal distension occurs.

5. Omo is a 4 month-old baby weighing 4 kg who was severely dehydrated due to diarrhoea. He has received 250 ml of Ringer's Lactate Solution intravenously over 3 hours and is improving. He can now drink. What treatment should be given next? (There may be more than one correct answer.)

1. He should be treated according to Plan A.
   
2. He should resume breast-feeding.
   
3. He should receive 150 ml of Ringer's Lactate Solution intravenously in the next 3 hours.
   
4. He should begin taking small amounts of ORS solution, about 25 ml each hour.

6. Sanjay, a 3 month-old boy weighing 4 kg, has been treated for severe dehydration for 6 hours, by means of IV Ringer's Lactate Solution given intravenously. The child has just been reassessed. He is improving, but still has some signs of dehydration. What treatment should he receive now? (There may be more than one correct answer.)

1. He should be given 200-400 ml of ORS solution over the next 4 hours.
   
2. He should continue to receive IV treatment, following Plan C, until all signs of dehydration have disappeared.
   
3. He should be given an antidiarrhoeal drug or antibiotic to help stop his diarrhoea.
   
4. He should resume breast-feeding if he has not done so already.

7. You are a doctor working in an urban clinic. Ria, an 8 month-old girl is brought to you. She is comatose, with a very rapid heart rate; the radial pulse cannot be felt; the skin of her arms and legs is cool and moist and her skin pinch goes back very slowly; her abdomen is distended and bowel sounds are infrequent. Ria has been having profuse, watery diarrhoea and severe vomiting for the past 2 days. The local pharmacist prescribed antiemetic drops and a suspension containing codeine. The baby has a temperature of 38° C and weighs 6 kg.

1. What type of dehydration does Ria have?
   
2. How much fluid is needed to replace her deficit? ml
   
3. How should the fluid be given?
   
4. Over what time periods would you divide her rehydration therapy?
   
5. What is the probable cause of Ria's abdominal distension?

8. Hawa is 3 years old and weighs 12 kg. She lives in an area where cholera has recently been diagnosed. Her diarrhoea started yesterday and she has had 6 large watery stools. Her alarmed mother suspended all food but started giving her extra liquids. However, Hawa has had severe vomiting all morning. The doctor examining Hawa at the local health facility notices that she is very sleepy, has very dry and sunken eyes, and a very dry tongue; a pinch of her skin goes back very slowly. The doctor works at a health facility where IV fluid is available.

1. What type of dehydration does Hawa have?
   
2. You decide to give IV treatment, but Ringer's Lactate Solution is not available. What solution would be your next choice?
   
3. How would the possibility that Hawa has cholera affect your choice of treatment?
   
4. When should you start to give Hawa ORS solution by mouth?

9. Ali is 5 months old and weighs 4.5 kg. His mother breast-feeds him. His diarrhoea started last night, and he has had 8 very watery stools. His mother said there was no blood in the stools. As the doctor examines Ali, she finds that the skin pinch goes back slowly, the eyes are a little sunken, and Ali drinks some ORS solution very eagerly. Ali does not have a fever.

1. What type of dehydration does Ali have?
   
2. Which treatment plan should be followed for Ali?
   
3. Approximately how much ORS solution should Ali receive in the first 4 hours?
   
4. When should the mother start to breast-feed Ali again?
   
5. If Ali has no signs of dehydration after 4 hours, what treatment plan should be followed next?

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ANSWERS

1. B

2. B,D

3. B,C,D

4. B

5. B,C,D

6. A,D

7. A. Ria has severe dehydration.

B. She requires 100 ml/kg, for a total of 600 ml.

C. The fluid should be given intravenously.

D. She should receive 30 ml/kg in the first hour, and 70 ml/kg in the next 5 hours.

E. Codeine, possibly combined with a potassium deficit.

8. A. Hawa has severe dehydration, possibly caused by cholera.

B. Normal saline solution (O.9% NaCl), half strength Darrow's solution with 2.5% or 5% dextrose, or half Normal saline with 5% dextrose.

C. Hawa should receive an oral antibiotic for cholera, usually tetracycline or doxycycline, after rehydration is complete and vomiting has stopped.

D. Give Hawa small amounts of ORS solution as soon as she is able to drink; this should be possible after 1-2 hours of rehydration therapy.

9. A. Ali has some dehydration.

B. Treatment Plan B.

C. Ali should receive 200-400 ml of ORS solution during the first 4 hours.

D. The mother should resume breast-feeding at once and breast-feeding should not be interrupted during ORT.

E. Treatment Plan A should be used.

updated: 7 June, 2017