Dehydration scale. Factors affecting the development of severe dehydration in children. Patients and Methods

Valery Viktorovich Vasiliev, Doctor of Medical Sciences, Professor, North-Western State Medical University. I. I. Mechnikov, St. Petersburg

In the comments to the publication of the respected Andrey Borisovich Taevsky "Insane Quality Project" * promised to give an example of the use of the "criteria for assessing the quality of medical care" proposed by the Ministry of Health in practice. I'm keeping my promise.

* The paper presents the results of the analysis of the draft order of the Ministry of Health "On the approval of criteria for assessing the quality of medical care" (hereinafter - the Draft), which cancels and replaces the order of the Ministry of Health of July 15, 2016 No. 520n "On the approval of criteria for assessing the quality of medical care" (hereinafter - Order 520n ).

I believe that other experts can find, to put it mildly, weaknesses in the ministerial project.

Preamble

I happened to participate in the creation of several clinical recommendations (hereinafter referred to as CR), which are now posted on the website of the Federal Electronic Medical Library. In our projects, we did not provide any “models of patients” and “criteria for the quality of medical care” (at least in my specialty), based on the fact that each patient is unique in his own way, and Western CDs do not contain such items. Some of the CR, located in the same place, are a combination of the CR itself and the standards of medical care, are huge in volume and are of little use in everyday life.

The problem with the orders of the Ministry of Health, which are trying to introduce the treatment and diagnostic process into the Procrustean bed of standards of medical care, in combination with the CR, is, in my (private) opinion, in the endless long-term persistent desire to harness “a horse and a quivering doe” into one team. Moreover, in inadequate terms, without taking into account (and, even, I’m not afraid of this expression, without knowledge) reality.

Below is mine personal opinion on the application of drafts of some "criteria ..." in practice.

They are real nowhere men

sitting in their nowhere land,

Making all their nowhere plans for nobody.

Doesn't have a point of view

Know not where they're going to…

(paraphrase of the famous composition by J. Lennon and P. McCartney)

The patient was delivered to the emergency department of the infectious diseases hospital on the 2nd day of illness with a diagnosis of acute gastroenterocolitis. Complaints of weakness, fever up to 39, aching paroxysmal pain mainly in the lower abdomen, nausea, mushy stools (about 10 times since the onset of the disease) in a decreasing volume, without pathological impurities. When viewed in the emergency department - no signs of dehydration, a clinic of acute enterocolitis of moderate severity, no signs of peritoneal irritation, lymphadenopathy, hepatolienal syndrome; hemodynamics is stable. Preliminary diagnosis: Acute gastroenterocolitis of moderate severity. Laboratory diagnostic methods were prescribed and carried out: general blood and urine tests, coprogram, cultures and stool PCR. Therapeutic treatment was prescribed in the specialized department: diet, intravenous infusion of crystalloids (1 liter), fluoroquinolone in an average therapeutic dose; inside, a glucose-salt mixture (up to 1.5 l / day), a polyenzymatic preparation (in the absence of vomiting).

In the morning - normalization of temperature, vomiting, no stool. In the blood - a small neutrophilic leukocytosis, ESR up to 20 mm per hour. IV fluoroquinolone was cancelled, administered orally, infusion therapy was cancelled. Further observation in the hospital - the temperature is normal, no vomiting, stool 1 time per day, semi-formed, without impurities. On the fourth day, the results of laboratory tests were obtained: bacterial cultures (three), PCR - negative. Clinically - practically healthy. On the sixth day - normocytosis in the blood, ESR = 15 mm per hour. Discharged on the 7th day with a diagnosis of acute gastroenterocolitis of unknown etiology (A09) of moderate severity.

Has the goal of hospitalization been achieved? Yes.

In time? Yes.

What claims??? Yes, the sea!

Analysis of paragraphs 3.1.5 “Quality criteria for specialized medical care for adults and children with intestinal infections (ICD-10 codes: A02.0; A02.2+; A02.8; A02.9; A03; A04; A05.0; A05.2; A05.3; A05.4; A05.8; A05.9; A08; A09)" in terms of formal compliance.

1. P. 1. - completed.

2. P. 2. - evaluation of the dehydration syndrome on the Clinical Dehydration Scale - not performed.

3. P. 3 - blood and urine analysis - completed.

4. P. 4. - hematocrit assessment - not performed.

5. P.p. 5, 6 - bacteriology of feces, PCR - performed

6. P. 7. - microscopy of feces - completed

7. P. 8. - oral rehydration - completed

8. P. 9. - calculation of the volume of infusion - not performed.

9. P. 10. - intestinal adsorbents - not fulfilled.

10. P. 11. - antimicrobial therapy - completed.

11. P.12. – normalization of the stool for discharge – completed.

Of the 12 points not met 4. What is the quality? That's right, "violations in the provision of medical care have been identified." Guilty! Punish! Collect!

Analysis of outstanding items from a practical point of view of an infectious disease specialist

P. 2. The patient has zero signs of dehydration, why formally apply CDS?

P.4. Why hematocrit (see just above)?

P.9. Why is an accurate calculation of the volume of infusion therapy needed? Fundamentally, in this case, an intravenous infusion in a volume of 1 liter. nothing did not decide, it was possible to do without it altogether. Moreover: in Acute gastroenterocolitis, it is not dehydration that has more important prognostic value, but the risk of infectious-toxic shock, in which the calculation of fluids is completely different.

P.10 - not important in the treatment of this patient, especially in the presence of vomiting.

In practice, "unfulfilled" items need to be implemented in certain situations that are not stipulated by either Order 520n or the Project under discussion. These situations should be spelled out in the KR, but they (KR) do not have the force of a regulatory legal act. The proposed criteria are poorly substantiated, to put it mildly. But the patients described in the example are the vast majority in the structure of the OCI!

Consider the "criteria" on some examples.

