Rehydration therapy oral or intravenous. Tactics of rehydration therapy with acute intestinal infections in children

Riddatt with diarrhea is necessary in order to compensate for the loss of fluid and normalize the water-salt balance. If this is not done, changes in metabolism will increase, up to the development of acute cardiac and renal failure. The massive loss of fluid (more than 10-12% of the body weight) is fatal for humans.

The success of rehydration depends not only on the solution used, but also on the technique of implementing the procedure. To help help, it is necessary:

It is advisable not only to carry out rehydration therapy, but also to eliminate the cause that caused diarrhea. For this you need a consultation of the doctor.

Alone prepared solutions

In diarrhea, there is a loss of not only water, but also the main electrolytes: sodium, potassium and others. It is these losses that need to be compensated with solutions for oral rehydration.

It is not always possible to buy a prepared drug in the nearest pharmacy. Within the usual kitchen, you can always find components for the preparation of a "home" solution. The easiest recipe is:

All this needs to be stirred in a clean container and drinking the above rules.

There are also more complex solutions recommended by WHO:

• NaCl - 3.5 g;
• NaHCO 3 - 2.5 g;
• KCL - 1.5 g;
• Glucose - 20 g

Pharmacy solutions

In such preparations contain electrolytes, selected in a certain ratio for rapidly compensating for water and electrolyte balance. Pharmacist in the pharmacy will help to choose a solution for any age and financial capabilities. These are popular medicinal products:

All these drugs are made in the form of a dry powder, which dissolves in a liter of pure water. After that, the solution is ready for use, but not stored for more than 24 hours even in the refrigerator.

Additional methods of making diarrhea consequences

All other drugs are probiotics, enzymes, intestinal antiseptics - do not affect the water-salt balance, therefore are not rehydatic therapy. Other drugs are used in complex treatment diarrhea.

Rehydration therapy in children

Rehydration therapy

Timely and adequate rehydration therapy is the primary and most important link in the treatment of certain diseases. Rehydatic therapy is carried out taking into account the severity of dehydration of the child's body (Table 1)

Severity of dehydration by clinical signs (2 or more of the indicated signs are taken into account)

Oral rehydation

When carrying out rehydration therapy, the advantage is necessary to give oral rehydration. Oral rehydration is highly efficient, simple, available at home and inexpensive method. It is necessary to emphasize that oral rehydration is the most effective when applied from its first hours from the beginning of the disease. The early appointment of oral solutions allows most of the children to effectively treat them at home, reduce the percentage of hospitalized patients, prevent the development of severe forms of excocosis. Contraindications for performing oral rehydration does not exist.

The contents of sodium and potassium in solutions for oral rehydration should respond to its average losses. The concentration of glucose in them should contribute to water resorption not only in the intestine, but also in the kidney channels. The optimal absorption of water from the intestinal cavity is carried out from isotonic and light hypotonic solutions with osmolarity 200-250 mosmol / l. It is due to the high concentration of glucose, high osmolarity in them and an inadequate sodium concentration, the use of fruit juices, sweet carbonated beverages (Coca-Cola, and the like) not recommended when performing oral rehydration.

Full rehydration therapy is carried out in 2 stages.

The 1st stage is the rehydration therapy, which is carried out within 4 - 6 hours to resume the volume of the lost fluid. When dehydrating a light degree, it is 30 - 50 ml / kg of body weight, with a medium degree - 60-100 ml / kg of mass. The calculation can be carried out according to the above Table 2.

Calculation of solutions for oral rehydration

The rate of injection of fluid through the mouth is 5 ml / kg / hour.

Criteria for the effectiveness of the 1st stage: (estimated after 4-6 hours): the disappearance of thirst, improved tissue turgora, moisturizing mucous membranes, increasing the diurea, disappearance of signs of microcirculation disorders.

Selection of subsequent tactics:

a) if there are no signs of dehydration - to move to supporting rehydration therapy (2nd stage).

b) Signs of dehydration decreased, but still persist - it is necessary to continue to give a solution through the mouth over the next 4-6 hours in the previous volume.

c) Signs of dehydration increase - the transition to parenteral rehydration.

Stage II - Supporting therapy, which is carried out depending on the loss of fluid that continues.

Methodology for the 2nd stage:

Supporting oral rehydration is reduced to the fact that the child for every next 6 hours is administered as much glucose-salt solution as long as he lost fluids for the previous 6-hour period. An indicative volume of the solution for maintaining rehydration in children under the age of 2 years is 50-100 ml, children over 2 years of 100-200 ml or 10 ml / kg of the body of glucose-salt solution of the body after each emptying. At this stage, the solution for oral rehydration can be alternate with fruit or vegetable boosters without sugar, tea, especially green. When vomiting after a 10-minute pause, rehydration therapy continues. In the conditions of the hospital in the event of a child failure from drinking or if there is vomiting, probe rehydration is used. The thin gastric probe is administered through the nose (the length of the probe is equal to the distance from the ear to the nose + from the nose to mesia-shaped process Breasts). Probe rehydration can be carried out continuously droplet using a system for intravenous administration, with maximum speed 10 ml / min.

Parenteral Rehydatutation

With an excacosis of 3 tbsp., Multiple vomiting, anorexia, refusal to drink, oral rehydration is combined with parenteral. To this end, children are used by Ringer's solutions lactate, ringer acetate, glucose isotonic solutions, sodium chloride. In children of the first 3 months of life, a 0.9% solution of sodium chloride is better not to use, as it contains a relatively large amount of chlorine (154 mmol / l) and relatively high osmolarity (308 mosmol / l). Monotherapy with glucose solution during exicosis is ineffective. The composition and the ratio of solutions depends on the type of dehydration.

