technical seminar -...
TRANSCRIPT
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T e c h n i c a l S e m i n a r s
DiarrhoeaDiarrhoea
Assessment
DehydrationAssessment • Classification
Home FluidsSelection • Fluids to avoid
DysenteryAntibiotics
ShigellaAntibiotics
Persistent DiarrhoeaDefinition • Causes
Classification • Therapy
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D i a r r h o e a
Diarrhoea
Assessmentof dehydration
for ALL
Persistentdiarrhoea
conditional
Dysenteryconditional
Diarrhoea
Assessment
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D i a r r h o e a
Dehydration
• Sensorium (lethargic OR restless)• Sunken Eyes (ask caretaker as well)• Drinking (poorly OR eagerly)• Skin Pinch (very slowly OR slowly OR immediately)
– Pinched in longitudinal manner– Pinched between the thumb and the bent fore-finger
Assessment
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D i a r r h o e a
Dehydration
• Mistakes in taking a skin pinch:– Pinching either too close to the midline or too far laterally
– Pinching the skin in an horizontal direction
– Not pinching the skin long enough
– Releasing the skin so that the finger and thumb remain in a closed position
• Classification of skin pinches:– Normal — it goes back immediately
– Slowly — the fold is visible for less than 2 second
– Very slowly — the fold is visible for more than 2 seconds.
Assessment
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D i a r r h o e a
• Severe dehydration will have two of these signs:– sensorium abnormally sleepy or lethargic– sunken eyes– drinking poorly or not at all– very slow skin pinch
• Some dehydration will have two of these signs: – restlessness or irritability– sunken eyes– drinking eagerly– slow skin pinch
• No dehydration – None of these signs
DehydrationAssessment
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D i a r r h o e a
Dehydration
• Simplified to two of our of four possible signs
• Use of term “floppy” eliminated
• Tears and dryness of mouth and tongue excluded
• “Very sunken” eyes modified to “sunken” eyes
• Skin pinch test qualified
Assessment
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D i a r r h o e a
Dehydration
• The Star signs (*) that marked essential signs for the classification of dehydration complicated assessment and have been excluded.
• Any two of the four possible signs are sufficient to classify the child as dehydrated or severely dehydrated.
Classification
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D i a r r h o e a
Home Fluids
• Home Fluids for Diarrhoea Must Be:
– Safe when given in large volumes
– Easy to prepare
– Acceptable color and palatability
– Effective in preventing dehydration
Selection
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D i a r r h o e a
• Ideal home fluids contain:– salts and nutrients (sodium, potassium, chloride, and
bicarbonate)– calories to replenish diet
• Examples of home fluids:– ORS solution– salted soup– salted drinks
Home FluidsSelection
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D i a r r h o e a
• Other acceptable home fluids that do not contain salt:– plain clean water
– water in which a cereal has been cooked (unsalted)
– soup (unsalted)
– yoghurt-based drinks (unsalted)
– green coconut water
– weak tea (unsweetened)
– fresh fruit juice (unsweetened)
Home FluidsSelection
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D i a r r h o e a
• Fluids causing hypernatraemia– most soft drinks– sweetened fruit drinks– sweetened tea
• Fluids with stimulant, diuretic or purgative effects– coffee– some medicinal teas or infusions
Home FluidsFluids to avoid
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D i a r r h o e a
Dysentery
• Effective for Shigella species and for Salmonella in infants under one year of age
• Early Treatment with Antibiotics:
– shortens the duration of the illness– reduces the risk of serious complications and death
Antibiotics
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D i a r r h o e a
• Delaying treatment or giving ineffective antibiotics can progress the disease
• Complications that could result:– extensive damage to the bowel– septicaemia and septic shock, hematogenous spread
to bones, brain and meninges– hemolysis, renal failure and hemorrhage– haemolytic uremic syndrome
• Complications occur more often in infants and undernourished children, and may be fatal.
DysenteryAntibiotics
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D i a r r h o e a
• Antimicrobials for home treatment of dysentery should be:– effective against most strains of Shigella (Sd1 is the most
important pathogen) based on local data
– effective when given by mouth
– affordable
– readily available, or can be rapidly obtained
DysenteryAntibiotics for home treatment
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D i a r r h o e a
• Shigella are resistant to:
– Metronidazole– Streptomycin– Tetracyclines– Chloramphenicol– Sulfonamides
ShigellaIneffective Antibiotics
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D i a r r h o e a
• Shigella are sensitive to, but are ineffective in vivo, with:
– Nitrofurans– Aminoglycosides – First- and second-generation cephalosporins– Amoxicillin
ShigellaIneffective Antibiotics
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D i a r r h o e a
• Ampicillin and Trimethoprim-Sulfamethoxazole
– Inexpensive, but becoming resistant
• Nalidixic acid
– More expensive, less available, has side effects
• Pivmecillinam, Ciprofloxacin and other quinolones
– Much more expensive and not readily available in most countries
• Ceftriaxone
– Most expensive and must be given intramuscularly
ShigellaEffective Antibiotics
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D i a r r h o e a
Persistent Diarrhoea
• Diarrhoea that occurs for 14 or more days
• Less than 10 percent of all diarrhoea but associated with 30 to 50 percent of diarrhoea deaths
• Malnutrition greatly increases the risk of death
Definition
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D i a r r h o e a
• Proximate Causes– Secondary disaccharidase deficiency– Salmonella sp.– Shigella sp.– Enteroadherent E. coli– Cryptosporidium
• Contributing Factors– Protein energy malnutrition– Micronutrient deficiencies– Immunodeficiency
Persistent DiarrhoeaCauses
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D i a r r h o e a
• Refer those who have persistent diarrhoea AND who are also dehydrated to hospital– mortality is 8 to 10 times higher than that with acute
diarrhoea
– may need nutritional rehabilitation
– may need investigation for immune deficiencies and/or resistant bacteria
Severe Persistent DiarrhoeaClassification
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D i a r r h o e a
• Correct Dehydration
• Correct Nutritional Problems– Reduce disaccharides– Increase energy intake– Supplement micronutrients (possibly)
• Give Antibiotics for Dysentery
• Avoid These Therapies– Antibiotics for watery diarrhoea– Anti-motility agents– Diluted feeds
Persistent DiarrhoeaTherapy