Clause 3.1.12 of the Project, “Quality criteria for specialized medical care for adults and children with tick-borne viral encephalitis (ICD-10 code: A84)”:

Point 5 is a clear evidence of the deep unprofessionalism of the creators of the Project: we are talking about tick-borne viral encephalitis, but it is proposed “... determination of the pathogen in the blood and cerebrospinal fluid bacteriological method with the definition susceptibility of the pathogen to antibiotics and other medicines…”!

CR for tick-borne viral encephalitis in adults (2014) in the performance criteria indicate: "liquor sanitation", but not "eradication" (as in the Project), because negative PCR, immunocytochemistry, etc. (blood, cerebrospinal fluid) not proof of eradication . Opisthorchiasis is even “more fun” (“Quality criteria for specialized medical care for adults and children with opisthorchiasis (ICD-10 code: B66.0)”, clause 3.1.13 of the Project):

A patient with opisthorchiasis is a planned patient! What is the significance of the first hour of examination after admission to the hospital for his health? That's right, none.

What is the significance of antibodies in the diagnosis of opisthorchiasis? That's right - more often zero (or overdiagnosis, especially in endemic areas). The acute phase of opisthorchiasis is rarely suspected (and diagnosed), while chronic ELISA is positive in just over 30% of cases. And if the medical organization does not have the necessary equipment, reagents, specialists to fulfill the “criteria” provided for by this paragraph of the Project (in the absence of a real clinical need)? It is offered to all to carry out IFA? Well done and received: blood ELISA "+", feces "-". What is the diagnosis?

If opisthorchis are found in the feces - why ultrasound? Train a specialist? And if they are not detected, will they be detected during an ultrasound scan? However, I once heard this from a clinical intern, a future gastroenterologist ...

Further. “Therapy was carried out with ... drugs (in the absence of medical contraindications).” There are no contraindications and testimony there is? For antispasmodics, for example? If anthelmintic drugs are contraindicated for the patient, what is the purpose of hospitalization? And according to what section is it supposed to evaluate the quality?

"The absence of opisthorchis eggs at discharge"? If only one of the authors of the Project opened a book! If a patient comes in whose doctor suspects opisthorchiasis, a positive ELISA is not a reason for his hospitalization and anthelmintic therapy. We need to find the eggs. If not, what are we going to treat? Antibodies? Follow the patient? And where then are the criteria "decrease in the amount of antibodies in the blood"?

Returning to the example given at the beginning of the publication. It occurred to some "smart" person to bring the codes according to ICD-10 A02.0 into one group; A02.2+; A02.8; A02.9; A03; A04; A05.0; A05.2; A05.3; A05.4; A05.8; A05.9; A08; A09. But nothing, what is it salmonellosis (including localized!), All escherichiosis, shigellosis, bacterial food poisoning? But nothing that the etiopathogenesis of these diseases is deeply different? But what about the fact that the diagnostic value of various research methods various in these diseases, based on the characteristics of pathogenesis and etiology? What about the fact that therapy for bacterial food poisoning is not therapy for gastrointestinal salmonellosis, for example?

Why are the criteria the way they are? When they were going to be introduced, my colleagues and I discussed this issue and came to the conclusion that in the absence of an evidence base for these criteria, the only thing that can save practitioners from voluntarism in assessing the quality of care is the inclusion in the criteria of those activities that have an application coefficient of 1 .0 or close to it in the standards of care. It turned out that we are not the only ones who are so "smart", and this "hung" in the projects. However, as we all remember, according to the standards of medical care, Ivanov, Petrov and Sidorov cannot be treated! Accordingly, it is inappropriate to evaluate the quality of care according to the standards of medical care ...

The idea of ​​the Ministry of Health is clear: to put into the hands of the "experts" of the supervisory service and insurance medical organizations a measure that is understandable to these experts, who, as a rule, are very far from real knowledge in the "expert" area. However, the extreme in this situation will be doctors working with the patient, even if the patient himself does not make claims to the quality of care (as in the above example). In a good way, the expert who evaluates the quality must himself have a certificate in this area and periodically undergo improvement. A.B. wrote about this earlier and much better. Taevsky.

In conclusion, I would like to say the following: haste is needed in certain situations, which obviously do not include the development of criteria for assessing the quality of medical care. If I were the Ministry of Health, I would send these projects to the chief specialists for a start and give time (not “answer tomorrow”) to develop sound recommendations and adopt them medical community (congresses, congresses on specialties) separately from accepted CGs (the CG structure recommended by GOST and the Ministry of Health is a separate topic for discussion).

Posted on the ExpertZdravService resource with the permission of the author.

For citation: Guarino A., Lo Vecchio A., Zakharova I.N., Sugyan N.G., Israilbekova I.B. Tactics of management of children with acute gastroenteritis at the prehospital stage: implementation of international recommendations in pediatric practice // BC. 2014. No. 21. S. 1483

Acute gastroenteritis (AGE) occupies an important place in the structure of pathology in childhood, yielding in frequency and economic damage only to acute respiratory diseases and influenza.

In 2008, the European Society of Pediatric Gastroenterologists, Hepatologists and Nutritionists (ESPGHAN), together with the European Society of Pediatric Infectious Diseases (ESPID), published guidelines for the management of children with OGE, including data on the epidemiology, etiology, diagnosis and treatment of this pathology. This guideline was updated in 2014 based on evidence-based evidence accumulated in recent years (Table 1).
Definition. OGE - liquefied (liquid or unformed) stools and / or an increase in the frequency of stools (more than 3 bowel movements in 24 hours), with or without fever or vomiting. However, a change in stool consistency is a clearer indicator of diarrhea than stool frequency, especially in the first months of a child's life. The duration of acute diarrhea should not exceed 7 days. It is possible to speak about the protracted course of gastroenteritis when the duration of diarrhea is more than 7, but less than 14 days.