Given the features children's agewhich create conditions for the development of hypernatremia, cell edema, with inadequate rehydration therapy, in children early age It is necessary to eliminate the solutions that contain a relatively large amount of sodium, chlorine, glucose is the solutions of the disol, trisol, quarterly, acel, lactasol, chille, and the like.

If there is a shortage of some ions in the blood plasma deficiency (sodium, potassium, magnesium, calcium), the shear in the acid-alkaline balance is carried out by their correction.

For parenteral rehydration, it is necessary to determine:

1. Daily need for fluid and electrolytes.

2. Type and degree of dehydration.

3. The level of fluid deficiency.

4. Current fluid loss.

The principle of calculation of volume infusion therapy:

The daily volume of the child's fluid with dehydration consists of a liquid deficiency to the beginning of treatment (loss of body weight during the disease), physiological needs (FP) in fluid, current pathological losses.

To calculate the daily need for fluid, you can recommend the Holiday SEGAR method, the most widely used in the world

Determination of physiological needs for the Holiday SEGAR method.

An example of calculating the need for liquid according to the Holiday-SEGAR method - in a child with a body weight of 28 kg, the daily physiological need for liquid is: (100 ml x 10 kg) + (50 ml x 10 kg) + (20 ml x 8 kg) \u003d 1660 ml / day.

The calculation of fluid needs, depending on the degree of dehydration, is determined by clinical features or by% of body weight loss:

1% dehydration \u003d 10 ml / kg

1 kg of weight loss \u003d 1 liter

Therefore, at 1 degree of excacosis (5% of body weight loss), the deficit must be introduced in addition to the daily physiological need for 50 ml / kg / day; at 2 tbsp. (10% mass loss) - 100 ml / kg / day. The calculated volume of fluid is injected throughout the day. The fluid is injected into the peripheral veins for 4-8 hours, repeating infusion if necessary after 12 hours. Accordingly, this patient intravenously receives the part of the calculated daily volume of the fluid, which is allocated to this period of time (1/6 of the daily volume for 4 hours, 1/3 - for 8 hours and so on). The volume that remained is injected through the mouth.

The calculation of the need for a child's fluid for each hour of infusion therapy is more physiological compared to the daily definition, since it creates conditions for preventing complications during infusion therapy.

The physiological need for fluid in this way can be calculated in this way:

Newborn:

1st day of life - 2 ml / kg / h;

2nd day of life - 3 ml / kg / h;

3rd day of life - 4 ml / kg / h;

weighing up to 10 K - 4 ml / kg / h;

weigh from 10 to 20 kg - 40 ml / hour + 2 ml per kg of body weight over 10 kg;

weighing more than 20 kg - 60 ml / hour + 1 ml per each kg of body weight Over 20 kg.

2) Calculation of salts:

Special attention to the elimination of dehydration should be given to the correction of sodium and potassium deficiency, the losses that can be significant. It is necessary to remember that sodium child will receive with crystallide solutions, which are introduced in certain ratios with glucose, depending on the type and severity of dehydration. If laboratory control is not carried out, potassium is introduced at the calculation of the physiological need (1-2 mmol / kg / day). The maximum amount of daily potassium should not exceed 3-4 mmol / kg / day. Potassium preparations, mainly potassium chloride, are introduced intravenously with a 5% glucose solution. Currently, the addition of insulin to these solutions is not recommended. The concentration of potassium chloride in the infusage should not exceed 0.3-0.5% (maximum 6 ml of 7.5% KSL per 100 ml of glucose). The 7.5% solution of potassium chloride solution is most often used (1 ml of 7.5% KCl contains 1 mmol to +). Before entering potassium into infusat, it is necessary to achieve the resumption of diurea, since the presence of Anururia or pronounced Oliguria is a contraindication for intravenous administration of potassium. A threat to life occurs when potassium content in a blood plasma is 6.5 mmol / l, at a concentration of 7 mmol / l need hemodialysis.

The daily volume of the fluid for newborns is at an excacio of 1 degree (8 - 12%) - 190 - 250 ml / kg, at 2 degrees (13-20%) - 230 - 300 ml / kg, at 3 degrees (21-30%) - 300 - 450 ml / kg.

There is another volumetric method Fluid calculation:

Hp \u003d fp + bvv + zhtpr;

FP (physiological need)

LIQUE (refund liquid)

ZhTPP (fluid of current pathological losses).

Convenient and informative is nomogram Aberdeen. The nomogram determines the minimum daily need for sodium and potassium, water, the result obtained is summarized with pathological loss figures.

Yeah \u003d min. Daily need + pathological losses

Immount to water losses 1. Her skin increase by 10ml / kg The body weights per day with an increase in temperature above 37 s per degree with a fever duration of more than 8 hours. In the presence of 2. Well Added 15 ml / kg body masses per day for each degree 20 respiratory movements above the norm for vomiting - 20 ml / kg per day, with liquid stool on average - 20 ml / kg per day. But if a large amount of fluid is lost with the chair, then the following calculation is proposed: with moderate diarrhea - 30 - 40 ml / kg, with a strong diarrhea - 60 - 70 ml / kg, with profuse - 120 - 140 ml / kg.

For pararey intestine The need for fluid increases in parallel its degree. For 9 degree intestinal paresis - 20 ml / kg / day is additionally introduced, at 3 degrees - 40 ml / kg / day. This method of calculating the fluid is used in the first day until the deficit of body weight deficiency is eliminated, and the FP and ZhTPP are taken into account.

