Oral rehydration salts инструкция по применению на русском языке

Oral Rehydration Solution (ORS) Use and Availability

ORS packets are available in the United States from Jianas Brothers Packaging Company, 2533 Southwest Boulevard, Kansas City, Missouri 64108, USA (816-421-2880). ORS packets may also be available at stores that sell outdoor recreation and camping supplies.

In addition, Cera Products, 9017 Mendenhall Court, Columbia, Maryland 21045, USA (410-309-1000 or 888-Ceralyte; www.ceraproductsinc.com), markets a rice cereal rather than a glucose-based product, Ceralyte, in different flavors.

Oral Rehydration Solutions

Admittedly, incorporating ORS into a patient’s care plan is challenging, as the solutions can be unpalatable. Patients should be advised to have their ORS handy throughout the day for sipping to limit dumping. Patients may choose to refrigerate ORS or use ice cubes or popsicles made out of ORS if preferred. Beverage flavor packets or artificial sweeteners may be added to improve taste. Ideally the volume of ORS consumed should be titrated to exceed enterostomy output and maintain urine output of at least 1 L over the course of 24 hours, but a lower starting amount is reasonable while a patient establishes an ORS routine and develops a taste for it. It is also reasonable to start with a lower sodium-containing ORS and titrate up to higher sodium formulas as patients become used to them (Kelly and Nadeau, 2004; Matarese, 2013; Parrish and DiBaise, 2015).

Oral Rehydration

Oral rehydration solution (ORS) is an oral fluid whose composition was developed by the World Health Organization (WHO) to maximize intestinal absorption of fluid and electrolytes (Atia and Buchman, 2009). Historically ORS has been used for the correction of dehydration and reduction of mortality with diarrheal disease; however, though not necessarily an antidiarrheal treatment, patients with SBS have demonstrated improved hydration with adherence to ORS recommendations (Atia and Buchman, 2009). Unaffected by the pathological processes that increase mucosal secretion, ORS stimulates the jejunal glucose–sodium cotransporters to drag fluid across the intestinal mucosa increasing the expansion of extracellular fluid compartment without changing serum osmolarity (Atia and Buchman, 2009; Parekh and Steiger, 2007).

Clinicians can consider starting with a goal of 1 L of ORS/day and adjust based on patient’s needs (Parrish, 2005). ORS may not be required for patients who have an intact portion of colon remaining (SBS types II and III—see Chapter 2: Short Bowel Syndrome (SBS): Classification, Underlying Causes, and Global Footprint) given they have more optimal sodium and fluid absorption (Matarese and Steiger, 2006). Due to variant degree of water and sodium absorption in the jejunum and ileum; ORS containing bicarbonate may be warranted for segmental jejunal resection; however, remains unnecessary if the jejunum is completely resected (Atia and Buchman, 2009). ORS should remain undiluted and should not be served on ice. ORS should be sipped throughout the day, avoiding consumption of large volumes during meal times. Isotonic, sodium-free fluids should be avoided as they may provoke additional enteric losses and may contribute to dehydration. Hypertonic solutions may promote increased fluid secretion into the intestinal lumen resulting in even larger volumes of enteric loss. Patients with <65 cm of jejunum without colon may not benefit and it may be suggested that a fluid restriction of ≤1.5 L of ORS be implemented (Parekh and Steiger, 2007). If patients are unable to ingest enough ORS to meet fluid needs, supplemental ORS via nasogastric or percutaneous endoscopic gastrostomy tube may be considered to allow independence from IV fluids (Parrish, 2005). ORS may be simply added as flushes to enteral feeding regimens.

Oral rehydration therapy (ORT)

In home settings, dehydration can usually be prevented by having the child drink recommended home fluids or by providing food-based fluids (such as gruel, soup, or rice-water) as soon as the diarrhea starts. If dehydration occurs, the child should be brought to a community health worker or health center for further treatment. Where feasible, families should have ORS ready-to-mix packages and zinc (syrup or tablet), readily available for use. Breast feeding should continue simultaneously with the administration of appropriate fluids or ORS.

Patients with Mild to Moderate Volume Depletion

ORS (50 mL/kg) should be given initially to people with mild volume depletion (loss of 3% to 5% of body weight) in the first 2 to 4 hours of therapy, and 100 mL/kg to people with moderate volume depletion (loss of 6% to 9% of body weight). In both cases, volume status is reassessed at 4 hours. If volume depletion is corrected, treatment enters the maintenance phase. If losses continue, fluid deficit is re-estimated, and fluid administration is resumed.⁸¹ Ongoing losses can be replaced at home with ORS after initial observed volume resuscitation. Additional ORS always can be administered coincident with thirst.

Oral rehydration therapy

Early oral rehydration solutions (ORS) contained only electrolytes and water and it was not until it was realized that glucose or sucrose was required to enhance sodium absorption that effective oral rehydration therapy became available. Glucose and sodium transport into enterocytes are coupled. Sucrose, a dimer of glucose and fructose, must be cleaved by brush-border sucrase for it to be absorbed. Nevertheless, glucose and sucrose seem to be equally effective in ORS,³⁰ although there may be minor advantages with glucose.³¹