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An important aspect of the etiological structure of acute intestinal infections in children is currently the change of dominant pathogens from bacterial to viral, among which the most significant is rotavirus infection. The Decree of the Chief State Sanitary Doctor of the Russian Federation G. G. Onishchenko dated March 19, 2010 No. 21 “On the Prevention of Acute Intestinal Infections” states: “The increase in recent years in the incidence of acute intestinal infections caused by established bacterial and viral pathogens in the Russian Federation is mainly due to rotavirus infection, the incidence rates of which for the period 1999-2009. grew almost 7 times. The share of this nosology in the structure of AEI increased from 1.4% to 7.0%. The most affected contingent in rotavirus infection are children under 14 years of age, accounting for about 90% in the structure of pathology. This fact causes a revision of the main therapeutic approaches for AII in children, in particular, the correction of dehydration syndrome.

Dehydration syndrome is the leading pathogenetic factor in acute intestinal infections in children, causing the severity of the disease. Therefore, the efficiency and correctness of assessing the degree of dehydration in a child with AII is of particular importance for practical healthcare. Basic research by N. V. Vorotyntseva, V. V. Maleev, V. I. Pokrovsky on the assessment of the severity of dehydration based on the assessment of acute loss of body weight of the patient remains relevant to the present: exsicosis I degree corresponds to a loss of up to 5% of body weight, which is up to 50 ml/kg of liquid, exsicosis II degree - loss of 6-10% of body weight (60-100 ml / kg), exsicosis III degree - loss of more than 10% of body weight (110-150 ml / kg). Dehydration with a loss of body weight of more than 20% is not compatible with life. However, in relation to pediatric practice, the determination of a child's body weight deficiency against the background of an illness is not always possible due to the intensive growth of children, therefore, the assessment of the degree of dehydration is carried out on the basis of clinical data. In this regard, the recommendations of the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) of 2014 are now widely used. However, they provide for a clinical assessment of only the appearance, the condition of the eyeballs and mucous membranes, as well as the presence of tears in the child. A more complete clinical scale by M. H. Gorelick additionally includes determining the time of capillary reperfusion (normally no more than 2 seconds), diuresis reduction, basic hemodynamic parameters (pulse rate and filling) and indicators of respiratory failure. There are other scales for the clinical assessment of the severity of dehydration. However, the significance of each of the symptoms of dehydration in clinical practice may not always be high enough, especially in grade I exicosis, which makes them most applicable to grade II exicosis (Table 1).

In acute intestinal infections in children, the isotonic type of dehydration predominates, characterized by a proportional loss of fluid and electrolytes, primarily sodium. At the same time, there is no change in the osmotic pressure of water in the intracellular and extracellular spaces, which makes it difficult to determine it by laboratory methods.

Objectification of the diagnosis of the severity of dehydration in children is possible using an algorithm that includes clinical (an increase in the time of capillary reperfusion, clinically determined dryness of the mucous membranes), anamnestic (severity of diarrhea and vomiting), instrumental (assessment of skin moisture) and laboratory (deficiency of buffer bases in blood serum ) data .

Also, one of the important aspects of pathogenesis, which is natural for AEI of any etiology, is the development of disorders of the microflora of the gastrointestinal tract (GIT). Previously, it was shown that with Sonne dysentery in 67.8-85.1% of patients, with salmonellosis - in 95.1%, yersiniosis - in 94.9%, rotavirus infection - in 37.2-62.8% of patients sides of the microflora of the gastrointestinal tract are pronounced.

Destabilization of the microbiocenosis of the gastrointestinal tract against the background of the course of the infectious process leads to a decrease in the colonization resistance of the microflora, an increase in the severity of inflammatory reactions from the intestinal mucosa and a decrease in the rate of reparative processes in the intestine, which leads to an aggravation of the intoxication syndrome due to the release of toxins not only of pathogenic pathogens, but also representatives conditionally pathogenic microflora (UPF), the proportion of which increases with AII.

The main pathogenetic aspects of acute intestinal infections also substantiate therapeutic approaches - rehydration and probiotic therapy, the duration of the disease and its outcomes depend on the timeliness and adequacy of the appointment.

With the development of dehydration, the main principle of managing such patients is the rapid replacement of fluid and salt losses, as well as an increase in the buffer capacity of the blood. It is generally accepted that oral rehydration should be preferred in pediatric practice, as it is less traumatic and more physiological for the child. The international practice of using oral rehydration for acute intestinal infections has been widely used since the 70s of the XX century, and its inclusion in the standards of patient management has reduced the number of hospitalizations by 50-60% and significantly, by 40-50%, reduced the mortality of children. However, the first recommendations that can be attributed to rehydration therapy, which include the appointment of rice water, coconut juice and carrot soup, date back more than 2500 years and belong to the ancient Indian physician Sushruta. In 1874 in France, Dr. Luton substantiated the appointment of additional water for the treatment of children with acute intestinal infections. For the first time, a solution, which included glucose, sodium and chlorine, was proposed by Dr. Robert A. Phillips, after the discovery of the mechanism of glucose potentiation of absorption of sodium and potassium ions in the intestine. In our country, in the 30-50s of the XX century, the development of methods for rehydration therapy of acute intestinal infections was carried out by M. S. Maslov (1928, 1945, 1955), V. I. Morev (1937), V. E. Balaban (1937). The basic principles of oral rehydration, the composition of solutions and methods for organizing care for patients with acute intestinal infections in our country were developed by the Central Research Institute of Epidemiology under the leadership of V. I. Pokrovsky.

The general therapeutic approach to oral rehydration involves the early administration of rehydration solutions and is carried out in two stages:

• Stage 1 - replenishment of losses that occurred before the moment of seeking medical help. The total amount of liquid is prescribed 50-80 ml / kg for 6 hours;
• Stage 2 - maintenance rehydration, the task of which is to replenish the current fluid losses during acute intestinal infections. 80-100 ml / kg of liquid is prescribed per day. The duration of the second stage of oral rehydration continues until the moment of recovery or the appearance of indications for parenteral correction of dehydration.

