pedia alhamdollilah fluids
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Gimnaste Glenn Paquit Adajar
Medicine III
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TBWTBW ICFICF ECF ( ISF + PV)ECF ( ISF + PV)
NewbornNewborn 7575 80 %80 % 40 %40 % 3030 35%35%
Infants/Infants/
ChildrenChildren
65%65% 40%40% 25 % ( 16 + 9)25 % ( 16 + 9)
AdultAdult 60%60% 40%40% 20%20%
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The infant is more prone to suffer from
disturbances of hydration and acid-base
balance due to the ff.:
1. Infant has higher metabolic rate
which results in a greater turnover of
water
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2. Infant has a larger skin surface area (2-3x
the adult) in relation to the volume of his
total body water. Infants body water isdepleted more rapidly.
3. Infant is more prone to greater loss offluid.
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4. Immaturity of the infants kidneys
predisposes to hydration, and acid-
base balance.
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Non-ionized molecules:
Glucose
Urea
Lipids
Electrolytes:
Cations Anions
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SERUM INTERSTITIALFLUID
INTRACELLULARFLUID
CATIONS
Sodium 140 mEq/L 138 mEq/L 9mEq/LPotassium 5 8 155
Calcium 5 8 4
Magnesium 4 6 32
Total 154 mEq/L 160mEq/L 200mEq/L
ANIONS
Chloride 100mEq/L 119mEq/L 5 mEq/L
Bicarbonate 26 26 10
Protein 19 7 65
Organic Acids 6 6 -
HPO4 2 1 95
SO4 1 1 25
Total 154mEq/L 160mEq/L 200mEq/L
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Multiply serum sodium concentration by 2
Example: 145 mEq/L Na x 2 = 290 mOsm/L
Normal: 280-300mOsm/L
.: approximately 10mOsm/L come from bloodglucose and urea nitrogen contributing
5mOsm/L each
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HYPERTONIC- Na > 150 mmol/L
HYPOTONIC Na < 130 mmol/L
ISOTONIC Na = 135-145 mmol/L
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Cell shrinkage
Negative pressure in the cranium
increases Subarachnoid vessels rupture
Hyperirritability
Convulsions Residual neurological damage
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Cell edema in the CNS Somnolence Coma Convulsions
Shock
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There is an equal or
proportional loss of waterand electrolytes without a
change in the waterdistribution between the twofluid compartments
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Rehydration phase Deficit therapy
Immediate correction of the abnormal losses offluid and electrolytes
Accomplished within 6 hours Maintenance phase
Normal maintenance and active replacementtherapy
Stabilize the internal milieu after it has beenrestored to normal during the rehydration phase
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Is employed to maintain or restore the
normal volume & composition of body
fluids Goal: to normalize the intracellular &
extracellular chemical environments
that optimize cell & organ function
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Dimensions offluid therapy
Maintenance Phase
NormalMaintenance(Normal daily
requirement of water)
Active Replacementtherapy ( activereplacement of
continuing losses)
Rehydration Phase
Deficit therapy
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Following should be corrected:
1. Fluid loss
2. Osmolality or sodium ion disturbance3. Other electrolyte disturbances like potassium,
magnesium, calcium, etc.
4. Acid-base imbalance
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In most instances, computation of weightloss is difficult due to no record of infantor childs previous weight.
However, estimation to the degree ofdehydration can be assessed based onfairly evident clinical criteria.
