Oral Rehydration Salts

By
Dr Utpal Sharma
Assistant Professor
Department of Community Medicine
SMIMS, Gangtok, Sikkim
 Introduction
Worldwide, diarrhea claims several million lives
annually, mostly those of infants.

Poverty, crowding, and contaminated water supplies

all contribute.

Almost all of these deaths could have been

prevented with adequate fluid replacement.

Incidence is much lower in developed nations but

remains one of the two most common reasons for
visits to pediatric emergency departments
Cont…

More than 5 million children under the age of 5

years die every year due to diarrhoea .

In India, more than 1 million children get killed by

this miserable disease known as diarrhoea .

Before the advent of ORT, death from diarrhea was

the leading cause of infant

Between 1980 and 2006, With the introduction of

ORT, infant deaths, worldwide have decreased the
number of, from 5 to 3 million per year.
 What is diarrhoea?

Increases in volume or fluidity of stools, changes

in consistency, and increased frequency of
defecation.

Blood in stool indicate an acute diarrhoeal

illnesses or dysentery, irrespective of frequency.
“Passage of loose or watery stools at least three times
in a 24 h period”
WHO
Cont….
Diarrhoeal disorders are divided into:

Acute Diarrhoea
 The most usual form of diarrhoeal illness, have an
abrupt onset, resolve within 14 days and are mostly
caused by infections

Persistent Diarrhoea
 Diarrhoea which persists for longer than 14 days

Chronic Diarrhoea
 Duration of symptoms is longer than a month
 Pathophysiology of diarrhea
 Fluid from the body enters the intestinal lumen (isosmotic i.e
approx.142 mEq/L Na+) during digestion.

 A healthy individual secretes 2000–3000mg of sodium per day

into the intestinal lumen.

 Nearly all of this is reabsorbed so that sodium levels in the body

remain constant.

 In a diarrheal illness, sodium rich intestinal secretions are lost

before they can be reabsorbed.

 This can lead to a life-threatening hyponatraemia within hours.

 This is the motivation for sodium and water replenishment in ORT.

Ion exchange in intestine
 Physiological basis of using ORT in
Diarrhoea
 Sodium passes into epithelial cells by co-transport via the
SGLT1 protein.

 From the intestinal, sodium is pumped by active transport

by the Na+ K + pump through to extracellular space.

 The Na+ K + ATPase pump moves 3 Na+ in exchange for 2

K+

 This creates a “downhill” sodium gradient within the cell.

 SGLT proteins use energy from sodium gradient to

transport glucose into the cell against the glucose
gradient..
Cont….

 The GLUT uniporters then transport glucose across

membrane.

 SGLT1 protein requires 2 Na+ to co-transport one

molecule of glucose (as galactose).

 Without sodium, intestinal glucose is not absorbed.

 This is why oral rehydration salts (ORS) include

both sodium and glucose.

 For each cycle, hundreds of water molecules move

into the epithelial cell, slowly rehydrating the patient.
 Oral rehydration therapy
 Most diarrhea-related deaths in children are due to
dehydration……
….loss of large quantities of water and
electrolytes from the body in the liquid stool.

 Many of these deaths can be prevented with the use of

oral rehydration therapy (ORT).

 Oral rehydration therapy (ORT) is a type of fluid

replacement used as a treatment for dehydration.

 It involves drinking water mixed with sugar and salt and

other home available fluids, while continuing to eat.
 History of ORT
 Over 2,500 years ago, Sushruta described the treatment of
acute diarrhea with rice water, coconut juice and carrot soup.

 In 1831, William Brooke treated cholera patients with IV Fluids

reducing mortality from 70 % to 40 %.

 IV fluid replacement became the standard of care for

moderate/severe dehydration for over a hundred years.

 Late 1950’s: Dr Hemendranath Chatterjee

 1971: Dr. Dilip Mahalanabis 350,000 treated with mortality of

0.36%
 Oral rehydration solution
 So as soon as diarrhoea starts, it is essential to give the
child extra drinks to replace the liquid being lost.
 Oral Rehydration solution (ORS) is the cheap, simple and
effective way to treat dehydration caused by diarrhoea.
 ORS drink contains the main elements that are lost from
the body during diarrhoea.
 effective in treating dehydration resulting from all types of
acute diarrhoeal diseases.
 ORS drinks should be given to the child every time a
watery stool is passed.
Oral rehydration salts
 PRINCIPLE of ORS
Glucose when given orally enhances the intestinal
absorption of salt & water.
Thus it can correct electrolyte & water deficit.