The ratio of glucose and colloid salt solutions It must be as follows: at 1 degree - 4 or 3: 1, at 2 degrees - 2: 1, at 3 degrees - 1: 1. Considering that colloidal solutions are prepared on saline, sodium salts deficiency are compensated for by colloids. Potassium deficiency is replenished due to the administration of potassium with glucose, so the introduction of salt solutions should be limited, with the exception of the extraction 2 - 3 degrees.

The choice of glucose-colloid-salt solutions is determined by the task of infusion therapy: Rehydatution, disintellation, liquidation of protein deficiency, etc. For this purpose, low molecular weight plasma substitutes of disinfective action (hemodez, polydetis 10 ml / kg ). Reopolyglyukin (10 - 15 ml / kg), natural colloids (plasma, albumin, blood 10-15 ml / kg)to improve the rheological properties of the blood, the elimination of microcirculation disorders and the replenishment of protein, glucose-potassium insulin mixtures for restoration and maintenance of water-salt metabolism. With "clean" intestinal infections without background and concomitant diseases, a 5% glucose solution can be administered, where encephalopathy is available, pneumonia is advisable to use a 10% glucose solution. In the injected glucose, insulin is evenly dissolved (at the rate of 1 unit. Insulin per 5 grams of sugar) and a 7.5% solution of potassium chloride (at the rate of 1 - 4 ml / kg per day).

Potassium needs can be determined on the basis of laboratory studies according to the formula:

By per day \u003d to the norm - to the patient x m (the weight of the patient in kg).

Potassium concentration in 100 ml of glucose should not exceed 13 ml. In the same formula, it is possible to calculate the need for sodium. For the correction of metabolic acidosis, sodium bicarbonate is prescribed 4% from the calculation of 1 - 2 ml / kg permanent dose, or 4 - 5 ml / kg per day.

The volume of the starting solution with an excacosis of 1 degree is 8 ml / kg of body weight, at 2 degrees - 12 ml / kg, at 3 degrees - 16 ml / kg. The volume of the starting solution for the correction of the BCC deficiency can be determined in other ways.

The need for water can be calculated by the magnitude of the hematocrit:

N.t. Norma - N.t. Patient M.

K \u003d ------------ x ----

100 - N.t. Norma 5.

where, k - the amount of fluid necessary to eliminate the deficiency of the BCC,

NT Norma - Hematokrit Healthy Child

NT Patient - Hematokrit Patient Child

M is the mass of the patient's body (in kg).

The following method of calculating the starting solution is below:

K \u003d 4 x m x d

Where, k - the amount of liquid in ml

M - body weight in kg

D - degree of dehydration

4 - constant value

All the calculated amount of fluid is introduced into / in inkjet, slowly, in heated form up to 37 s under the control of the CVD, pulse, cardiac activity. With an increase in the CCD, above 50 - 80 ml of water column (according to various authors), it is necessary to go to / in drip administration.

In case of variciate dehydration, a starting solution is a 5 or 10% glucose solution, with salted - colloidal saline solutions.

Speed \u200b\u200bin / in drip administration Liquid depends on the age of the child and dehydration degree. The rate of administration will depend on the Correction of the BCC during the first hour, in the next 8 - 10 hours the weight deficit is covered. Infusion therapy of the next hours of the day is aimed at covering continuing losses, in such cases the speed will depend individually. With the introduction of glucose-saline solutions in the 2nd phase of infusion therapy, a slower introduction of solutions from 6 to 10 kap / min is necessary. With an excacosis of 2 degrees and, especially, at 3 degrees, it is necessary to distribute the entire volume of the liquid evenly during the day.

Infusion therapy must be carried out by observing a certain sequence of fluid administration by phases.

1st phase (Duration from 30 minutes to 2 - 4 hours) The restoration of the BCC is envisaged.

2nd phase (18 - 24 hours) - Restoration of the deficiency of extracellular sodium and partially acidic alkaline equilibrium.

3rd phase (up to 4 days) - Restoration of potassium deficiency and complete leveling of acid-alkaline equilibrium.

With 1 degree excacosis and when saving the passage by the intestine, infusion therapy is not shown. In these cases are prescribed oral rehydration, when carrying out glucose saline solutions ( glucosolyan or reghyron.).

Oral rehydration is carried out in 2 stages.. During the first 6 hours, the water-salt deficiency arising before the start of treatment is eliminated. In subsequent hours, they carry out supportive therapy, taking into account the daily need of a child in liquid, salts and continuing losses. The calculation of the fluid at the first stage is carried out according to the following formula:

V \u003d M x 75

Where, V is the volume of fluid, M is the mass of the patient's body, 75 - the coefficient.

In the 2nd stage, supporting therapy is carried out, which depends on the continuing pathological losses of fluid and salts lost with vomiting and feces. At the same time, in each subsequent 6-hour period of time, the child should drink so much fluid as he lost for the previous 6 hours. Approximate volume of fluid at the 2 stage of this stage - 80,0 – 100 , 0 ml / kg / day. Rehydration continues until the normalization of the chair. Calculated for 1 hour the volume of the liquid is dosed by teaspoons (1 - 2 spoons) every 5 - 10 minutes. Along with glucose saline solutions, it is necessary to prescribe tea, boiled water, rice decoction, a coratin mixture, a decoction of raisin and grasses. The efficiency of oral rehydration is estimated to be liquidated or decreasing the symptoms of dehydration, the cessation of water diarrhea.

Dietherapy. Currently, the water and tea pause is not recommended, because It has been proven that even with severe forms of intestinal infections digestive function Most of the intestines are preserved, and water-tea pauses significantly weaken the body's protective forces and slow down the projection processes.

The volume and composition of food is determined by the age of children, the nature of feeding to the disease, the severity and the form of the disease. In early age children during the period of sickness of the disease, it is recommended to reduce the amount of food on the first day of treatment by 50% and an increase in feeding multiplicity to 6 - 8 - 10 times a day (respectively after 2-2.2 - 3 hours). Within 3 - 4 days, the normal supply must be restored.