According to the current modern approaches, for oral rehydration, it is recommended to use ready-made solutions that are balanced in electrolyte composition and osmolarity (75 meq/l sodium and 75 meq/l glucose and an osmolarity of 245 mosm/l), while the osmolarity value of solutions recommended for pediatric application is given great importance.

At the dawn of the introduction of the method into routine clinical practice in 1970, the World Health Organization recommended formulations with a total osmolarity of 311 mmol/L for oral rehydration. Despite their effectiveness in correcting dehydration, the main drawback of these stock solutions was the lack of a positive effect on diarrheal syndrome. One of the achievements proposed in 2004 by WHO was to reduce the osmolarity of oral rehydration solutions to 245 mmol/l, and the concentration of sodium to 75 mmol/l and glucose to 75 mmol/l. The fundamental difference between hypoosmolar formulas for oral rehydration is that the previous solutions had higher osmolarity compared to blood plasma, which did not contribute to a decrease in the volume of feces during diarrhea and could lead to the development of hypernatremia. In 2001, Seokyung Hahn made a meta-analysis of 15 randomized clinical trials conducted around the world, which showed that the use of oral rehydration solutions with reduced osmolarity optimizes the absorption of water and electrolytes in the intestine to a greater extent than the use of hyperosmolar solutions, while no cases of clinically significant hyponatremia have been reported, with the exception of cases of cholera.

It has also been shown that this type of solution reduces the need for infusion therapy, reduces the severity of diarrheal syndrome and vomiting, and allows you to reduce the volume of solutions during oral rehydration, which is an important advantage for pediatrics.

It should be borne in mind that dehydration correction should be carried out using salt-free solutions, among which preference should be given to drinking water (not mineral!), It is possible to use pectin-containing broths (apple compote without sugar, carrot-rice broth). The ratio of glucose-salt solutions and drinking water should be 1:1 for watery diarrhea, 2:1 for severe vomiting, 1:2 for invasive diarrhea.

Severe forms of acute intestinal infections, lack of effect from oral rehydration or the presence of profuse vomiting, edema, the development of functional (acute) renal failure are indications for parenteral rehydration, which can be carried out using one of the modern domestic solutions - 1.5% solution of meglumine sodium succinate , which has proven its effectiveness in the intensive care of these conditions.

The pathogenetic substantiation of the need for the use of probiotic drugs in AEI is beyond doubt both in domestic and foreign literature. It is recommended to prescribe probiotic therapy as part of a complex initial therapy, regardless of the etiology of the disease and as early as possible. These drugs are also shown to all patients in the period of convalescence in order to restore the parameters of microbiocenosis. Their use in AEI in children is not only pathogenetically justified, but also refers to the highest level of evidence - A - in accordance with the principles of evidence-based medicine. This fact was confirmed in 2010 by the results of a meta-analysis that included the results of 63 randomized controlled clinical trials. It showed that the use of probiotics significantly reduced the duration of diarrhea by an average of 24.76 hours and reduced the frequency of stools, while these drugs have a high safety profile.

One of the pathogenetic mechanisms that allow probiotics to be recommended for AII is their positive effect on the mucin layer of the gastrointestinal mucosa. Against the background of the course of the infectious process, a change in the physical characteristics of this barrier is observed - a decrease in viscosity due to the destruction of disulfide bonds between the cysteine ​​bridges of the superstructure of this gel, which can lead to the translocation of microorganisms from the intestinal lumen to tissues. These processes develop under the action of pathogenic microorganisms that have the appropriate pathogenicity factors in the form of enzymes that destroy mucus (neuraminidase, hyaluronidase, mucinase). A long-term, including in the post-infection period, a change in the physical properties of the mucin layer leads to the risk of developing inflammatory bowel diseases. Microorganisms related to the components of the normal microflora of the human gastrointestinal tract, as well as the products of their metabolism, have a potentiating effect on the state of the mucin layer through a number of mechanisms, including genetic ones.

The modern view of probiotic therapy implies a strain-specific approach, which includes the establishment in clinical trials of therapeutic effects characteristic of certain genetically certified strains and their further use, taking into account the strain-specific properties of probiotics in various clinical situations.

In relation to acute intestinal infections in children, the ESPGHAN working group in 2014, based on an analysis of published systematic reviews and the results of randomized clinical trials, including placebo-controlled ones, published a memorandum in which they divided all probiotic strains into probiotics with a positive recommendation, with a negative recommendation and probiotics with insufficient evidence of their effectiveness. The recommended strains (despite the low level of evidence base according to experts) for the treatment of AII in children were Lactobacillus GG, Saccharomyces boulardii, Lactobacillus reuteri strain DSM 17938 (original strain ATCC 55730), as well as a thermally inactivated strain Lactobacillus acidophilus LB, which formally cannot be attributed to probiotics as living microorganisms with specified beneficial properties, but it has shown its effectiveness in acute infectious gastroenteritis.

Lactobacillus reuteri DSM 17938 is one of the most studied strains. This microorganism is authentic for the human body - it is found in human breast milk, lives in the human large intestine, is found in the oral cavity, stomach, small intestine, and vagina. In the human intestine Lactobacillus reuteri produces an antimicrobial substance - "reuterin", which inhibits growth Escherichia spp ., Salmonella spp ., Shigella spp ., Proteus spp ., Pseudomonas spp ., Clostridium spp . and Staphylococcus spp . , as well as some yeasts and viruses.

