Oral Rehydration Therapy
Oley Meeting St Petersburg Florida July 1, 2009 Rehydration Therapy
Ezra Steiger MD Cleveland Clinic
Oley Picnic July 2009
50 (Female) 60% of your Body (Male)
Coach: Gatorade not only quenches your thirst better, it tastes better too Bobby: No, you people are drinkin the wrong water Coach : Gatorade Bobby: H2O Coach : Gatorade Bobby: H2O
Coach: (singing) Water sucks, it really, really sucks! Water sucks, it really, really sucks! WATER ?
SPORTS DRINK ?
ORAL REHYDRATION SOLUTION ? IntestinalIntestinal FluidFluid DynamicsDynamics
•• SodiumSodium •• WaterWater •• SugarSugar •• OsmolalityOsmolality IntestinalIntestinal FluidFluid DynamicsDynamics
Sugar Intestinal Wall
Contents of Small Blood Bowel
Courtesy of Darlene G Kelly MD, PhD IntestinalIntestinal FluidFluid DynamicsDynamics
== DiarrheaDiarrhea DehydrationDehydration
Sugar Intestinal Wall
Contents of Small Blood Bowel
Courtesy of Darlene G Kelly MD, PhD AcuteAcute FluidFluid VolumeVolume DeficitDeficit
•• BPBP lowlow •• HeartHeart RateRate increasedincreased •• UrineUrine outputoutput lowlow •• RecussitateRecussitate withwith isotonicisotonic solutionssolutions suchsuch asas RingersRingers ConsequencesConsequences ofof DehydrationDehydration
•• EachEach 1%1% ofof dehydrationdehydration increasesincreases bodybody temperaturetemperature byby 0.10.1--0.20.2 degreesdegrees CC •• HeatHeat lossloss byby evaporationevaporation ofof sweatsweat isis decreaseddecreased whenwhen aa personperson isis dehydrateddehydrated •• EachEach 1%1% ofof dehydrationdehydration increasesincreases thethe heartheart raterate byby 44 beatsbeats perper minuteminute •• WhenWhen dehydrationdehydration exceedsexceeds 2%2% workwork performanceperformance isis decreaseddecreased
Kenefick and Sawka J Am Coll Nutr 26:597s-603s, 2007. ChronicChronic FluidFluid VolumeVolume DeficitDeficit
•• DecreasedDecreased skinskin turgorturgor •• BUN/CrBUN/Cr >15>15 •• WeightWeight lossloss •• HematocritHematocrit elevatedelevated (6(6--88 •• SunkenSunken eyeseyes pointspoints forfor eacheach literliter •• HypothermiaHypothermia deficit)deficit) •• OliguriaOliguria •• UrineUrine spsp grgr highhigh •• HypotensionHypotension •• UrinaryUrinary NaNa <20mEq/L<20mEq/L •• TachycardiaTachycardia
Short Bowel Jejunostomy CompositionComposition ofof BodyBody FluidsFluids
Na+Na+ K+K+ ClCl-- HCOHCO3-- PlasmaPlasma 135135--150150 3.53.5--55 9898--106106 2222--3030 GastricGastric 1010--150150 44--1212 120120--160160 00 BileBile 120120--170170 33--1212 8080--120120 3030--4040 SmlSml IntInt 8080--150150 22--88 7070--130130 2020--4040 DiarrheaDiarrhea 2525--130130 1010--6060 2020--9090 2020--5050 ChallengesChallenges inin thethe ManagementManagement ofof DiarrheaDiarrhea
•• ReplaceReplace FluidFluid LossLoss
•• ReplaceReplace SodiumSodium (Na)(Na) LossLoss OralOral RehydrationRehydration TherapyTherapy HistoryHistory
•• SushrutaSushruta IndianIndian physicianphysician –– 1,0001,000 BCBC •• TepidTepid waterwater withwith rockrock saltsalt andand molassesmolasses
Elliott Clinical Medicine 8:296-297, 2008 OralOral RehydrationRehydration TherapyTherapy HistoryHistory •• DarrowDarrow TheThe retentionretention ofof electrolyteelectrolyte duringduring recoveryrecovery fromfrom severesevere dehydrationdehydration duedue toto diarrheadiarrhea 19461946 •• ChatterjeeChatterjee ControlControl ofof vomitingvomiting inin choleracholera andand oraloral replacementreplacement ofof fluidfluid 19531953 •• HirschhornHirschhorn DecreaseDecrease inin netnet stoolstool outputoutput inin choleracholera duringduring intestinalintestinal perfusionperfusion withwith glucoseglucose containingcontaining solutionssolutions 19691969
Elliott Clinical Medicine 8:296-297, 2008 Sodium/Glucose Co-Transport OralOral RehydrationRehydration TherapyTherapy HistoryHistory