Optimal diet of children breast-age is maternal milk. Children, including the first year of life on artificial feeding, preferably prescribe fermented milk mixtures (acidophilic milk, "Narina", "Baldyrgan", "Bioolat", etc.). For 3 - 4 day of the disease, after restoring the normal amount of nutrition, it is gradually listed.

The leading cause of the severity of the eye in children leading to death is the development of dehydration. Therefore, the basis rational treatment Patients of Oka, especially in the debut of the disease, is the widespread use of oral rehydration using glucose-salt solutions in combination with proper nutrition.

The use of these solutions for oral rehydration is physiologically substantiated: glucose has a property to enhance the transfer of potassium and sodium through the mucous membrane thin gutAnd this contributes to the rapid restoration of violations of the introductory and salt balance and the normalization of metabolism.

WHO recommends applying the method of oral rehydration at oki, accompanied by the so-called "water-bright diarrhea" (cholera, enterotoxygenic escheriosis, etc.), as well as intestinal infections other etiologies that occur with enititis, gastroenteritis and enterocolitis (salmonellosis, rotavirus infection and etc.). Oral rehydration is most effective if it is carried out from the first time from the beginning of the disease.

The advantages of the method of oral rehydration:

With an excacus of 1-2 degrees with oral rehydration restoration of potassium concentration, sodium and braids are faster than when intravenous administration rehydration solutions, although the normalization of the chair may be departing for 1-2 days;

The use of the method of oral rehydration in hospitals allows to reduce the number of intravenous infusions, which, on the one hand, reduces the cost of treating the patient and reduces the timing of its stay on the bed, and also has anti-epidemic importance (prevention viral hepatitis with parenteral by transferring infection);

The simplicity and availability of the method allows you to apply it already on chipboard treatment of patients with Oci (in a clinic and even at home), and when used in the initial period, the disease often avoids hospitalization;

With high efficiency (in 80-95% of patients), with its proper application, this method practically does not give complications, while at the infusion therapy, by the direction reactions occur in 16% and more patients.

Indications for oral rehydration - The initial manifestations of diarrhea, moderate (1-2 degrees) dehydration, not a severe condition of the child.

Readings for parenteral rehydration:

Heavy forms of dehydration (2-3 degrees) with signs of hypovolemic shock;

Infectious toxic shock;

The combination of the excacosis (either) with severe intoxication;

Oliguria or Anururia, not disappearing during the first stage of rehydration;

Non-corrosive vomiting;

The increase in the volume of the chair during the oral rehydration during the 2 days of treatment. These phenomena may be due to congenital or acquired glucose absorption disorders (rare).

Not the effectiveness of oral rehydration during the day.

To combat dehydration, the use of the drug "REGIDROON" and "GLUKOSOLAN" is recommended. Other solutions can be used for oral rehydration - oralitis, biorine or carrot-rice decoction. However, with intestinal infections of the "invasive" and, especially "osmotic" type, when the diarrhea is based on the hyperosmolarness of the chimus, preference for oral rehydration should be given hyposmolarglucose saline with chamomile extract "Gastracier

Calculation of fluid for oral rehydration. Oral rehydration in the presence of dehydration 1-2 degrees is carried out in two stages:

I stage: In the first 6 hours there is an elimination of the existing body mass deficit due to the excocosis. The volume of fluid necessary for this stage is equal to the deficit of body weight in percentage and is calculated by the formula:

ml / hour \u003d (m x r x 10): 6

where, ml / hour - the volume of fluid introduced by the patient in 1 hour

M - the actual mass of the child's body in kg

P is the percentage of acute body weight loss due to the excacosis

10 - proportionality coefficient

When determining the degree of dehydration on clinical data, it is also possible to use the approximate data on the volume of the fluid necessary for the patient for the first 6 hours of rehydration, taking into account the actual mass of the body and the degree of dehydration (Table 50).

Table 50.

The amount of solution depending on the weight of the child

The leading cause of the severity of the eye in children, often leading to death, is the development of dehydration. In the 70s, the WHO method was introduced - oral rehydration with glucose-saline solutions. In this regard, the basis of rational treatment of patients with OCI is the wide use of oral rehydration using glucose-salt solutions in combination with proper power.

The use of glucose saline solutions for oral rehydration is physiologically justified, because It has been established that glucose has a property to enhance the transfer of potassium and sodium through the small intestine mucous membrane - it contributes to the rapid restoration of disorders of the water-salt balance and the normalization of metabolism. Oral rehydration is most effective when applied from 1 hour from the beginning of the disease.

The method of oral rehydration has its advantages:

with an excucosis of 1-2 degrees with oral rehydration, the restoration of potassium concentration, sodium, braids occurs faster than when in / in the introduction of rehydration solutions, although the normalization of the chair can be found for 1-2 days.;

the number of in / in infusions is reduced, which reduces the cost of treating the patient and reduces the timing of its stay on the bed on the one hand and has anti-epidemic importance in terms of the prevention of viral hepatitis - on the other;

the simplicity and availability of the method allows it to apply it in the prehospital stage of treatment of patients with OKI - in the clinic and at home, and in the early use of its use in the initial period of the disease can not be done by hospitalization;

with high efficiency (in 80-95% of patients), the method does not give almost complications, while at infusion therapy adverse reactions There are 16% of patients. But it also has its drawbacks - does not have a significant effect on the consistency of the chair, the duration of diarrhea, and the high sodium content creates conditions for hypernatremia (i.e. high-grade).