Strain Lactobacillus reuteri DSM 17938 is resistant to the following antimicrobials (possible co-administration of probiotics Lactobacillus reuteri Protectis with these agents): amoxicillin, ampicillin, Augmentin, dicloxacillin, oxacillin, penicillin G, phenoxymethylpenicillin, cefuroxime, cephalothin, vancomycin, doxycycline, tetracycline, fusidic acid, ciprofloxacin, enrofloxacin, nalidixic acid, metronidazole. Lactobacillus reuteri DSM 17938 are sensitive to cefotaxime, neomycin, streptomycin, clarithromycin, erythromycin, roxithromycin, clindamycin, chloramphenicol, rifampicin, imipenem, linezolid, virginiamycin.

Wherein Lactobacillus reuteri DSM 17938 has a good safety profile as confirmed by the Food and Agriculture Organization of the United Nations (FAO) and WHO in 2002.

Clinical Efficiency Lactobacillus reuteri DSM 17938 is indicated for functional colic in children of the first year of life, as part of complex eradication therapy H. pylori- infections, prevention of antibiotic-associated diarrhea, metabolic syndrome, in the treatment of allergic diseases. The effectiveness of this strain was confirmed in 163 clinical studies in 14,000 patients, of which 114 were randomized, double-blind or blind placebo-controlled studies, 47 were open studies, 56 studies were conducted among 7300 children 0-3 years of age.

However, the clinical effects of this strain in AII are the most well studied, which was the reason for its inclusion in the ESPGHAN recommendations. Thus, in a multicenter, randomized, single-blind clinical trial conducted among children hospitalized with acute gastroenteritis who received conventional therapy with or without 1 × 10 8 CFU Lactobacillus reuteri DSM 17938 for 5 days, it was shown that the administration of this probiotic strain reduced the duration of diarrhea after 24 and 48 hours (50% in the main group vs. 5% in the control group, p< 0,001) и 72 ч (69% против 11%, р < 0,001), позволяет уменьшить сроки госпитализации (4,31 ± 1,3 дня против 5,46 ± 1,77 дня, р < 0,001) и снизить вероятность развития затяжного характера диареи (17% в группе сравнения и ни одного пациента в основной группе) . Аналогичные данные были получены и в других исследованиях .

Given the above, we can conclude that at present in the Russian Federation the only low-osmolar glucose-salt rehydration solution containing Lactobacillus reuteri DSM 17938, is BioGaia ORS (Dietary Supplement). This solution has a therapeutic effect in two main pathogenetic directions - to correct both dehydration and microbiocenosis disorders in children with acute intestinal infections. It is important to emphasize that, in addition to glucose, salts and probiotics, BioGaia ORS contains zinc, which has a positive effect on water absorption, which also potentiates immunological defense processes and participates in regeneration processes.

In terms of composition and osmolarity, the combination of BioGay ORS salts complies with the recommendations of the European Society of Pediatrics, Gastroenterologists and Nutritionists, as well as WHO and UNICEF for oral rehydration with mild to moderate degrees of dehydration (Table 2).

The effectiveness of this combination is Lactobacillus reuteri DSM 17938 and oral rehydration solutions - was confirmed in a prospective placebo-controlled study, which showed an 84% reduction in the proportion of children with dehydration on the second day of taking this combination.

Thus, combination therapy with a probiotic and a low-osmolar oral rehydration solution (BioGaya ORS) in children without age restrictions is not only pathogenetically substantiated, which has proven its undoubted efficacy and safety in controlled clinical trials, but also the most promising direction in the treatment of acute diarrhea of ​​any etiology, significantly reducing polypharmacy.

Literature

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A. A. Ploskireva 1 , Candidate of Medical Sciences
A. V. Gorelov,Doctor of Medical Sciences, Professor, Corresponding Member of the Russian Academy of Sciences

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2017

Viral and other specified enteric infections (A08), Diarrhea and gastroenteritis of suspected infectious origin (A09), Other bacterial enteric infections (A04), Other salmonella infections (A02), Cholera (A00), Shigellosis (A03)

Infectious diseases in children, Pediatrics

general information

Short description

Approved
Joint Commission on the quality of medical services
Ministry of Health of the Republic of Kazakhstan
dated August 18, 2017
Protocol No. 26

bacterial intestinal infections is a group of human infectious diseases with an enteral (fecal-oral) mechanism of infection caused by pathogenic (Shigella, Salmonella, etc.) and opportunistic bacteria (Proteus, Klebsiella, Clostridia, etc.), characterized by a predominant lesion of the gastrointestinal tract and manifested by syndromes of intoxication and diarrhea.

INTRODUCTION

ICD-10 code(s):

Classification

Classification :

Diagnostics

METHODS, APPROACHES AND DIAGNOSIS PROCEDURES

Diagnostic criteria

Complaints:
· fever;
· nausea, vomiting;
lethargy;
· stomach ache;
loose stools 3 or more times a day;
flatulence.

WHO and ESPGHAN/ESPID criteria (2008, 2014):

Assessment of fluid deficiency in a child according to WHO:

Severity of dehydration as a percentage of the child's body weight before illness

ESPGHAN recommends using the Clinical Dehydration Scale (CDS), where 0 is no dehydration, 1 to 4 is mild dehydration, and 5 to 8 is severe dehydration.

Clinical Dehydration Scale (CDS):

Laboratory research :
KLA - leukocytosis, neutrophilia, accelerated ESR;
Coprogram: the presence of undigested fiber, mucus, leukocytes, erythrocytes, neutral fats;
bacteriological examination of vomit or washings of the stomach and feces, isolation of pathogenic / conditionally pathogenic flora.

Additional laboratory and instrumental studies:
b / x blood test: concentration of electrolytes in blood serum, urea, creatinine, residual nitrogen, total protein (with dehydration);
coagulogram (with DIC);
bacteriological examination of blood and urine - isolation of pathogenic / conditionally pathogenic flora;
· RPHA (RNHA) of blood with specific antigenic diagnosticums - an increase in antibody titers with a repeated reaction by 4 or more times.
· PCR - determination of DNA of intestinal infections of bacterial etiology.