FLUIDLOSS
WeightLOSS
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Degree of
Dehydration
Infant
(%
weight
lo
ss)
Children
(% weight
loss)
Clinical Features
MILD 5% 3% Sunken eyes; depressed
anterior fontanelle; dry skin,
lips, and tongue; mild oliguria
MODERATE 10% 6% Early shock: loss ofskin
elasticity and turgor (+ skin fold
test): pale, mottled skin;
collapsed neck veins; marked
enophthalmos; markedoliguria; unstable vital signs
SEVERE 15% 9% Late shock: patient is dying or
moribund
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ISOTONIC HYPOTONIC HYPERTONIC
SKIN Cold and dry; poor
elasticity and turgor
Cold and clammy;
very poor elasticity
and turgor
Warm, velvety, and
doughy normal to
slightly poor
LIPS &TONGUE
dry Clammy or moist;
presenceof
hypersalivationand
sheddingoftears if
serum sodium is 110mEq/L or less
Parched; patient
complainsofextreme
thirst
CNS lethargic comatose,;occasionallywith
generalized
convulsions
Lethargicwhenundisturbed;
hyperirritable when
aroused; focal or
generalized seizures;increase muscle tone
and tendon reflexes;meningismus
VITAL SIGNS Normal to low
temperature; normal to
low BP rapid PR
Very low
temperature; BP;
in shock; threadypulse
Febrile temperature;
normal BP; normal to
slightly increased PR
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Degreeofdehydration
MILD
Volumeoffluid
Mannerofadministra
tion
Isotonic Hypotonic Hypertonic
INFANTS
CHILDREN
5%wt. loss
3%wt. loss
50mL/kg
30mL/kg
1st 6hours
0.3%NaClin D5W
(50mmol/L NaCl)
0.45%NaCl in
D5W(75mmol/
L NaCl)
Deficit,maintenance and
replacement are
combinedand givenand given
in 48
hours as0.15%
NaCl inD5W
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Degreeofdehydration
MODERATE
Volumeoffluid
Mannerofadministra
tion
Isotonic Hypotonic Hypertonic
INFANTS
CHILDREN
10% wt. loss
6% wt. loss
100mL/kg
60mL/kg
1st hour. oftotal
Next 5-6
hours: orremainder
ofdeficit
Ringerslactate or
acetate in
D5W
After the
initialhydrating
solutionfollowwith
IV fluid asabove:
0.3% NaClin D5W
Ringerslactate or
acetate in
D5W
Follow
with 0.45%NaCl
(mix 1 partof0.3%
NaCl to 1
part plain
D5W tomake
0.15% NaClin D5W)
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Degreeofdehydration
SEVERE
Volumeoffluid
Mannerofadministra
tion
Isotonic Hypotonic Hypertonic
INFANTS
CHILDREN
15%wt. loss
9% wt. loss
150mL/kg
90mL/kg
1st hour.1/3 oftotal
Next 5-6
hours: 2/3or
remainderofdeficit
Ringerslactate in
D5W
0.3% NaCl
in D5W
Ringersacetate in
D5W
0.45%
NaClIn D5W
(mix 1 partof0.3%
NaCl to 1
part plain
D5W tomake
0.15% NaClin D5W)
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After the patient has voided, add 20-
30mEq/L ofKCl to IV fluid for maintenance
po
tassium requirement. In hypernatremiaand in the presence ofhypokalemia (ileus,
muscle weakness, and ECG changes)
administer 40-50 mEq/L ofKCl. For
hypokalemia, maintain a constant
concentration ofpotassium for 3-4 days.
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Basal caloric expenditure
(calories/kg/24hrs) x bodyweight (in kg) x 1.5 mL/calorie
= total amount
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Goals:
Prevent dehydration
Prevent electrolyte disorders Prevent ketoacidosis
Prevent protein degradation
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-designed to replace usual losses of fluid &
electrolytes
-based on measured or estimatedcontinuing abnormal losses
F
luid is continually lost from the body inthe form ofinsensible water losses (skin
and lungs) and urinary loss.
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Replaces urine, water and sweat lossand therefore avoid the developmentof dehydration and deficiencies ofsodium and potassium
Maintenance Fluid Requirement
amount ofFluid required to keep thebody fluid in BALANCE .
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Newborn = 45-50 calories/kg/24hrs
3-10 kg = 60-80
10-15 kg = 45-6515-25 kg = 40-45
25-35 kg = 35-40
35-60 kg = 30-35over 60 kg = 25-30
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Estimate Fluid Deficit
(Mild, Moderate, Severe = % weight loss)
FindType ofDehydration
(Isotonic, Hypotonic, Hypertonic)
Give daily Maintenance
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A 5kg infant developed severe diarrhea withvomiting. On physical examination, the followingclinical features were noted: weak and lethargic butarousable; deeply depressed anterior fontanelle andsunken eyes; pale and mottled skin which felt coldand dry with positive skin fold test indicating poorskin turgor and elasticity; collapsed neck veins.Patient had no urine output for over 12 hours andthe V/S showed temperature of36.8C, pulse rate of160/min,BP ofless than 60mmHg (flush method)and respiratory rate of45/min describes as deep andrapid.