Indications for oral rehydration – the initial manifestations of diarrhea, moderate (1-2 degrees) dehydration, not a severe condition of the child.

Indications for parenteral rehydration:

Heavy forms of dehydration 2-3 degrees with signs of hypovolemic shock, ITS; the combination of excitosis (either degree) with intoxication; Oliguria or Anururia, not disappearing during the first stage of rehydration; Non-corrosive vomiting; the increase in the volume of the chair during the oral rehydration for 2 days of treatment (these phenomena may be due to congenital or acquired impaired glucose absorption and rarely); Ineffectiveness of oral rehydration

To combat dehydration, it is recommended to use "REFIDRON" (in 1 g of powder: 3.5G sodium chloride, 2.9 sodium citrate, 2.5 g of potassium chloride: and 10.0 glucose) or domestic "glucosalan" (3.5 g Sodium chloride. 2.5 g of sodium bicarbonate, 1.5 g of potassium chloride and 20 g of glucose). Other solutions can be used for oral rehydration - oralitis, biorine or carrot decoction, "Children's Head".

When performing oral rehydration, it is necessary to take into account the osmolarity of the chimus. With the "invasive" and "osmotic" type, Himus hyperosmolarity takes place. The new standard of osmolarity of glucose-salt solutions is determined - 200-250 mmol / l. A new hyposmolar glucose-saline solution "Gastracier", developed in accordance with the latest recommendations of the European Society of Children's Gastroenterology and Nutrition, appeared. The dry matter content is in terms of 1 liter: sodium chloride - 1.75 g, chloride potassium - 1.5 g. Sodium hydrocarbonate - 2.5 mg, glucose \u003d - 14.5 g, drug chamomile extract - 0.5. Opelolar solution - 240 mmol / l. The drug replenishes not only water-electrolyte losses, but also stops metabolic acidosis. Chamomile extract additionally has anti-inflammatory, antiseptic and antispasmodic effect on the intestines, has a moderately pronounced anti-diagram effect. Available in powders of 4.15 g for the preparation of a solution of 200 ml.

Methods for calculating fluid for oral rehydration.

I. stage:in the first 6 hours after the treatment of the patient with diarrhea, the water-salt deficiency is eliminated, having a place for the beginning of treatment. On average, the amount of fluid in the 1st stage is from 50 ml / kg to 80 ml / kg and 100 ml / kg in 6 hours. The required amount of fluid in 1 hour and in 6 hours, depending on body weight and the degree of operation, calculated on the table:

II. stage – supporting therapy, which is carried out depending on the continuing losses of fluid and salts with vomiting and feces. Approximate volume of the solution for supporting rehydration - from 80 to 100 ml / kg body weight per day. The second stage of rehydration continues until the diarrhea ceases.

Failure a child should be fractionally 1-2 teaspoon or pipette every 5-10 minutes (with a violation of swallowing - drip through the probe), the regions can be combined and alternating with insensible solutions - tea, water, compote without sugar. The effectiveness of oral rehydration is estimated on the disappearance and decrease in the symptoms of dehydration, the cessation of water diarrhea, an increase in body weight. In the absence of a clinical effect, as well as at an excacio of 2-3 degrees, multiple vomiting and shock states, infusion rehydration therapy is carried out.

Determination of the optimal composition of the liquid. In young children (up to 3 years), glucose saline solutions are expedient to combine with baking sheets (tea, water, rice decoction, rosehip, carotic mixture) in the ratio:

1: 1 - with severe water diarrhea;

2: 1 - with loss of liquid, mainly with vomiting;

1: 2 - with a loss of permissions (with hyperthermia and moderately pronounced diarrheal syndrome); In case of enterocolitis syndrome with invasive Oka, when the excacosis is connected not so much with the loss of fluid, as with the redistribution of it between the cell and the extracellular space. The introduction of salt and nonsense solutions alternates (not mix them).

3. Etiotropic therapy

The differentiated approach to etiotropic therapy is optimal - taking into account the pathogenesis (type of diarrhea), estimated on the basis of the clinical and epidemiological data of the ECO etiology (shgelles, rotavirus infection, etc.), gravity and phases of the disease, the age of patients and concomitant pathology, peculiarities of immune reactivity organism.

At the same time, etiotropic therapy is not limited to the use of antibiotics and chemotherapy, and includes enteral immunoglobulins and lactoglobulins, probiotics, sorbents, specific bacteriophages.

Antibiotic therapy.

Indications for the appointment of antibiotic therapy:

1 Invasive diarrhea (colitis, enterocolitis, ENTEROCOLITS CHGELLESS, SALMONEELLEST, IRISINIOSAL, CAMPILOILSTER, ESECHERIOGICAL AND N / UH etiology) in the acute phase of the disease and under clinically pronounced exacerbation (recurrence)

a) in severe forms - regardless of etiology and age

b) with the medium-free forms of the disease in children under 2 years old, patients from a risk group, regardless of age, with shgellosis, regardless of age, with hemorrhagic colitis phenomena

c) with light forms of the disease: children up to the year "Risk Groups", with hemorrhagic colitis phenomena

Patients with cholera, abdominal typhoid, and amoebic dysentery - regardless of the age of the patient and the severity of the disease

Patients of any age with generalized (typhoid, septic) Oka forms, regardless of the severity of the disease

All A / B and chemotherapy for empirical therapy OKI are conditionally divided into 3 groups:

I. Row "Starting" - prescribed often empirically at the first meeting with the patient (more often in outpatient conditions, less likely - when entering the hospital in the first hours of the disease). These include widespread inexpensive drugs, which, when taking inside, are completely absorbed in the intestine and have a bacteriostatic or bactericidal effect in the lumen of the intestine that the pathogenetically justified in the first hours of the disease. They are ineffective with severe forms and as monotherapy in half cases with medium-free forms. Clinical and exploring effectiveness increases significantly when used in combination with the hepon immunomodulator or enterosorbents.