Indications for expert advice:
· consultation of the surgeon - if you suspect appendicitis, intestinal obstruction, intestinal intussusception.

Diagnostic algorithm :

Differential Diagnosis

Differential diagnosis and rationale for additional studies:

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Treatment

Drugs (active substances) used in the treatment

Groups of drugs according to ATC used in the treatment

Treatment (ambulatory)

TACTICS OF TREATMENT AT THE OUTPATIENT LEVEL

At the outpatient level, children with mild and moderate forms (children older than 36 months) of AII of bacterial etiology receive treatment.
The principles of treatment of patients with acute intestinal infections include: regimen, rehydration, diet, means of pathogenetic and symptomatic therapy.
In case of ineffectiveness of outpatient treatment or its impossibility, the issue of hospitalization of the child in a specialized hospital is considered.

Non-drug treatment:
semi-bed mode (during the entire period of fever);
diet - depending on the age of the child, his eating habits and eating habits before the onset of the disease;
breastfed babies should be breastfed as often and for as long as they want;
continue to feed children who are bottle-fed with their usual diet;
children aged 6 months to 2 years - table number 16, from 2 years and older - table number 4;

Medical treatment
For the relief of hyperthermic syndrome over 38.5 0 С:
. paracetamol 10-15 mg/kg at intervals of at least 4 hours, no more than three days by mouth or per rectum or ibuprofen at a dose of 5-10 mg/kg no more than 3 times a day by mouth.

For diarrhea without dehydration - plan A:
· Breastfeed more frequently and increase the duration of each feed, if the baby is exclusively breastfed, give extra ORS or clean water in addition to breast milk.
· if the child is formula-fed or bottle-fed, give any combination of the following liquids: ORS solution, liquid food (eg soup, rice water) or clear water.
Explain to the mother how much fluid to give in addition to the usual intake:
Up to 2 years 50-100 ml after each liquid stool;
· 2 years and older 100-200 ml after each loose stool.
· Continue feeding;
· Advise the mother to immediately return the child to the hospital if any of the following signs appear:
cannot drink or breastfeed;
The child's condition is deteriorating
a fever developed
The child has blood in the stool or is not drinking well.

For diarrhea with moderate dehydration - plan B:
The volume of ORS required (in ml) can be calculated by multiplying the child's weight (in kg) by 75.
Drink the calculated volume of liquid for 4 hours.
· If the child is willing to drink the ORS solution and asks for more, you can give more than the recommended amount. Breastfeeding should continue as the child wishes. For formula-fed infants, food is canceled in the first 4 hours and oral rehydration is performed.
· After 4 hours, re-evaluate the child and determine the status of hydration: if 2 or more signs of moderate dehydration persist, continue Plan B for another 4 hours and give meals according to age.
In the absence of the effect of oral rehydration on an outpatient basis, the patient is referred for inpatient treatment.
· with the substitution purpose for the correction of exocrine pancreatic insufficiency pancreatin 1000 IU/kg/day during meals for 7-10 days.
For the purpose of etiotropic therapy of acute intestinal infections: azithromycin on the first day 10 mg/kg, from the second to the fifth day 5 mg/kg once a day inside;
Children over six years of age - ciprofloxacin 20 mg / kg / day in two divided doses for 5-7 days.

List of essential medicines:

Treatment (hospital)

TACTICS OF TREATMENT AT THE STATIONARY LEVEL
The basis of therapeutic measures for acute intestinal infections of bacterial etiology is therapy, including: regimen, rehydration, diet, means of etiotropic, pathogenetic and symptomatic therapy.

Oral rehydration is carried out in two stages:
Stage I - in the first 6 hours after the patient's admission, the water-salt deficiency that occurs before the start of treatment is eliminated;
With dehydration I st. the volume of liquid is 40-50 ml/kg, and in case of dehydration II stage - 80-90 ml/kg of body weight in 6 hours;
Stage II - maintenance oral rehydration, which is carried out throughout the subsequent period of the disease in the presence of ongoing fluid and electrolyte losses. The approximate volume of solution for maintenance rehydration is 80-100 ml/kg of body weight per day. The effectiveness of oral rehydration is evaluated by the following features: a decrease in the volume of fluid losses; reducing the rate of weight loss; disappearance of clinical signs of dehydration; normalization of diuresis; improving the general condition of the child.

Indications for parenteral rehydration and detoxification:
severe forms of dehydration with signs of hypovolemic shock;
Infectious-toxic shock;
neurotoxicosis;
severe forms of dehydration;
Combination of exicosis (of any degree) with severe intoxication;
uncontrollable vomiting;
failure of oral rehydration therapy within 8 hours in plan B or transition from moderate dehydration to severe dehydration.

The program of parenteral rehydration therapy on the first day is based on the calculation of the required amount of fluid and the determination of the qualitative composition of rehydration solutions. The required volume is calculated as follows:
Total volume (ml) \u003d FP + PP + D, where FP is the daily physiological need for water; PP - pathological losses (with vomiting, loose stools, perspiration); D - fluid deficiency that the child has before the start of infusion therapy.
The amount of fluid needed to compensate for the existing fluid deficit depends on the severity of dehydration and is tentatively determined based on the body weight deficit. With exicosis of the I degree, 30-50 ml / kg per day is required to compensate for the deficiency, with exicosis of the II degree - 60-90 ml / kg per day, and with dehydration of the III degree - 100-150 ml / kg per day. The volume of the existing deficit is corrected gradually, only with dehydration of the first degree is it possible to compensate for the deficit within one day. For a more accurate account of pathological losses, it is necessary to carefully record all external losses (vomiting, loose stools) by measuring or weighing them. Replenishment of current pathological losses is carried out with pronounced massive losses every 4-8 hours, with moderate losses - every 12 hours.
The choice of starting solution for infusion therapy is determined by the degree of hemodynamic disorders and the type of dehydration. Severe hemodynamic disorders in all types of dehydration are corrected with balanced isoosmolar saline solutions (physiological saline, Ringer's solution, etc.), and, if necessary, in combination with colloidal solutions. The basic principle of infusion therapy for dehydration syndrome is that the replacement of losses must be done with an infusion medium similar to that lost.
No low osmolarity solutions (5% dextrose solutions, low osmolarity polyionic solutions) should be used as a starting solution. In this regard, 5% dextrose solutions are the most dangerous. First, because of their hypoosmolarity; secondly, the utilization of glucose is accompanied by the formation of "free" water, which further enhances intracellular overhydration (danger of cerebral edema); thirdly, underoxidation of glucose under conditions of tissue hypoperfusion leads to even greater lactic acidosis.

