Oral Rehydration Salts

By

Dr Utpal Sharma

Assistant Professor

Department of Community Medicine

SMIMS, Gangtok, Sikkim

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 of infant

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 diarrhoealillnesses or dysentery, irrespective of frequency.

“Passage of loose or watery stools at least three timesin 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

Over 2,500 years ago, Sushruta described the treatment of acute diarrhea with rice water, coconut juice and carrot soup.

In 1831, William Brooke treated cholera patients with IV Fluids reducing mortality from 70 % to 40 %.

IV fluid replacement became the standard of care for moderate/severe dehydration for over a hundred years.

Late 1950’s: Dr Hemendranath Chatterjee

1971: Dr. Dilip Mahalanabis 350,000 treated with mortality of 0.36%

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.

Oral rehydration salts

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 aetiologiesAll countries

Types of ORS??

Sodium bicarbonate based

Trisodium citrate based

Reduced osmolarity ORS

Super ORS

Sodium bicarbonate based ORS

Composition

Contents (gm)

NaCl 3.5

Glucose 20.0

KCl 2.5

Sodium bicarbonate 2.5

Trisodium citrate based ORS

Composition

Contents (gm)

NaCl 3.5

Glucose 20.0

KCl 1.5

Trisodium citrate 2.0

Bicarbonate vs.

Tricitrate ORS

Bicarbonate-based ORS

Less stable

Stool output not reduced

Tricitrate-based ORS

More stable

Less stool output in high

output diarrhoea

Tri Na citrate-increases

intestinal absorption of

Na & water

WHO ORS Osmolarity

Na+ 90mM

Cl + 80mM

Glucose 110mM

K+ 20mM

Citrate 10mM

TOTAL 310mM

Any adverse effect of this WHO ORS ????

How to overcome this????

Possible adverse effects is hyper tonicity in net

fluid absorption

We should reduce the osmolarity of the ORS

Reduced osmolarity ORS

Contents (gm)

NaCl 2.6

Glucose 13.5

KCl 1.5

Trisodium citrate 2.9

Composition

Osmolarity of this new ORS

Na+ 75mM

Cl + 65mM

Glucose 75mM

K+ 20mM

Citrate 10mM

TOTAL 245mM

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.

DOSAGE & REQUIREMENT?

Age <4mths 4-11mths 1-2yrs 2-4yrs 5-14yrs ≥15yrs

Wt.(kg) <5 5-7.9 8-10.9 11-15.9 16-29.9 ≥30

Soln.(ml) 200-400 400-600 600-800 800-1200 1200-

2200

2200-

4000

If the child’s weight is known…..

….. the amount of ORS soln.for rehydration

during the first 4hrs may be calculated as 75ml/kg

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 it ORS again. Usually vomiting will stop.

If diarrhoea increases and /or vomiting persists, take child over to a health clinic.

How to prepare oral rehydration solution

How to prepare….

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

Wait for 10 minutes

Give a teaspoonful every 2-3 minutes

If the child vomits??

Cont…..

If the child wants to drink more than the estimated

amount ?

If the child refuses to drink ?

If the child is breast fed ?

Non breast fed infants less than 6 months

No harm , give more

See whether the signs of dehydration has disappeared

If yes

Treat similar to a non dehydrated diarrheal child.

Nursing + treatment with ORS solution

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