Oral preparations of "Starting therapy": Nalidixic acid derivatives (Neversman, blacks), nitrofuran derivatives (Furazolidon, Ercephuril), combined (Intetrix - over 6 years old) and aminoglycosides of 1 generation - (gentamicin, Canamycin sulfate).

Parenteral preparations of starting therapy: penicillins (amoxicillin, amoxicillin / clavulanate) - have a wide range of actions, secreted into the intestinal lumen and have an impact on the causative agents of the OCIs that are both in the intestines and in the presence of Bacteriamia); aminoglycosides (gentamicin, sizomycin, tombromycin); Cefalosporins 1-2 generations - (cefasoline, cephalotin, cefuroxime, cefhamandol, cephalexin - clinical and sanitative efficacy with medium-stage and heavy forms of OKOi significantly increases in combination with the hepon immunomodulator or heating).

II. A series "Alternative" - usually prescribed in the hospital in the ineffectiveness of drugs 1 row, with medium-and-heavy and heavy forms of the disease, as well as in the case of receipt at the later dates - as "starting", since within these deadlines of invasive OUTS, the pathogen is already penetrating the boss of the intestine. These include: Nalidix acid, amoxicillin / clavulanic acid and aminoglycosidesii-separation (amikacin, neutylmicin inside), and according to indications - in combination with parenteral administration

III row of "reserve" - it is recommended to apply only in the hospital (mainly in resuscitation and intensive care departments). They are prescribed: a) with severe and generalized forms of Oak children "risk groups" - as starting;

b) with moderate and severe diseases of the disease - in the event of the ineffectiveness of drugs 2 rows;

c) with a combination of OKI with bacterial complications of ARVI. This is a / b of a wide range of action, with a wide bioavailability, penetrating into tissues that have a bactericidal effect on intracellular microbes. These include: aminoglycosides (amikacin, neutylmicin), rifamycin, cephalosporins III-II-ipolation (ceftibutene and ceftazidim), fluoroquinolones - Ciprofloxacin, Norfloxacin, Opleloxacin (children over 12 years old, the rest only on vital testimony), carbapinem - imipenem, meropenem; Macrolids 2 generations (azithromycin). Expanding the testimony for this group of drugs is unacceptable due to the possibility of developing the resistance of pathogens (as for rifampicin) and high costs. Reserve preparations are advisable to periodically change, based on the results of antibiograms and analyzing the effectiveness of therapy.

Alternative means of etioretic therapy

To date, the choice of etiotropic therapy of the eye is not limited to the use of a / b and x / p. When choosing the funds of "starting" etiotropic therapy in the initial period of the disease with the lungs and moderate forms of the Oci, the preference should be given not to A / B and C / P, but with drugs with direct or mediated etiopathotically effect on the causative agents - immunoglobulins and lactoglobulins, oral use, Probiotics, enterosorbents, specific bacteriophages.

In secretory and osmotic diarrhea, these drugs should be considered the main. In the absence of positive dynamics of Oci symptoms in the first 2-3 days of treatment with starting drugs (A / B, chemotherapy, alternative means), the question of the additional purpose of another drug or the preparation of the reserve is solved.

Kip -it is the first domestic drug for enteral use (inside and rectally), IHL "Progress" (Moscow) is produced under the license of the MNIEM. G.N. Gabrichevsky from the ballast fractions of commercial immunoglobulin, oh, differing from the last high content of immunoglobulin A, M and the increased concentration of antibodies to enterobacteries and viruses, which contributes to the rapid and highly efficient elimination of the causative agents of the OCI, the normalization of the intestinal microbiocenosis, the positive impact on the immune status, mainly On its cellular link.

Employees of the MNIEM them. G. G. Gabrichevsky successfully carried out tests of a normal human immunoglobulin with an increased content of antiviral antibodies. When it is prescribed by patients with watery diarrhea, most of which had rotavirus gastroenteritis, shortening for intoxication terms, dialing the diarrheal syndrome, the elimination of rotavirus from feces of patients.

The introduction of finished specific antibodies is carried out in the treatment of patients with lactoglobulin preparations (obtained in the hyperimmunization of cows), both in the acute phase of the disease and in the reconvaluation period - anti-chiegeless, anticoalonellic, quiproture lactoglobulins.

"BIFFORM"combined probiotic production of the pharmaceutical company FERROSAN ITERNESHNL A / C. (Denmark). The preparation has high antagonistic and enzymatic activity. It includes anaerobic (Enterococcus faecium) and aerobic (Enterococcus faecium) bacteria, in the norm present in the intestines and having high activity, as well as the nutrient medium (represented by lactulose, glucose, growth factor - yeast-like extract, soybean oil), providing The stability of the capsule in the acidic area of \u200b\u200bthe stomach and is a substrate for the natural enression and reproduction of bacteria, possessing the prebiotic properties .. The bofform of fecal enterococcus, which colonizing the fine intestine, has a pronounced enzyme (including lactase) and antagonistic activity in relation to pathogenic Bacteria, causative agents of Oka. Additional inclusion in the preparation of apatogenic enterococcus, in contrast to monocomponent bifido-containing probiotics, makes it possible to have a positive effect on the normalization of the quantitative and high-quality composition of microflora not only a thick, but also the thin intestinal department. The drug is produced in capsules, the acid-resistant shell of which protects the bacteria included in its composition when passing through the gastrointestinal tract. The composition of the drug allows it to be used in the treatment of OCI with a lesion of both thick and small intestines.

