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The Role of Bicarbonate and Base Precursors in Treatment of Acute Gastroenteritis

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The Role of Bicarbonate and Base Precursors in Treatment of Acute Gastroenteritis Arch Dis Child: first published as 10.1136/adc.62.1.91 on 1 January 1987. Downloaded from Archives of Disease in Childhood, 1987, 62, 91-95 Current topic The role of bicarbonate and base precursors in treatment of acute gastroenteritis E J ELLIOTT, J A WALKER-SMITH, AND M J G FARTHING Departments of Child Health and Gastroenterology, St Bartholomew's Hospital, London Widespread use of oral glucose-electrolyte rehydra- tion as to whether rehydration with base was tion solutions (ORS) has resulted in a dramatic superior to rehydration with saline alone. decrease in the morbidity and mortality associated The use of parenteral bicarbonate was not without with childhood gastroenteritis, regardless of its its problems. In the 1940s Rapoport et al recom- aetiology. Nevertheless, diarrhoeal disease remains mended vigorous rehydration with saline containing the most common cause of death of children in sodium bicarbonate but without potassium and developing countries, and current research efforts reported a 'post-acidotic state' in children whose are directed towards optimising the efficacy of ORS, diarrhoea had improved and in whom recovery aiming for both simplicity and economy. Con- seemed imminent. The clinical syndrome he de- troversy regarding the 'ideal' sodium and glucose scribed of lethargy, irritability, abnormal cardiac concentration continues to the extent that different function, intracranial haemorrhage, generalised copyright. formulations are now recommended in the develop- oedema, and tetany can be attributed to the ing and industrialised world. The inclusion of alkalosis and electrolyte disturbance (hypoka- bicarbonate or a base precursor (citrate, acetate, or laemia, hypocalcaemia, hypophosphataemia, and lactate) in ORS is generally assumed to be neces- hypernatraemia) after excessive rapid administra- sary, both for promotion of water and sodium tion of sodium and alkali. absorption and correction of acidosis. This issue, however, has received little critical attention since Oral treatment. Darrow was the first to recommend the formal introduction of oral rehydration therapy. oral rehydration with a glucose-electrolyte solution http://adc.bmj.com/ We have reviewed the available evidence from as an alternative to intravenous fluids. Although all animal and human studies and conclude that there is the children in his original study had low serum little evidence to support the inclusion of bicarbon- bicarbonate concentrations, these returned to nor- ate or a base precursor in ORS. mal after treatment with solutions containing lactate (53 mmol/l), even in the most severe cases. Historical considerations Although this often took more than 24 hours, acidosis did not recur after rehydration began, and on September 28, 2021 by guest. Protected Intravenous treatment. As early as 1832 Latta alkalosis and the 'post-acidotic state' were never recommended intravenous saline containing 'two observed. Further studies confirmed these findings, scruples of subcarbonate of soda' for the treatment leading Darrow and colleagues to conclude that of cholera and its associated acidosis.' A similar additional bases such as sodium bicarbonate were regimen with intravenous sodium acetate or bicar- seldom if ever required for the treatment of acidosis bonate was used by 1910 by Sellards.2 This treat- in diarrhoeal disease of infancy.7 Furthermore, ment decreased the mortality from renal failure these investigators recognised that if bicarbonate associated with cholera. Acidosis in infantile di- was given rapidly or in large amounts the condition arrhoea of other causes was also shown to improve described by Rapoport could occur. after administration of bicarbonate.3 Powers recom- Since those early days, the use of oral rehydration mended bicarbonate in his plan of treatment for the solutions has rapidly increased. Bicarbonate or a 'intestinal intoxication of infants' in 1926,4 and base precursor is included in the World Health Hartmann used sodium lactate to relieve acidosis in Organisation (WHO) ORS and in commercially diarrhoeal disease in 1938.5 None of these studies, manufactured ORSs in the United Kingdom (Table however, attempted to answer the important ques- 1) and throughout the world, on the premises that 91 Arch Dis Child: first published as 10.1136/adc.62.1.91 on 1 January 1987. Downloaded from 92 Elliott, Walker-Smith, and Farthing Table 1 Composition of WHO and commercial ORSs (mmol/l) WHO WHO citrate BNF* Dioralvtet Rehidratt Dextrolvte§ Bicarbonate 30 18 18 20 Citrate 10 9 Lactate 18 Sodium 90 90 35 35 50 35 Chloride 8( 8( 37 37 50 3(0 Potassium 20 21) 2(0 20) 20 13 Glucose 111 111 201) 202 91 200 Sucrose 