Intestinal ecstasy in children

Intestinal exicosis is one of the most frequently occurring emergency conditions, caused by the action of heat-labile enterotoxin of gram-negative bacteria and some viruses on enterocytes. The pathogenesis of intestinal exicosis is based on the loss of fluid and electrolytes, as well as buffer bases with diarrheal masses, which leads to the development of dehydration, metabolic acidosis, disorders of central and peripheral circulation and oxygen-transport function of blood.

There are three degrees of exicosis (from 5 to 10-12% of acute weight loss) and three types: isotonic, hypertonic and hypotonic exicosis. A feature of early childhood (children under 5 years of age with ACI) is the development of only the isotonic form of dehydration, which is associated with hyperaldosteronism and low sodium content in diarrheal masses. Depending on the volume of fluid loss with stool and the type of ACI, a child loses from 60 to 80 mmol / l of sodium, while an adult patient loses 140-145 mmol / l. But, unlike adults, a child loses twice as much potassium with diarrheal masses (25 mmol / l). For this reason, with the isotonic form of exicosis and normal sodium content in plasma, young children always have relative (with exicosis of grade II) or absolute (with exicosis of grade III) hypokalemia. These features are important to take into account during infusion rehydration therapy.

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Pathogenetic intensive therapy of intestinal exsicosis of II and III degree

The main requirements for pathogenetic, intensive therapy of a patient with intestinal exicosis of II-III degree:

• replacement of lost salts and fluids,
• increase in the buffer capacity of the blood,
• reduction of pathological losses with the help of enterosorbents.

Pathological losses are the result of three components: fluid deficit, physiological needs of a specific patient and ongoing pathological losses (vomit and feces), the volume of which is determined gravimetrically. For correction, the following solution is used: sodium - 78 mmol/l, potassium - 26 mmol/l, chlorine - 61 mmol/l, sodium bicarbonate - 11.8 mmol/l, sodium acetate - 31.6 mmol/l, water - 1 l.

Isotonic solution with pH 7.4. Of the total volume of liquid calculated for the day, the child is able to absorb 25-30% enterally even on the first day. The fluid deficit is compensated for fairly quickly, in about 6 hours, if the patient's condition allows. In the first two hours, 50% of the lost liquid is administered at a rate of 40-50 drops per minute, the second half - in 4 hours. After covering the deficit, the liquid is administered at a rate of 10-14 drops per minute to cover physiological needs and pathological losses. The infusion rate at this stage depends on the volume of pathological losses.

Pathological losses:

• severe diarrhea - losses up to 3 ml/(kg h),
• severe diarrhea - from 3 to 5 ml/(kg h),
• cholera-like, profuse diarrhea - more than 5 ml/(kg h).

Rehydration, corrective therapy usually lasts on average two days. The criteria for its effectiveness are:

• weight gain of 3-7% in the first day,
• normalization of plasma electrolyte concentrations and reduction of metabolic acidosis,
• positive CVP,
• decrease in body temperature, increase in diuresis, cessation (decrease) of vomiting, improvement in the general condition of the child.

In parallel, etiotropic and symptomatic therapy is carried out, which includes:

• antibacterial agents from the aminoglycoside or cephalosporin group, starting with the third generation (parenterally and orally), in cases of bacterial or mixed acute intestinal infections and enterosorbents (smecta, neosmectin, enterosgel, etc.),
• diet - fractional meals according to age without water and tea breaks,
• dosed intake of liquid (in case of repeated vomiting, first wash out the stomach),
• probiotics, biopreparations and enzyme preparations (as indicated) during the convalescence period.

The prognosis for children with intestinal exicosis is favorable, and the duration of intensive treatment in acute cases does not exceed 2-3 days.

Symptoms of intestinal exsicosis

The most characteristic signs of intestinal exsiccosis:

• sunken anterior fontanelle,
• symptom of "standing" fold,
• decreased diuresis,
• dry skin and mucous membranes,
• cold extremities,
• dyspnea,
• hypocapnia,
• zero or negative CVP,
• subcompensated or decompensated metabolic acidosis.

Signs of dehydration in the second and third degree of exsicosis

Symptoms and laboratory data	Degree of exsicosis and fluid deficit, %
II (5-9%)		III (10% and more)
1	2	3
Symptom of "standing fold"	The fold is straightened out in 2 seconds	The fold straightens out in more than 2 seconds
Large fontanelle	It sinks in	It falls sharply
Chair	Losses 2.7-3.9 ml/(kg x hour)	Losses more than 4 ml/(kg x hour)
Vomit	1-3 times a day	More than 3 times a day
Eye symptoms	"Shadows" under the eyes, sunken eyes	Eyes are sharply sunken, eyelids do not close completely
Mucous membranes	Dryish, hyperemic	Dry, bright, no tears
CVP	Zero or negative	Negative
PH	7.26+0 016	7 16+0.02
VE	-13.6+1.2	-17.5+1.3
PCO2, mm Hg	28.2+2.9	23.3+1.7
Na+, mmol/l	137-141	135-138
K+, mmol/l	3.5-4.0	3.1-3.3
Hematocrit	36-38	38-40

A body weight deficit of up to 5% corresponds to grade I exicosis, 6-9% to grade II exicosis, and 10% or more to grade III exicosis.

The reliability of the diagnosed degree of exicosis can be controlled by a retrospective assessment of the increase in the patient's body weight in percentage 2-3 days after corrective therapy, provided that the concentration of the main electrolytes in the plasma, the acid-base balance indicators are normalized, and the symptoms of exicosis are eliminated. A 3-5% increase in body weight corresponds to exicosis of degree II, and 5-9% to exicosis of degree III.