There is also some debate over the use of bicarbonate or citrate to correct acidosis. Both are equally effective, but citrate is more stable and has replaced bicarbonate in World Health Organization (WHO) solutions. A further modification has been the incorporation of glycine, which is taken into the enterocyte by a specific amino acid transport system. Glycine, when present in ORS at a concentration of 111 mmol/L, was found to decrease both duration of diarrhoea and stool volume.³² The composition of various ORS is shown in Table 50.7. ORS can be obtained in packets from UNICEF or can be made up locally. They should contain sodium chloride (3.5 g), potassium chloride (1.5 g) and glucose monohydrate (22 g), made up to 1 L with potable water (sucrose, 40 g, may replace glucose, and trisodium citrate dehydrate, 2.9 g, sodium bicarbonate). To be fully effective ORS should be available at the village level so therapy can be initiated as rapidly as possible. This will require the solution(s) to be available either pre-packed or in bulk, with appropriate measuring spoons, a method of providing the correct volume of potable water, and instructions on use as well as to discard unused solution within 24 hours. Studies have shown that when properly instructed 98% of mothers can prepare ORS with a sodium range of 30–110 mmol/L.³³ Recently, rice powder-based ORS have been investigated, since these are more readily available. Rice powder at 30–50 g/L is an effective substitute for glucose. It tastes better than simple electrolyte–glucose ORS and is thus more acceptable to children. A recent meta-analysis of 13 randomized trials of rice-based versus glucose-based oral rehydration therapy demonstrated the superiority of the rice-based solution in cholera diarrhoea, although the benefit was considerably smaller for children with acute non-cholera diarrhoea.³⁴ During the initial phase of oral rehydration therapy, while the patient is dehydrated, adults can consume 750 mL/h and children up to 300 mL/h. Maintenance therapy of 20 mL solution per kilogram body weight should be started as soon as signs of dehydration have gone. ORS are suitable for rehydration of all except severely dehydrated infants and those with shock (Table 50.8). Decreased-osmolarity ORS (178–268 mmol/L) has been shown to be as safe and effective as conventional ORS (311 mmol/L).³⁵

Treatment with Oral Rehydration Solutions

Oral rehydration solutions (ORS solutions) contain the proper amounts of glucose (or starch), sodium, potassium, and base (citrate or bicarbonate) and are essential for keeping the body in metabolic balance when diarrhea is more severe. Premixed ORS solutions (PediaLyte, RiceLyte) are available at pharmacies in the United States and Canada, but these are bulky and are meant for home use, not for carrying abroad. For travel, there are small packets of ORS salts (WHO formula, CeraLyte) to which measured amounts of noncontaminated water are added. Travelers without these packets can easily prepare effective “homemade” ORS using table salt, sugar, and water. Instructions are found in Chapter 6.

Ideally, small children should take about 100 mL (about 3 ounces) of ORS with every loose stool or bout of vomiting. Solid food should be avoided as long as vomiting continues, which is rarely for more than 12 hours. If small children refuse to drink, they can be given smaller amounts every few minutes, by teaspoon or dropper. Amounts larger than 100 mL (3 ounces) should be avoided when children are vomiting; large amounts may induce vomiting. Unless vomiting occurs more frequently than every 45 minutes, water reaches the intestine and is absorbed. Infants should continue to breastfeed or drink formula and regular milk. Parents should watch for the return of urine output and improvement in the child’s appearance and behavior, and restore a regular diet as soon as possible.

Cereal-based ORS (CB-ORS) is more effective than plain ORS. CB-ORS contains cooked starches (usually rice) in place of glucose. Starch causes more calories and water to be absorbed by the intestine. CB-ORS is available in the United States as a ready-to-drink solution (e.g., Ricelyte, available in most stores and pharmacies) and in packets (CeraLyte, available from Travel Medicine, Inc., at www.travmed.com). If RiceLyte is not available, children can be given plain water with one or more of the following: pretzels, salted crackers, mashed potatoes, rice cereal, or Cream of Wheat cereal. Drinks made with precooked infant rice cereal, unsweetened yogurt, or vegetable juices can also be used. Older children can be offered carbohydrates in the forms of rice, potatoes, cereal, pasta, and bread during the transition to their regular diet.

75 What are the basic principles guiding optimal treatment of children with diarrhea and mild dehydration?

King CK, Glass R, Bresee JS, Duggan C, Centers for Disease Control and Prevention: Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy, MMWR Recomm Rep 52:1–16, 2003.

MEDICAL TREATMENT OF CASUALTIES

Oral rehydration solutions are helpful in patients with E. coli O157:H7 infection, because most patients have minimal vomiting. The World Health Organization recommends solutions containing 2.6 g sodium chloride, 2.9 g trisodium citrate dihydrate, 1.5 g potassium chloride, and 13.5 g anhydrous glucose, all dissolved in 1 L of clean water for a total osmolarity of 245 mOsm/L solution. Recommendations have also been suggested to include zinc supplementation that varies by age, because it has been shown in some studies to improve outcomes.^13,27,31-34 Appropriate infection control practices should be instituted for E. coli and include body substance isolation and hand washing. Masks are optional for E. coli, because airborne spread is inconsequential (unless contaminated feces are aerosolized). Rehydration should include intravenous solutions if oral intake is poorly tolerated or if the patient fails to improve.

Evidence-Based Interventions to Address Childhood Diarrhea

Use of ORS, improved nutrition, increased breastfeeding, better supplemental feeding, female education, measles immunization, and sanitation and hygiene improvements have contributed to substantial declines in the morbidity and mortality of diarrhea over the past 30 years. The best outcome for diarrhea requires that mothers recognize the problem and seek medical care promptly and that health workers give ORS or other fluids to prevent or treat dehydration, dispense an appropriate antibiotic when needed, advise on appropriate feeding, and provide follow-up, especially for children at increased risk of serious morbidity or death. Recently, low-osmolarity ORS and zinc supplementation (10–20 mg day⁻¹) have led to significantly improved diarrhea outcomes.