The inclusion in the complex therapy of the lungs and medium-stage forms of Oki in children is a boform, instead of A / B, has a fast and pronounced disinfecting and anti-diabey clinical effect, normalizes the microflora, reliably reduces the average duration of the acute period of the disease.

Enterosorbents(Smekt, enterrosgel, filter, enterodez, microspherb) is a new and very promising direction of etiotropic oco therapy in children, which plays a leading role in secretory diarices, and, above all, rotavirus gastroesterites - as the only type of etiotropic therapy (without a / b and x / n). A prerequisite for increasing the therapeutic effectiveness of enterosorbents is their purpose as possible in more early deadlines Diseases. The use of drugs from the first hours of the disease significantly improves its outcome, especially in young children, can have a "tearing" action on Oci. The use of enterosorbents at the later dates of the disease (after 5-7 days), especially with invasive OKI, less affects the diarrhea syndrome, but has a pronounced disintellation and enteroprotective effect.

Existing sorbents: coal (activated carbon, coal type SNK, GS-01E, microsorb), fibrous (biligin, polyvinyl polyvinyl), low-counter polyvinylpiralidones (enterosezor, enterosorb), natural porous natural (smects, kaolin), ion-exchange resins ( hololtiramine), etc. - They are the smallest particles with a very large sorbing surface, capable of extracting, fix on themselves and remove viruses, microbes and their exo- and endotoxins, biologically active metabolites, allergens from the intestine. There is a direct and indirect effect of sorbents: direct (sorption of toxins and microbes), indirect - eliminate meteorism, weaken toxicoallergic reactions, reduce the metabolic load. The possibility of a combination of sorbents with oki with a / b, probiotics, immunoglobulin.

Specific bacteriophages- There are an important type of etiotropic therapy of the oil of invasive genesis. Interest in specific medical and prophylactic bacteriophages, widely used in Daentibiotic Era, has been revived in the 60-80s due to a decrease in the effectiveness of A / B. Currently, in different cities (N-Novgorod, Ufa, Khabarovsk) produce many different specific b / phages with a wide range of action and in different dosage forms - Liquid (vials, ampoules), tableted (with acydore and pectin coating), in candles. Indications:

as monotherapy with erase and light shame forms

in combination with other A / bacterial preparations with moderate forms in the acute phase of the Oka

in combination with pathogenetic therapy for conducting 2 course of etiotropic therapy with insufficient effectiveness of the first

when re-bacterial release - in the form of monotherapy or in combination with immunoprotectors

for treatment intestinal dysbacteriosisaccompanied by increasing intestinal sticks with changed properties and proteis (quiproture b / phage) or caused by associations of conditionally pathogenic micromanis (intest-phage).

Phages are prescribed 1-2 hours before eating a course of 5-7 days, which, if necessary, can be repeated with a break of 4-5 days. It is impossible to combine phageotherapy with the reception of biological products - due to different values \u200b\u200bof the pH of the intestinal environment required for their action. The main way of administering the phages is oral, but a combination of oral with rectal (in enema) is more efficient. Bacteriophages are not recommended to be prescribed in a period of pronounced intoxication, because Free toxins can be released during lysis can enhance intoxication.

Enzyme therapy

The replacement enzyme therapy should be carried out with the Oka in children only in the presence of clinical and coprological signs of impaired digestion in order to correct the digestive and absorption function of the GCT.

Clinical indications for enzyme therapy are the average and heavy forms of Oci, flowing with the involvement in the pathological process of the small intestine (enteritis, gastroenteritis, etc.) by the type of invasive or osmotic diarrhea. In these cases, enzymes are assigned:

after liquidation clinical symptoms infectious toxicosis (neurotoxicosis, toxicosis with an exicose II-II system, ITS, etc.);

during the expansion of the diet after unloading in nutrition;

in the presence of concomitant gastroenterological pathology (enzymesopathy, gastroduodenit, etc.);

indications for the conduct of enzyme therapy can also serve as a dense tongue, the phenomenon of the ferment or rotary dyspepsia (flatulence), the presence of a large number of greenery and non-digested peaks, unpleasant (slicer or rotten) smell of detergents.

The choice of an enzyme preparation is carried out taking into account the age of the child, the topics of the lesion of the gastrointestinal tract (enteritis, colitis, etc.), the pathogenesis of the diarrhea syndrome (invasive, osmotic, etc.) and the results of the coprogram.

Choosing an enzyme preparation depending on the type of diarrhea

With invasive diarrhea with involvement in the pathological process of the subtle intestine (enteritis, gastroenteritis, etc.), the need for enzyme therapy occurs on 3-4 day of the disease during the period of diet expansion. An enzyme preparation of "starting" therapy (before obtaining the results of the copron) is Pancreatin (Yugoslavia / Russia) or its analogues with low activity of pancreatic enzymes (mesim forte, Pangrol 400, etc.). With gastritis, the prescription of proteolytic enzymes is shown (Abomin et al.), Gastroenteritis - enzymes based on pancreatin, with colitis - enzymes with high amylolytic activity (polecuts, panzinorm).

With the "osmotic type of diarrhea" (viral diarrhea) - enzymes with high amylolithic activity (lactase, t-lactase, oraza, socomilasis, polecut, pangrool 400, UNIENZIM) from 1 days of the disease should be prescribed from 1 days of the disease or translate a child to a low-beam or brick-free diet ;

In the presence of meteorism phenomena (regardless of the type of diarrhea), polyenimized drugs based on pancreatin with di- or sytlecone (pancreatophula, wintering) or UNIENZIM, because "Plenochiters", which are part of these drugs prevent gas formation.