Patient follow-up card, patient routing:

Non-drug treatment[ 1-4 ] :
. semi-bed mode (during the entire period of fever);
. diet - depending on the age of the child, his eating habits and eating habits before the onset of the disease;
. breastfed babies should be breastfed as often and for as long as they want;
. children who are bottle-fed, continue to feed their usual diet;
. children aged 6 months to 2 years - table number 16, from 2 years and older - table number 4;
. children with lactose intolerance are prescribed low/lactose-free formulas.

Medical treatment:
for the relief of hyperthermic syndrome over 38.5 ° C, the following is prescribed:
paracetamol 10-15 mg/kg at intervals of at least 4 hours, no more than three days by mouth or per rectum;
· or
ibuprofen at a dose of 5-10 mg / kg no more than 3 times a day by mouth;

For diarrhea without dehydration - plan A, with moderate dehydration - plan B.

For severe dehydration - plan B: IV fluids for the child<12 мес. 30 мл/кг в течение 1 часа, затем введите 70 мл/кг за 5 часов. Если ребенок ≥ 12 мес. в/в за 30 мин 30 мл/кг, затем 70 мл/кг за 2,5 часа. Повторяйте оценку через каждые 15-30 мин. Если статус гидратации не улучшается, увеличьте скорость капельного введения жидкостей. Также давайте растворы ОРС (около 5 мл/кг/ч) как только ребенок сможет пить: обычно через 3-4 ч (младенцы) или 1-2 ч (дети более старшего возраста). Повторно оцените состояние младенца через 6 ч, а ребенка старше одного года - через 3 ч. Определите степень обезвоживания. Затем выберите соответствующий план (А, Б или В) для продолжения лечения.

For the purpose of detoxification therapy, intravenous infusion at the rate of 30-50 ml / kg / day with the inclusion of solutions:
10% dextrose (10-15 ml/kg);
0.9% sodium chloride (10-15 ml/kg);
· Ringer (10-15 ml/kg).

With a replacement goal for the correction of exocrine pancreatic insufficiency, pancreatin 1000 IU / kg / day with meals for 7-10 days.
Antibacterial drugs are prescribed in age dosages, taking into account the etiology of AII. When choosing an antibacterial drug, the severity of the disease, the age of the child, the presence of concomitant pathology and complications are taken into account. If the temperature in a patient with confirmed AII does not decrease within 46-72 hours, alternative methods of antimicrobials should be considered.

Etiotropic antibiotic therapy[ 1-5 ] :

Azithromycin on the first day 10 mg/kg, from the second to the fifth day 5 mg/kg once a day orally;
children over six years of age ciprofloxacin 20-30 mg / kg / day in two divided doses for 5-7 days;
Ceftriaxone 50-75 mg/kg per day IM or IV, up to one gram - once a day, more than one gram - twice a day. The course of treatment is 5-7 days; or
Cefotaxime 50-100 mg/kg per day IM or IV, in two or three divided doses. The course of treatment is 5-7 days; or
Amikacin 10-15 mg/kg per day IM or IV in two divided doses. The course of treatment is 5-7 days; or
Cefuroxime 50-100 mg/kg per day IM or IV in two or three divided doses. The course of treatment is 5-7 days.

List of Essential Medicines[1- 5 ,11-18 ]:

Hospitalization

INDICATIONS FOR HOSPITALIZATION WITH INDICATING THE TYPE OF HOSPITALIZATION

Indications for planned hospitalization: No

Indications for emergency hospitalization:
Children with severe and moderate forms (up to 36 months) of viral gastroenteritis;
All forms of the disease in children under the age of two months;
forms of the disease with severe dehydration, regardless of the age of the child;
prolonged diarrhea with dehydration of any degree;
Chronic forms of dysentery (with exacerbation);
burdened premorbid background (prematurity, chronic diseases, etc.);
fever > 38°C for children<3 месяцев или>390 C for children from 3 to 36 months;
pronounced diarrheal syndrome (frequent and significant stools);
persistent (repeated) vomiting;
Lack of effect from oral rehydration;
Lack of effect of outpatient treatment within 48 hours;
Clinical symptom complex of a severe infectious disease with hemodynamic disorder, insufficiency of organ function;
· epidemiological indications (children from “closed” institutions with round-the-clock stay, from large families, etc.);
cases of disease in medical organizations, boarding schools, orphanages, orphanages, sanatoriums, nursing homes for the elderly and disabled, summer health organizations, rest homes;
Inability to provide adequate care at home (social problems).