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Degreeofdehydration
MODERATE
Volumeoffluid
Mannerofadministra
tion
Isotonic Hypotonic Hypertonic
INFANTS
CHILDREN
10% wt. loss
6% wt. loss
100mL/kg
60mL/kg
1st hour. oftotal
Next 5-6
hours: orremainder
ofdeficit
Ringerslactate or
acetate in
D5W
After the
initialhydrating
solutionfollowwith
IVfluid asabove:
0.3% NaClin D5W
Ringerslactate or
acetate in
D5W
Follow
with 0.45%NaCl
(mix 1 partof0.3%
NaCl to 1
part plain
D5W tomake
0.15% NaClin D5W)
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1ST 6 HOURS
TOTAL FLUIDVOLUMETO BEGIVEN =
100mL/kg for 10% weight loss Fluid deficit = 100mL/kg x 5kg = 500 mL
Given: 25 ml/kg or 125 mL in 1 hr as Ringerslactate or acetate solution
75 mL/kg or 375mL as 0.3% NaCl inD5W inthe next 5 hours (ISOTONIC)
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After the patient has voided, add20-30mEq/L of potassium to theparenteral fluid or in the presence ofhypokalemia, 40-50mEq/L of
potassium ion to be maintained for3-4 days.
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A 32 kg child with moderatedehydration, from several
diarrheal episodes. Computethe deficit and maintenance
therapy.
EXAMPLE 2
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child, 32 kg, moderate dehydration
Estimated fluid loss:6% Fluid to Administer:
(60 mL) (32 kg)
1, 920 mL in 6 hours
First hour: 1,800 mL/4 = 480 mL/hour
120 gtts/min Next 5-6 hours:
1, 920 mL- 480 mL = 1, 440 mL 1, 440 mL/5 hours = 288 mL/hour
72 gtts/min
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Holiday-Segar Method:
F
irst 10 kg = 1000 mL/kg Second 10 kg = 500 mL/kg
Above 20 kg = 20/mL/kg; thus,
First 20 kg = 1,500 mL
Above 20 kg: 32 kg-20 kg = 12 kg
(12 kg) (20 mL/kg)
240 mL
For 24 hour maintenance: 1,500 mL + 240 mL = 1, 740 mL
1, 740 mL/24 hours
73 mL/ hr----18 gtts/min
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Weight Method for Calculating Daily Maintenance Fluid VolumeWeight Method for Calculating Daily Maintenance Fluid Volume
BodyBody
WeightWeight
Fluid per dayFluid per day
00--10 kg10 kg 100 mL/kg100 mL/kg
1111--20 kg20 kg 1,000 mL + 50 mL/kg for each kg>10 kg1,000 mL + 50 mL/kg for each kg>10 kg
>20 kg>20 kg 1,5001,500 mLmL + 20+ 20 mLmL/kg for each kg>20 kg/kg for each kg>20 kg
*maximum fluid per day is normally 2, 400*maximum fluid per day is normally 2, 400 mLmL
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ACTUAL BODY WEIGHT
(KG)
TFR
1st 10 kg ofBW 100mL/kg/day, plus
2nd 10kg ofBW 50mL/kg/day, plus
Body weigh >20kg 20ml/kg/day
e.g. 25 kg child: (1000 + 500 + 100) = 1600 mL/day
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MILD MODERATE SEVERE
< 5 , < /o 5 cc/ 5
> 5 , > /o 3 6 9
D5 .3% in 6-
8 hours
hr: PLRS 1st hr: 1/3
PLRS
Next 5-7 hrs:
D5LRS
Next 5-7 hrs:
/3 D5 .3%
IVF Dextrose Na Cl K Lactate Others
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IVF Dextroseg/L
NamEq/L
ClmEq/L
K
mEq/LLactatemEq/L
OthersmEq/L
LRS 130 109 4 28 Ca 3
NSS 154 154
D50.15%NaCl
50 25 25
D50.3%NaCl
50 51 51
D50.45%NaCl
50 77 77
D50.9%NaCl
50 154 154
D5IMB 50 25 22 20 23 Mg-3;PO4-3
D5LRS 50 130 109 4 28 Ca-3
D5NM 50 40 40 13 Mg-3; Acetate-26
D5NR 50 140 98 5 Mg-3;Acetate-
27;gluconate-23
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SODIUM (135-150mEq/L or 3-4 mEq/kg/day
HYPONATREMIAmEq Na deficit = (desired-actual) xTBW
Where:TBW (in L) = 0.6 x body weight (kg)
Initial goal: 120mEq/L;subsequent:130 in 24-3 hrs
Correct only up to 15 mEq/L/day (2.5mEq/L/hr)
to avoid pontine myelinolysis
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Hypovolemic hyponatremia Replace the sodium deficit and any water deficit
1st, restore the intravascular volume withisotonic saline
Hypervolemic hyponatremia Water and sodium restriction
Diuretics Isovolumic hyponatremia Acute: Hypertonic saline