In mixed invasive-osmotic diarins (rotavirus-bacterial co-infection or layering of the osmotic nature of diarrhea on an invasive disease in the dynamics of the disease), polyenimensional preparations based on pancreatin with increased activity of amylase should be prescribed.

In solving the issue of the need to use enzyme preparations, when children, children should also be borne in mind that probiotics (bosporin, enterol, bifido- and lact-containing) used in complex therapy In order to intensify or as the means of etiotropic monotherapy of lungs and medium-stage forms, they have enzymatic (mainly amylolytic) activity and, in these cases, additional enzymes are usually not required.

When analyzing the results of the coprogram, it should be considered:

That starch, neutral fat, fatty acids, connective tissue And the iodophilic microflora is not normal.

The presence of a large amount of (+++) muscle fibers indicates a decrease in the proteolytic activity of the stomach (gastritis) or pancreas.

An unpleasant reeling smell and a large amount of muscle fibers, triphelphosphate crystals, iodophilic microflore are always associated with a decrease in the proteolytic activity of the small intestine enzymes - disruption of the digestion of proteins, which in the thick intestine decompose with the release of a large amount of ammonia, irritating the mucous membrane.

A neutral fat, bile - fatty acids, a small intestine - fatty acid salts (soaps), amylolithic - starch and iodophilic microflora (at the expense of clostridy) indicate the lipolytic activity of the pancreas enzymes.

On the insufficiency of suction in the small intestine (fast evacuation, inflammatory process, violation of tribal digestion) indicates an increase in the number of fatty acids, digestion - muscle fibers, neutral fat, fatty acids, soap, starch and tissue digestible.

If the cause of the disturbed digestion is only a fast evacuation of chimus from the small intestine - in the feces, greens appear, a large amount of muscle fibers and fatty acids, if the pathological process is involved and top departments Tolstish intestines - fatty acid salts (soaps).

In the presence of a ferment process, a lot of transsing fiber and iodophilic microflora (clostridium), a foam or nowood fence (due to increased gas formation CO 2), a large amount of transparent mucus.

5. Symptomatic therapy Includes the behavior of antipiretic, anti-ansified and anti-stage activities, the relief of pain syndrome, meteorism phenomena, etc. are held according to general rules.

Hyperthermic syndrome-with an increase in body temperature above 39 0 or in the presence of seizures in a history of temperature - antipyretic agents (Panadol, Aldolor, Calpol, Standol, Saridon, Efferoralgan, etc. are prescribed;

Physical cooling methods are carried out (cold on the vessels, skin rubbing with a mixture of alcohol, water and vinegar in equal ratios, child undressing)

Under the "white" hyperthermia - antispasmodics are prescribed additionally to the antipyretic, physical cooling methods are contraindicated;

In the presence of hypertermic syndrome (40-41 0) and convulsive readiness (trembling fingertips and chin) shown in / m or in / in the introduction of a lithic mixture (50% rr analgin + 2% DIMEDROL (or other antihistamine drug) - 0.25% pR NOVOKAINA in age dosages;

With a sharp concern of the child in a lithic mixture, droperidol (0.15%) or sled in age dosages are added;

Also also shown in the introduction of 10% p-ra glucose with lidocaine (2-4 mg / kg) or xanthinol (5 mg / kg).

Supervous syndrome. The addition of antipyretic measures in / m or in / in relanium (sadocent) of 0.3-0.5-1.0 ml of 0.5% R-ra (in the absence of the effect of h / s 15-20 min - The re-administration is shown) or the GOM 2% p-p (in a single dose of 100mg / kg of body weight is introduced);

At the same time, infusion therapy is carried out, aimed at combating brain edema; A diuretic (Laziks, 15-20% rr Mannitol, diakarb), as well as colloidal solutions (10-20% albumin, refooliglucin, etc.), 10% glucose with insulin, cocarboxylase, etc.

Antidiards:Enterosorbents (enterorosgel, filter, smect, enterodez); Motoric regulators: Loperamide hydrochloride or its analogues (enteroben, diarrole, diaspora) are prescribed to children from 2-5 years of age; Secrecy Inhibitors: Indomethacin, Otreotide (Sandostatin) - are prescribed in secretory diarrhea, and with invasive - are not prescribed;

Contamination: Metaclopramide (Raglan, Cerukal), Motilium, Domperon, Bonin, etc., if there are pain syndrome - but spasm (Riabal)

Purchase of pain syndrome:

Motropic antispasmodics: but-shpa (drootaverin), papaverine, spasmodomome 40

Blockers M-cholinoreceptors-bookpowders, metacin, but-spasm (riabal) - has both a controversial action

Enterosorbents (Enterosgel, Filter, Smekt)

meteorosphazmil - contains a "defoamer" Siemeticone AI Miotropic Safaszmolitik Alveherin, selectively acting on the intestinal muscles;

alginatol is prescribed at the "invasive" type with clinical manifestations of colitis ("hemocolite"), enterocolitis, gastroenterocolitis.

Shipping meteorism

Lowolate or lactose diet

- "Plenokers" based on di or Simeticon (dysflatyl, Espumizan, Simetikon)

Combined drugs - Maalox plus, phosphhalugel, etc.

Enzyme preparations - Zeezonlex, Pancreeoflat, Uniaventzim, etc.

Enterosorbent (smecta, filter, etc.)

Others - Plantex, Safety Teas "Impress" based on dill, fennel, chamomile

6. Immunotherapy.

Pathogenetically reasonable should be considered the use of immunomodulators (visiferon, kipferon, cycloferon, hepon), immunoglobulin preparations (kip, quiprothene, anticoalonellosis, anti-hatch, antitropolius immunoglobulins), as well as nonspecific immunity stimulants (petoxyl, lysozyme, sodium nucleicate).