Information

Sources and literature

1. Minutes of the meetings of the Joint Commission on the quality of medical services of the Ministry of Health of the Republic of Kazakhstan, 2017
   1. 1) Roberg M. Kliegman, Bonita F. Stanton, Joseph W. St. Geme, Nina F. Schoor/ Nelson Textbook of Pediatrics. Twentieth edition. International Edition.// Elsevier-2016, vol. 2nd. 2) Uchaikin V.F., Nisevich N.I., Shamshieva O.V. Infectious diseases in children: textbook - Moscow, GEOTAR-Media, 2011 - 688 p. 3) Treatment of diarrhea. Training manual for doctors and other senior health workers: World Health Organization, 2006. 4) Providing hospital care for children (WHO guidelines on the management of the most common diseases in primary hospitals, adapted to the conditions of the Republic of Kazakhstan) 2016. 450 p. Europe. 5) Farthing M., Salam M., Lindberg G. et al. Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organization, 2012 // www.worldgastroenterology.org/ 6) World Gastroenterology Organization (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology Organization (WGO); 2008 Mar.28p. 7) Implementation of new guidelines for the clinical management of diarrhea. Guide for decision makers and program managers. WHO, 2012.//www.euro.who.int/__data/assets/pdf_file/0007/.../9244594218R.pdf. 8) National Collaborating Center for Women's and Children's Health. Diarrhoea and vomiting in children. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Apr 9) Centers for Disease Control and Prevention. Salmonella Senftenberg Infections, Serbia. Emerging Infectious Diseases 2010; 16(5): 893-894. 10) Majowicz SE, Musto J, Scallan E, Angulo FJ, Kirk M, O'Brien SJ, et al.; International Collaboration on Enteric Disease ‘Burden of Illness’ Studies. The global burden of nontyphoidal Salmonella gastroenteritis. Clin Infect Dis. 2010;50:882–9. http://dx.doi.org/ 10.1086/650733 11) Petrovska L, Mather AE, AbuOun M, Branchu P, Harris SR, Connor T, et al. Microevolution of monophasic Salmonella Typhimurium during epidemic, United Kingdom, 2005–2010. Emerge Infect Dis. 2016;22:617–24. http://dx.doi.org/10.3201/eid2204.150531 12) Samuel J. Bloomfield, Jackie Benschop, Patrick J. Biggs, Jonathan C. Marshall, David T.S. Hayman, Philip E. Carter, Anne C. Midwinter, Alison E. Mather, Nigel P. FrenchLu J, Sun L, Fang L, Yang F, Mo Y, Lao J, et al. Genomic Analysis of Salmonella enterica Serovar Typhimurium DT160 Associated with a 14-Year Outbreak, New Zealand, 1998–2012 Emerging Infectious Diseases www.cdc.gov/eid Vol. 23, no. 6, June 2017 13) G. Gigante, G. Caracciolo, M. Campanale, V. Cesario, G. Gasbarrini, G. Cammarota, A. Gasbarrini Ospedale Gemelli, Rome, Italy; Fondazione Italiana Ricerca in Medicina, Rome, Italy Gelatine Tannate reduces antibiotics associated side-effects of anti-helicobacter pylori first-line therapy Copyright© 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 14) Gelatin tannate for treating acute gastroenteritis: a systematic review Center for Reviews and Dissemination Original Author(s): Ruszczynski M , Urbanska M and Szajewska H Annals of Gastroenterology, 2014, 27(2), 121-124 15) Esteban Carretero J , Durbán Reguera F, López-Argüeta Ál - varez S, López Montes J. A comparative analysis of response to ORS (oral rehydration solution) vs. ORS + gelatin tannate in two cohorts of pediatric patients with acute diarrhea. Rev Esp Enferm Dig 2009; 101:41-49. 16) Big reference book of medicines / ed. L. E. Ziganshina, V. K. Lepakhina, V. I. Petrov, R. U. Khabriev. - M.: GEOTAR-Media, 2011. - 3344 p. 17) BNF for children 2014-2015 18) Order of the Minister of National Economy of the Republic of Kazakhstan dated March 12, 2015 No. 194. Registered with the Ministry of Justice of the Republic of Kazakhstan on April 16, 2015 No. 10741 About approval of the Sanitary Rules "Sanitary and epidemiological requirements for the organization and implementation of sanitary - anti-epidemic (preventive) measures to prevent infectious diseases"

Information

ORGANIZATIONAL ASPECTS OF THE PROTOCOL

List of protocol developers:
1) Efendiyev Imdat Musa oglu - Candidate of Medical Sciences, Head of the Department of Children's Infectious Diseases and Phthisiology, RSE on REM "State Medical University of Semey".
2) Baesheva Dinagul Ayapbekovna - Doctor of Medical Sciences, Associate Professor, Head of the Department of Children's Infectious Diseases, JSC "Astana Medical University".
3) Kuttykuzhanova Galia Gabdullaevna - Doctor of Medical Sciences, Professor, Professor of the Department of Children's Infectious Diseases, RSE on REM "Kazakh National Medical University named after. S.D. Asfendiyarov.
4) Devdariani Khatuna Georgievna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, RSE on REM "Karaganda State Medical University".
5) Zhumagalieva Galina Dautovna - Candidate of Medical Sciences, Associate Professor, Head of the Course of Children's Infections, RSE on REM "West Kazakhstan State University named after I.I. Marat Ospanov.
6) Mazhitov Talgat Mansurovich - Doctor of Medical Sciences, Professor, Professor of the Department of Clinical Pharmacology, JSC "Astana Medical University".
7) Umesheva Kumuskul Abdullaevna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, RSE on REM "Kazakh National Medical University named after. S.D. Asfendiyarov".
8) Alshynbekova Gulsharbat Kanagatovna - Candidate of Medical Sciences, Acting Professor of the Department of Children's Infectious Diseases, RSE on REM "Karaganda State Medical University".

Indication of no conflict of interest: No .

Reviewers:
1) Kosherova Bakhyt Nurgalievna - Doctor of Medical Sciences, Professor of the RSE on REM "Karaganda State Medical University", Vice-Rector for Clinical Work and Continuous Professional Development, Professor of the Department of Infectious Diseases.

Indication of the conditions for revising the protocol: revision of the protocol 5 years after its publication and from the date of its entry into force or in the presence of new methods with a level of evidence.

Attached files

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