Chronic: child needs to receive an appropriateformula and excess water intake should beeliminated
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HYPERNATREMIA
Water deficit = plasma[Na] 140 xTBW140
Correct only 10-15 mmol/L/day
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HYPOKALEMIA
mmol K deficit = (desired-actual) x 0.3xwt (kg) or
Deficit = wt (kg) x 50 x estimated % deficit
KSerum Level Estimated deficit
3-3.5mEq/L 5% deficit
(appro
x 200-400mmo
l)2-2.5mEq/L 10% deficit
1-2.0mEq/L 20% deficit
(approx 600mmol and up)
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If asymptomatic: oral replacement 2-3mEq/kg/d
IV replacement guidelines:1. Rate: 0.2-0.3 mmol/kg/hr not to exceed 1 mmol/kg/hr
2. If via peripheral vein, not >40mmol/L
3. If via central vein, not >80mmol/L; continuous ECG
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HYPERKALEMIA
First action: STOP all sources ofpotassium
ECG changes: peaked/tentedT waves,
At > 7.0mEq/L: prolonged PR, ST, wide QRS
At >8.0mEq/L: P wave disappears, QRS merges w/T
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TREATMENT:
1. Reverse membrane effects: Ca gluconate 10% at
0.5-1.0ml/kg IV over 2-10 mins2.Transfer K into cells (redistribute): 2-agonists; or
regular insulin 10-20 U + glucose 25-50g; or
NaHCO3 3amp/L D5W
3. Enhance renal excretion of K:
Kayexalate 1g/kg PO diluted with 2-4mL sorbitol
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HYPOCALCEMIA
Ca gluconate 10% (8.9 mg/mL elemental Ca):0.5-1.0mL/kg IV bolus over 20-30mins with
cardiac monitoring x3 doses
Maintenance: 500 mg/kg/24hr PO
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HYPOMAGNESEMIA
For symptomatic children
4-7 kg: 0.5mL of 50% MgSO4 (1mmol Mg)
> 7 kg: 1mL of 50% MgSO4 (2mmol Mg)
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Hypophosphatemia
Oral maintenance doses:2-3 mmol/kg/day in divided doses
For severe deficiency or who cannot tolerate oralmedications:
0.08-0.16 mmol/kg over 6 hours
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Oral Rehydration
Principle
Glucose absorption (enterocytes) facilitates water
and electrolyte absorption.
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CHOCHO NaNa Cho:Cho:NaNa
KK BaseBase OsmolalityOsmolality
NaturalyteNaturalyte 140140 4545 3.13.1 2020 4848 265265
PediatricPediatric
electrolyteelectrolyte140140 4545 3.13.1 2020 3030 250250
PedialytePedialyte 140140 4545 3.13.1 2020 3030 250250
InfalyteInfalyte 7070 5050 1.41.4 2525 3030 200200
RehydralyteRehydralyte 140140 7575 1.91.9 2020 3030 310310
WHO ORSWHO ORS 111111 9090 1.21.2 2020 3030 310310
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Com ositio of ral e y ratio
Sol tio ( . .S)
303520452.5Pedialyte
308020902.0W.H.
sol tio
mmol/Lmmol/Lmmol/Lmmol/Lgram %
BaseCl-
K+
Na+
l cose
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treatment is aimed at providing adequate
fluids and continuing an age-appropriate diet
use of ORS should be encouraged (1 mL offluid should be administered for each gram of
output )
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When losses are not easily measured, 10 mLof additional fluid can be administered perkilogram body weight for each watery stool or2 mL/kg body weight for each episode ofemesis
Alternative: children weighing 10 kg should be administered 120--240 mL(4--8 ounces)
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Oral Rehydration Solutions Acceptable Pedialyte Infalyte (Ricelyte) WHO/UNICEFORS
Suboptimal Apple juice Coca-ColaGatorade
Tea Chicken broth
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GOAL: Usual diet + replace ongoing losses
Formula-fed infants should continue their usualformula immediately upon rehydration
Children receiving semisolid or solid foods should
continue to receive their usual diet during episodesof diarrhea. Encourage starchy foods, clear brothsoups, yogurt, fresh fruits and vegetables.