•• MahalanabisMahalanabis OralOral fluidfluid therapytherapy ofof choleracholera amongamong BangladeshBangladesh refugeesrefugees 19731973 MortalityMortality reducedreduced fromfrom 30%30% toto <4%<4% •• JournalJournal LancetLancet ““TheThe discoverydiscovery thatthat sodiumsodium transporttransport andand glucoseglucose transporttransport areare coupledcoupled inin thethe smallsmall intestine,intestine, soso thatthat glucoseglucose acceleratesaccelerates thethe absorptionabsorption ofof solutesolute andand waterwater waswas potentiallypotentially thethe mostmost importantimportant medicalmedical advanceadvance thisthis century.century.”” 19781978
Elliott Clinical Medicine 8:296-297, 2008 OralOral RehydrationRehydration SolutionsSolutions Sodium balance in Short Bowel Syndrome
20
10
0
-10 60 90 120 150 Sodium content, mmol/L
Rodriguez CA, et al. Clin Sci. 1988;74(suppl18):69. OralOral SaltSalt SupplementsSupplements forfor PatientsPatients withwith aa HighHigh OutputOutput JejunostomyJejunostomy
•• ExtraExtra sodiumsodium waswas absorbedabsorbed withwith eacheach formform ofof supplementsupplement •• 22 patientspatients receivingreceiving saltsalt capsulescapsules vomitedvomited •• AA sippedsipped glucoseglucose saltsalt solutionsolution seemsseems toto bebe thethe optimaloptimal modemode ofof sodiumsodium replacementreplacement
Nightingale JM, et al. Gut. 1992;33:759-61. OralOral Rehydration(?)Rehydration(?) SolutionsSolutions NaNa CarbohydrateCarbohydrate OsmolalityOsmolality ** mMolmMol/L/L gm/Lgm/L mOsm/kgmOsm/kg WHOWHO--ORSORS 9090 2020 310310 RiceRice--basedbased 9090 4040 260260 PediatricPediatric 5050 2020 270270 solutionsolution SportsSports drinkdrink 2020 2020 145145 GingerGinger aleale 33 9090 540540 AppleApple juicejuice 33 124124 730730
ChickenChicken*(g/L), all contain brothbroth glucose250 250except rice-based solution 00 450450 HomeHome RecipeRecipe forfor ORSORS
1000 11 literliter waterwater 750 500 ¾¾ teaspoonteaspoon tabletable saltsalt 250 44 tablespoonstablespoons sugarsugar (sucrose)(sucrose) 11 teaspoonteaspoon bakingbaking powderpowder (or(or ½½ teaspoonteaspoon bakingbaking soda)soda) ½½ teaspoonteaspoon 20%20% potassiumpotassium chloridechloride (by(by prescription)prescription) SugarSugar--freefree artificialartificial flavoring/sweetenerflavoring/sweetener toto tastetaste WHO/UNICEFWHO/UNICEF OralOral RehydrationRehydration SolutionsSolutions vsvs HomeHome RecipeRecipe ((mmolmmol/L)/L)
StandardStandard ORSORS HomeHome RecipeRecipe SodiumSodium 9090 9898 ChlorideChloride 8080 7777 GlucoseGlucose 111111 (20.0(20.0 gm)gm) 146146 (50.2(50.2 gm)gm) ** PotassiumPotassium 2020 AsAs neededneeded CitrateCitrate 1010 ------OsmolarityOsmolarity 311311 321321
* sucrose WHO/UNICEFWHO/UNICEF OralOral RehydrationRehydration SolutionsSolutions ((mmolmmol/L)/L)
StandardStandard ORSORS ReducedReduced osmolarityosmolarity ORSORS SodiumSodium 9090 7575 ChlorideChloride 8080 6565 GlucoseGlucose 111111 (20.0(20.0 gm)gm) 7575 (13.5(13.5 gm)gm) PotassiumPotassium 2020 2020 CitrateCitrate 1010 1010 OsmolarityOsmolarity 311311 245245 ReducedReduced OsmolarityOsmolarity ORSORS vsvs StandardStandard ORSORS inin HospitalizedHospitalized ChildrenChildren
•• DecreasedDecreased stoolstool outputoutput •• LessLess vomitingvomiting •• LessLess needneed forfor IVIV fluidfluid •• NoNo increaseincrease inin hyponatremiahyponatremia
Pediatrics 107:613-618, 2001. Cochrane Library Review Issue 2 , 2009 G2G2 ++ SaltSalt vsvs WHOWHO ReducedReduced OsmolarityOsmolarity OralOral RehydrationRehydration SolutionSolution ((mmolmmol/L)/L)
GatoradeGatorade G2G2 ++ ReducedReduced ½½ tsptsp saltsalt osmolarityosmolarity ORSORS SodiumSodium 6363 7575 ChlorideChloride 3232 6565 GlucoseGlucose 156156 (28(28 gm)gm) 7575 (13.5(13.5 gm)gm) PotassiumPotassium 33 2020 CitrateCitrate ------1010 OsmolarityOsmolarity 254254 245245
Intestinal Rehab & Transplant Program (IRTP)
To enhance absorptive capacity, improve nutritional status, and reduce need for PN through the use of: H2O
Sport Drink
ORS The End