Treatment of Neonatal Diarrhea Flashcards
What will eventually kill neonates with diarrhea?
- Fluid, electrolyte, acid/base derangements***
- Bacteremia, septicemia, toxemia
- energy deficits
TBW % of body weight
- 55-75%
What is ICF % of TBW?
2/3 (intracellular)
What % is ECF Of TBW? What % is plasma and interstitial fluid?
- 1/3 TBW
- 20% of that is ECF
- 80% of that is ECF
Where is most body water?
- Inside of cells
Where is most ECF water?
- Outside the vascular tree
Where is the deficit with dehydration?
- Extra-vascular primarily
Clinical signs of dehydration
- Skin tent is increased
- Eyes are sunken
- Mucous membranes are tacky
- Eyes are “dry”
Where is the deficit with decreased perfusion?
- INTRAvascular
Clinical signs of decreased perfusion
- HR is increased
- CRT is decreased
- Temp is decreased
- Pulse strength is decreased
- MM color is pale
When can calves maintain perfusion even while dehydrated?
- Early diarrhea
- Gut will still be functional
- CLinical signs associated with decreased bicarbonate and potassium
By the time you notice decreased perfusion, how significant are the deficits usually?
- Quite significant
What are 7 questions to consider with fluid therapy?
- Is it indicated?* (first)
- Cost? (first)
- Route?
- Volume?
- Rate?
- Type?
- Duration?
What do you need to know to determine if fluids are indicated?
- History
- PE
- lab analysis
At what % of dehydration can we recognize it clinically?
5%
At what % of dehydration is the animal at risk of death?
- 10-12%
What do you use to estimate fluid deficits with dehydration?
- Increased skin tenting
- Tacky mm
- Sunken eyes
- Dry eyes
What do you use to estimate fluid deficits with poor perfusion?
- Tachycardia
- Weak pulse
- Increased CRT
- Pale mm
- Decreased temperature
- Decreased muscle tone!*
- Recumbent!*
How do you come up with a decision for estimation of dehydration?
- Typically based on a conglomeration of all (or some) of the available information
- The more the better
- Not all parameters will be present or coincide 100%
Laboratory analysis that can be performed to assess dehydration (in adjunct to physical exam)
- PCV
- TP
- Na
- Osmolarity
- etc.
Mild dehydration
5-7%
Moderate dehydration
8-10%
Severe dehydration
> 10%
Relative cost of IV vs oral costs
- $150-250 for IV and $20-60 for oral meds
What three things do you need to think about with route of fluisd?
- Status (Stable vs critical)
- Nature of the case (locale, environment)
- Economic constraints
What are the two broad categories of route of fluids?
- Central
- Peripheral
Central route examples
- IV ONLY
Peripheral route examples
- Oral, subcutaneous, intraperitoneal, intraosseous
Oral route - what does it require?
- Requires a functional or well-perfused gut
- physiologic and natural approach
- Gut is often functional in the face of intestinal disease
Oral fluid ingredients to consider
- Na
- Glucose (energy and helps with glucose/Na co-transporter)
- K
- Cl
- Alkalinizing agents (HCO3, citrate, acetate) if metabolic acidosis
- Glycine to enhance glucose absorption
- Maybe geling agents?? (probably not)
Homemade oral fluid sample recipe
- 1 tsp light salt
- 2 tsp NaHCO3
- Pectin
- 1 can beef consume
SC route benefits
- Convenient
- No volume overload
- Owner administer
- Helpful for maintenance
- 50-200mL/site
When not to do SC route?
- Critical cases!
Intraperitoneal benefits
- Large volumes can be given
Intraperitoneal caveats
- Must use isotonic fluids
- Risk of peritonitis
- Don’t put glucose in there
Intraosseous catheter location
- Tibial tuberosity, trochanteric fossa of the femur and wing of the ilium
Benefits of intraosseous
- Rapid uptake
Caveats of intraosseous catheters?
- Risk of osteomyelitis
IV - which cases?
- CRITICAL cases
Benefits of IV
- rapid correction of deficits
- Large volumes
- Hypertonic tolerated
Drawbacks of IV
-Catheter management
During severe circulatory shock, which is the ONLY route that is not considered peripheral?
- IV
What clues on PE might suggest that an animal is a poor candidate for peripheral fluid therapy?