Foods high in simple sugars should be avoidedbecause the osmotic load might worsen diarrhea
practice of withholding food for >24 hours isinappropriate.
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Highly specific diets (e.g., the BRAT [bananas,
rice, applesauce, and toast] diet) have been
commonly recommended
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hemodynamic shock
abdominal ileus
Intestinal intussusception
Stool output in excess of 10 mL/kg bodyweight/hour has been associated with a lower
rate of success of oral rehydration
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Diarrhea causes:
increased stool zinc loss,
negative zinc balance reduced tissue levels of zinc
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An additional 10 ml/kg of ORS is given
for each stool. Fluid intake should be decreased if the
patient appears fully hydrated earlier
than expected or if periorbital edemadevelops.
ORS should be given in small amounts at
short intervals: 1-2 tsp every 1-2
minutes
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MildMild ModerateModerate
InitialInitial
DoseDose
5050 mLmL/kg over 4 hrs/kg over 4 hrs 100 mL/kg over 6100 mL/kg over 6
hourshours
SubsequentSubsequent Resume feeding 10Resume feeding 10 mLmL/kg/kg
ORS/diarrheic stoolORS/diarrheic stool
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Oral Hydrating SolutionPreparationPreparation Contents (mEq/L)Contents (mEq/L)
Formulated ORSFormulated ORS 1/3 tsp1/3 tsp NaClNaCl, baking, bakingsoda,soda, KClKCl; 1 L water; 1 L water
NaNa++ 50, K50, K++ 20, Cl20, Cl-- 50, HCO50, HCO33-- 20, Glucose 2020, Glucose 20gg
Glucolyte 60Glucolyte 60 1 sachet/ 250 mL1 sachet/ 250 mL NaNa++ 60, K60, K++ 20, Cl20, Cl-- 50, Mg50, Mg2+2+ 5, Gluconate 5,5, Gluconate 5,Citrate 10,Glucose 100 gCitrate 10,Glucose 100 g
HydriteHydrite ORS 45: 1 tab/ 200 mLORS 45: 1 tab/ 200 mL NaNa++ 90, K90, K++ 20, Cl20, Cl-- 80, HCO80, HCO33-- 30, Glucose 11030, Glucose 110gg
Oresol (DOH)Oresol (DOH) 1 sachet/1 L1 sachet/1 L NaNa++ 90, K90, K++ 20, Cl20, Cl-- 80, HCO80, HCO33-- 3030
OrhydrateOrhydrate
Concentrate SyrupConcentrate Syrup
60 MmL in 940 water or60 MmL in 940 water or
5 mL in 78 mL water5 mL in 78 mL water
NaNa++ 45, K45, K++ 20, Cl20, Cl-- 35, Mg35, Mg2+2+ 2.5, Gluconate2.5, Gluconate
2.5, Citrate 30,Glucose 10 g, Sucrose 20 g2.5, Citrate 30,Glucose 10 g, Sucrose 20 g
Pedialyte 45Pedialyte 45 PremixedPremixed NaNa++ 45, K45, K++ 20, Cl20, Cl-- 35, Citrate 30, Dextrose 2535, Citrate 30, Dextrose 25g, Calories 100g, Calories 100
Pedialyte 90Pedialyte 90 PremixedPremixed NaNa++ 90, K90, K++ 20, Citrate 30, Dextrose 25 g,20, Citrate 30, Dextrose 25 g,
Calories 100Calories 100
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MaintenanceTherapy:
MildDiarrhea: treated at home with100 mL of ORS/kg/24 hours until diarrhea
stops
ReplacementTherapy: volume/volume replacement; or
each episode = 10-15 ml/kg/hr is
appropriate
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