WHOM CAN IT BE GIVEN?

 All age groups

IN WHAT CONDITIONS CAN IT BE GIVEN?

 All aetiologies
 All countries
 Types of ORS??
Sodium bicarbonate based

Trisodium citrate based

Reduced osmolarity ORS

Super ORS
 Sodium bicarbonate based ORS

Composition

Contents (gm)
NaCl 3.5
Glucose 20.0
KCl 2.5
Sodium bicarbonate 2.5
 Trisodium citrate based ORS

Composition
Contents (gm)

NaCl 3.5

Glucose 20.0

KCl 1.5

Trisodium citrate 2.0

 Bicarbonate vs.
Tricitrate ORS

Bicarbonate-based ORS Tricitrate-based ORS

 Less stable  More stable

 Stool output not reduced  Less stool output in high
output diarrhoea
 Tri Na citrate-increases
intestinal absorption of
Na & water
 WHO ORS Osmolarity

Na+ 90mM
Cl + 80mM
Glucose 110mM
K+ 20mM
Citrate 10mM
TOTAL 310mM
Any adverse effect of this WHO ORS ????

Possible adverse effects is hyper tonicity in net

fluid absorption

How to overcome this????

We should reduce the osmolarity of the ORS

 Reduced osmolarity ORS

Composition

Contents (gm)

NaCl 2.6

Glucose 13.5

KCl 1.5

Trisodium citrate 2.9

 Osmolarity of this new ORS
Na+ 75mM
Cl + 65mM
Glucose 75mM
K+ 20mM
Citrate 10mM
TOTAL 245mM
 Advantages of low osmolarity ORS

Increased efficacy of ORS in non cholera diarrhoea

Need for unscheduled supplement IV therapy in children

fell by 33%.

Stool output decreased by 20%.

Vomiting decreased by 30%.

Safe & effective.

 DOSAGE & REQUIREMENT?
If the child’s weight is known…..
….. the amount of ORS soln.for rehydration
during the first 4hrs may be calculated as 75ml/kg

Age <4mths 4-11mths 1-2yrs 2-4yrs 5-14yrs ≥15yrs

Wt.(kg) <5 5-7.9 8-10.9 11-15.9 16-29.9 ≥30

Soln.(ml) 200-400 400-600 600-800 800-1200 1200- 2200-

2200 4000
 How to administer???

 Wash your hands with soap and water before preparing solution.

 Prepare a solution, in a clean pot, by mixing 1 packet of Oral

Rehydration Salts (ORS) with one litre of clean drinking water.

 Stir the mixture till all the contents dissolve.

 Wash your hands and the baby's hands with soap and water
before feeding solution.

 Give the sick child as much of the solution as it needs, in small

amounts frequently.
 Cont…..

 Give child alternately other fluids - such as breast milk and juices.

 Continue to give solids if child is four months or older.

 If the child still needs ORS after 24 hours, make a fresh solution.

 ORS does not stop diarrhoea. It prevents the body from drying up.

 The diarrhoea will stop by itself.

 If child vomits, wait ten minutes and give it ORS again. Usually
vomiting will stop.

 If diarrhoea increases and /or vomiting persists, take child over to a

health clinic.
How to prepare oral rehydration solution
How to prepare….
 Rules
 <2yrs :- give 1-2 teaspoon every 2-3 minutes

 Older children :- offer frequent sips out of a cup

 Adults:- drink as much as they can

 Give the estimated amount within 4hrs

If the child vomits??

 Wait for 10 minutes

 Give a teaspoonful every 2-3 minutes
Cont…..
 If the child wants to drink more than the estimated
amount ?

No harm , give more

 If the child refuses to drink ?

See whether the signs of dehydration has disappeared

If yes
Treat similar to a non dehydrated diarrheal child.

 If the child is breast fed ?

Nursing + treatment with ORS solution

 Non breast fed infants less than 6 months

Along with ORS solution give 100-200 ml of clean water for
first 4 hrs
 ORT programme
 First started in 1986-1987

 Implemented through RCH programme

 ORS packets are supplied by the central govt.

 Twice a year 150 packets of ORS are provided as apart of

drug kit supplied to all sub centers in the country
 Achievements & benefits
 Low cost treatment

 Treatment of the patient in their own homes

 Ingredients are inexpensive and readily available

 Drinking water is sufficient (no need for boiling or other

means of sterilization)

 Breakthrough in the fight against cholera and other

diarrheal diseases

 Mortality rate in cholera has been reduced to 0.11% from

49.3%
Thank you