94 Fructose 2 *British National FormularY, Sodium Chloride and Glucose Oral Powder Compound. tArmour Pharmaceutical Co Ltd. tSearle Pharmaceuticals. §Cow and Gate Ltd. (a) bicarbonate enhances sodium and water absorp- only recommended when pH fails to correct after tion and (b) the metabolic acidosis of acute di- restoration of adequate intravascular volume. Simi- arrhoea requires correction with exogenous base. larly, children with diabetes with ketoacidosis do not Justification for the continued use of bicarbonate or require bicarbonate providing adequate insulin and base precursor in ORS must be supported by fluids are given and cardiovascular and renal func- evidence for at least one or preferably both of these tion is normal, unless blood pH falls below 7-2.12 statements. Metabolic acidosis during acute diarrhoea is generally attributed to bicarbonate loss in the stool, Effect of base on intestinal sodium and water which results in loss of total blood buffering cap- transport acity. In addition, when dehydration is severe and renal plasma flow falls excretion of hydrogen ionscopyright. Bicarbonate stimulates water and sodium absorp- and regeneration of bicarbonate is impaired. Also tion in the normal human jejunum and ileum.8 The poor perfusion of peripheral tissue may contribute magnitude of this effect on sodium absorption in the to a lactic acidosis. Acidosis is more likely to human jejunum is comparable with that of glucose complicate cholera than other acute diarrhoea, as and independent of luminal pH.9 Short chain fatty the stool concentration of bicarbonate is higher than acids, such as the base precursor acetate, share the in rotavirus or enterotoxigenic Escherichia coli ability of bicarbonate to stimulate sodium and water diarrhoea and dehydration more pronounced absorption in the human small intestine."'( (Table 2).13 14 Despite these theoretical consider- http://adc.bmj.com/ Although bicarbonate has similar effects on water ations and the common finding of a reduced serum and sodium absorption in the normal rat small bicarbonate concentration in acute diarrhoea, mean intestine,t1 we have shown that bicarbonate and the arterial pH is often normal. base precursors acetate and citrate are unable Thus, providing perfusion is maintained, renal (unlike glucose) to reverse water and sodium compensation ensures that acid base state will secretion induced by cholera toxin (Unpublished normalise with rehydration without additional base observations). These findings suggest that bicarbon- in the vast majority of cases of acute gastroenteritis. on September 28, 2021 by guest. Protected ate may not be beneficial with respect to the In severely dehydrated or acidotic patients promotion of water absorption in the enterotoxin mediated diarrhoeas. Table 2 Electrolyte composition of stool in childhood Role of base in the correction of metabolic acidosis gastroenteritis Aetiology Stool (mmol/l) It is now generally accepted that in metabolic electrolytes acidosis of childhood administration of bicarbonate Sodium Potassium Chloride Bicarbonate should be reserved for conditions in which endogen- Cholera I10* 27 92 32 ous production or conservation of bicarbonate is 88t 30 86 32 inadequate to restore normal pH. Examples of such Rotavirus 37t 38 22 6 Enterotoxigenic specific disorders include salicylism, prolonged di- Escherichia coli 53t 37 24 18 arrhoea, disorders of organic and amino acid meta- Non-cholera diarrhoea 56* 25 55 14 bolism, and renal tubular acidosis. In acute hypoxia *Reference 13. and prerenal or circulatory failure bicarbonate is tReference 14. Arch Dis Child: first published as 10.1136/adc.62.1.91 on 1 January 1987. Downloaded from The role of bicarbonate and base precursors in treatment of acute gastroenteritis 93 (pH<7-2), in those with persistent high volume diarrhoea, and in those with impaired renal function and worsening metabolic acidosis the administration of intravenous base such as sodium bicarbonate is indicated and may be life saving. Correction of acidosis with parenteral sodium bicarbonate must be z z performed with caution to avoid its detrimental effects. 12 Clinical observations -~ O There is little clinical evidence to support the inclusion of base in the treatment of acidosis and dehydration in acute diarrhoea. Indeed, most regi- mens for intravenous rehydration are effective E x5E despite the omission of bicarbonate. 15 In a con- Ex SJ , ^ >tj trolled trial in Capetown Heese compared a mildly alkalinising intravenous solution (26 mEq/l lactate) with or without additional sodium bicarbonate for 33= Z 3 ,>E =t t3 3C3A treating children with acute gastroenteritis who were acidotic and 5-10% dehydrated. Those who re- ceived additional base regained normal pH, carbon dioxide tension, and serum bicarbonate more t c,) but no ill effects C,, c quickly than those who did not, E E Cd were suffered
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