- Cold extremities
- Difficulty ambulating
What are three factors to consider with volume replacement?
- Deficit
- Maintenance
- Ongoing losses
How to calculate deficit volume?
BW (kg) x % dehydration = deficit in liters
e.g. 100 kg x 0.08 = 8 L
What should maintenance fluids account for?
- Sensible losses (urine, feces)
- Insensible losses (skin, respiratory)
Maintenance requirements
mL/lb/hr
- OR 80 mL/kg/day
What do ongoing losses relate to?
- Disease
- Vomiting
- Diarrhea
- POlyuria
- Burns and wounds
What is the total fluid requirement plan?
- Deficit + maintenance + ongoing losses
How fast can a deficit be corrected?
- Generally 1/2 the deficit can be corrected IV quite rapidly
- Often in teh first hour with the remainder in the next 4-6 hours or longer
- Guidelines vary for species
How rapidly can calves with diarrhea have the deficit corrected?
- 2-4 hours
How quickly can you correct other species?
- Take 24 hours approximately
What multiple of maintenance is it generally considered okay to go?
Up to 4x maintenance
- More than that you need to pay attention to signs of overhydration
Shock rate of fluids
- 90 mL/kg/hR
Signs of excessive fluid flow rates
- Pulmonary and cerebral edema
- Ascites, chemosis (conjunctival edema), diarrhea
- Consider the cardiopulmonary state at high flow rates
- If at a high flow rate, consider measuring CVP
How to determine type of fluids?
- Based on history, PE, lab data
- Clinical experience and other non-measured parameters will guide the decision
Criteria for choosing a fluid
- Fluid is needed to correct the VOLUME deficit
- Correct electrolyte deficits or excesses
- Address acid/base problems
What are the polionic fluids?
- Lactated Ringers
- Normosol
- Plasmalyte
What is in D5W?
- 50g/L glucose
What is in 10% dextrose?
100 g/L
What is in D2.5%, NaCl 0.45%?
- 25 g/L dextrose
77 Na and 77 Cl
What’s in NaCl 0.9%?
- 154 Na
- 154 Cl
What’s in LRS?
- 130 Na
- 109 Cl
- 4 K
- 3 Ca
- 28 Buffer lactate
What is in plasma?
- 1 g/L glucose
- 145 Na
- 105 Cl
- 5 K
- 10 Ca
- 24-28 HCO3 buffer
What are the polyionic fluids?
- LRS
- Plasmalyte
- Normosol
What can happen if you choose 5% dextrose?
- Diuresis
What can happen if you choose 0.9% saline?
- Acidifying
Bicarbonate deficit formula
- HCO3 def = BW (kg) x deficit x (0.3-0.6)
Normal bicarbonate
30 mEq/L
- If they are at 10 mEq/L that’s a 20 deficit
How to calculate deficit
Normal HCO3 (30) - existing HCO3
What is the 0.3-0.6 in the equation for calculating deficits?
- % of body water interchangeable with HCO3
Look at the examples for a calf with a deficit
- Just do it
What happens if you add NaHCO3 to LRS?
- High sodium and osmolality
- We can push the sodium too high
What should you add NaHCO3 to keep sodium and osmolarity okay?
- Use 1.3% NaHCO3 added to water
What is a good rule of thumb in minimal deficit situations?
- Simply correcting the hydration status will allow correction of the deficit via renal and respiratory pathways
- The dumbest kidney is still smarter than the smartest clinician
Base deficit estimate for a calf that is still drinking <8 days and > 8 days
- 0 if <8 days
- 5 if >8 days
Base deficit estimate for a calf that is standing but having diarrhea <8 days and > 8 days
- 5 if <8 days
- 10 if >8 days
Base deficit estimate for a calf that is sternal but laying down <8 days and > 8 days
- 10 if <8 days
- 15 if >8 days
Base deficit estimate for a calf that is totally recumbent <8 days and > 8 days
- 10 if <8 days
- 20 if >8 days
Goal for duration of therapy
- Get calves back to oral fluids
- Monitor hydration parameters, mentation, temperature, suckle, etc.
- Realize that hydrating a calf with a history of severe diarrhea will often times result in the diarrhea returning
When should fluid therapy be dc’ed?
- When hydration is accomplished
- Animal is capable of maintaining fluid balance
- Hours to days
- Switch from IV to oral
- Clinical response
