What is the recommended management for severe diarrhea?

Management of Severe Diarrhea

For severe diarrhea with signs of shock (≥10% dehydration, absent pulse, hypotension), immediately initiate intravenous rehydration with Ringer's lactate or normal saline at 20 mL/kg boluses until pulse, perfusion, and mental status normalize, then transition to oral rehydration solution (ORS) to complete fluid replacement. 1, 2

Immediate Assessment of Dehydration Severity

Rapidly evaluate for signs of severe dehydration including:

• Absent or weak peripheral pulse and decreased blood pressure (indicating shock requiring immediate IV access) 1, 3
• Altered mental status, cool extremities, prolonged capillary refill time 1, 2
• Dry mucous membranes, decreased skin turgor, rapid deep breathing 2
• Obtain accurate body weight to calculate fluid deficit (most reliable indicator) 2

Classify dehydration as:

• Mild: 3-5% fluid deficit 2
• Moderate: 6-9% fluid deficit 2
• Severe: ≥10% fluid deficit, shock, or pre-shock state 1, 2

Rehydration Protocol by Severity

Severe Dehydration (Medical Emergency)

• Administer 20 mL/kg IV boluses of Ringer's lactate or normal saline 1, 2
• May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 1
• Continue boluses until pulse, perfusion, and mental status return to normal 1
• Once consciousness normalizes, transition to oral rehydration to complete the remaining estimated deficit 1
• Critical pitfall: Avoid normal saline or 5% glucose solutions as sole therapy, as these worsen acidosis and can lead to cardiac overload and circulatory collapse 3

Moderate Dehydration

• Administer 100 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours 2, 4
• Reassess hydration status after 2-4 hours and continue therapy until clinical improvement 2

Mild Dehydration

• Administer 50 mL/kg of ORS over 2-4 hours 2, 4

Replacement of Ongoing Losses

Replace ongoing stool and vomit losses throughout treatment:

• 10 mL/kg of ORS for each watery or loose stool 1, 2
• 2 mL/kg of ORS for each vomiting episode 1, 2

Optimal ORS Composition

Use reduced-osmolarity ORS (245 mmol/L total osmolarity) containing:

• Sodium: 50-90 mEq/L 2, 4
• Glucose: 75-90 mmol/L 5, 6

This formulation is as effective as standard WHO-ORS but results in significantly lower vomiting volume and higher urine output 5

Managing Vomiting

If patient is vomiting:

• Administer small, frequent volumes initially (5 mL every minute) 1
• Use spoon or syringe with close supervision to guarantee gradual progression 1
• Simultaneous correction of dehydration often lessens vomiting frequency 1

Nutritional Management

Do not withhold food during rehydration:

• Breastfed infants: Continue nursing on demand throughout illness 1, 4
• Formula-fed infants: Resume full-strength, lactose-free or lactose-reduced formula immediately after rehydration 1
• Older children and adults: Resume regular diet with easily digestible foods (starches, cereals, yogurt, fruits, vegetables) 1, 2
• Avoid foods high in simple sugars and fats which may worsen osmotic diarrhea 1, 2

Antibiotic Considerations

Consider antibiotics when:

• Bloody diarrhea (dysentery) or high fever is present 1, 2
• Watery diarrhea persists >5 days 1, 2
• Stool cultures, microscopy, or epidemic setting indicate a treatable pathogen 1, 2

Otherwise, antibiotics are not routinely indicated for acute diarrhea 1, 7

Critical Medications to AVOID

Do NOT use loperamide or other antimotility agents in severe diarrhea because:

• Contraindicated in children <2 years due to respiratory depression and cardiac adverse reactions 8
• Can cause toxic megacolon, especially in infectious colitis 8
• Must be avoided when bloody diarrhea is present 8, 7
• Risk of QT prolongation, Torsades de Pointes, and sudden death at higher doses 8
• Should be discontinued immediately if constipation, abdominal distention, or ileus develops 8

Key Pitfalls to Avoid

• Do not delay rehydration while awaiting diagnostic results - start ORS immediately 2
• Do not use plain water, juice, or sports drinks - these lack appropriate sodium concentration 1
• Do not allow ad libitum drinking of large ORS volumes in thirsty patients, as this worsens vomiting 9
• Do not overlook medication-induced diarrhea - review all current medications including recent antibiotics 2
• In AIDS patients, stop loperamide at earliest signs of abdominal distention due to risk of toxic megacolon 8

Monitoring and Reassessment

• Reassess hydration status after 2-4 hours of rehydration 2, 4
• If patient remains dehydrated, reassess fluid deficit and restart rehydration 4
• Clinical improvement should be observed within 48 hours 8, 7
• If no improvement after 48 hours, discontinue current therapy and contact healthcare provider 8