Causes of exicosis and why dehydration is dangerous for a child. Intensive care of exsicosis in children

Description:

Exicosis (from lat. siccus-dry), drying, dehydration, stalemate. a condition arising from the acute loss of significant amounts of water and salts by the body, depletion of the body's water depots and, in cases of impaired ability of cells and tissues to bind water. The term "exsicosis" is especially widely used in the pediatric literature in connection with the value of E. in the occurrence of symptoms of a toxic symptom complex in infants.

Symptoms:

Salt-deficiency dehydration exsicosis (hypotonic): the child sluggishly refuses water and food, after drinking it is often observed, which is frequent at first, then it may stop. The skin is cyanotic with an earthy tint, muscle tone is reduced. Large fontanel sunken eyeballs soft, sunken. Characteristic low temperature, reduced arterial pressure, oliguria or. With the progression of exsicosis, the patient may fall into soporous, and then into coma. Simultaneously appear atony and paresis of the intestine, high standing diaphragm, gases are not released, vomiting becomes more frequent. Breathing is shallow, may be tonic or tonic-clonic, there are no symptoms of meningism.

Water-deficient dehydration exsicosis (hypertonic) proceeds rapidly. The child is excited, restless, the body temperature is elevated, the pulse is frequent, there is a tendency to muscle hypertonicity, sleep disturbance, neck muscle tension, convulsions. The child willingly and drinks a lot, but sweat, saliva and urination are reduced.
exsicosis is the most common. The child is lethargic, adynamic. Characterized by food refusal frequent vomiting. The skin is pale, cold to the touch, dry, skin elasticity and turgor are reduced. Mucous membranes dry, lose their luster: Tongue covered with white coating. Heart sounds are muffled, blood pressure is normal or low.

Clinically, there are 3 degrees of exsicosis.

I degree - fluid loss up to 5% of body weight;

II degree - fluid loss up to 10% of body weight, there are changes in the cardiovascular system;

III degree - loss of fluid more than 10% of body weight, severe condition, hypovolemic shock, severe violations hemodynamics.

Fluid loss of more than 20% of body weight is usually incompatible with life. If the child is not provided with timely assistance, a fatal outcome is possible.

Causes of occurrence:

Exsicosis syndrome usually develops against the background of acute gastrointestinal diseases, acute respiratory infections, staphylococcal infection, etc. Exsicosis syndrome is characterized by a deficiency of water and electrolytes in the body, a child, resulting from repeated persistent vomiting and (or) frequent liquid stool. Water loss can occur through the lungs, kidneys, and skin. Dehydration exsicosis develops within 2-3 days. Depending on the predominance of loss of water or electrolytes, dehydration is distinguished as salt-deficient (the loss of electrolytes predominates), water-deficient (the loss of water predominates), isotonic (the loss of water and electrolytes is proportional.

Treatment:

For treatment appoint:

Rehydration therapy is carried out depending on the degree of exicosis and dehydration. At the I degree, the patient is given to drink (50-100 ml per 1 kg of body weight) a glucose-salt solution (rehydron, oralit, etc.). The standard glucose-saline solution contains: sodium chloride 3.5 g, sodium bicarbonate 2.5 g, potassium chloride 1.5 g, glucose 20 g, boiled water 1 l. With the normalization of the state, vomiting stops, blood pressure and diuresis stabilize.

Grade 1 - deficiency of 5% 50-80 ml / kg

Grade 2 - deficiency 6-8% 100 ml / kg

IIstage- supportive therapy.

On average, the volume of fluid administered at this stage is 80-100 ml/kg per day.

The duration of rehydration is until the fluid loss stops.

The liquid is given in fractions of 1-2 tsp. every 5-10 minutes. In the presence of one or two vomiting, rehydration does not stop, but is interrupted for 5-10 minutes and then continues again.

Determination of the optimal composition of the liquid.

With loss of fluid mainly with vomiting - 1: 2;

With water-deficient exicosis, the optimal ratio is 1: 2.

The introduction of salt and salt-free solutions alternates, they do not mix.

The OP should not stop at night, during the child's sleep. If you refuse to drink, OR can be carried out using a dropper through a gastric tube or nipple.

Infusion therapy (IT).

IT with exicosis of 2-3 degrees is carried out exclusively in stationary conditions.

Calculation of the required volume of liquid on the first day:

Total volume (ml) is equal to FP+PP+D, where

FP - daily physiological need for water;

PP - pathological losses (with vomiting, loose stools, perspiration);

D-fluid deficiency with which the child enters the hospital.

Physiological need for water:

For children weighing up to 10 kg -4 ml / kg per hour or 100 ml / kg per day;

2ml/kg per hour for every kg over body weight 10kg or +50ml/kg per day;

1ml/kg for every kg over body weight 20kg or +20ml/kg per day.

Calculation of pathological losses:

Unspecified losses with stool and vomiting - 20 ml / kg per day.

For every 10 breaths above the age norm - 10 ml / kg per day.

For every degree above 37C -10 ml / kg per day.

Calculation of the need for fluid per day according to Dennis per 1 kg / mass

The method of administering the fluid depends on the severity of the child's condition. Not the entire calculated volume of daily fluid requirements is administered parenterally, the rest of the fluid is given per os.

In case of I degree of exsicosis, oral rehydration is used and, if necessary, infusion therapy in a volume of not more than 1/3 from the patient's daily fluid requirements. The need for IT arises if it is not possible to drink the child, and signs of toxicosis with exsicosis increase.

At the II degree of exsicosis, IT is indicated in the amount of not more than 1/2 from the patient's daily fluid requirements. The amount of liquid missing to the daily requirements is given per os.

At the III degree of exsicosis, IT is indicated in the amount of not more than 2/3 from the patient's daily fluid requirements.

The ratio of aqueous and colloid-saline solutions used for IT, depending on the type of exsicosis.

Colloidal solutions (albumin, rheopolyglucin, rheomacrodex) for all types of dehydration of any severity should not exceed 1/3 of the calculated amount of infusion fluid and should be administered after replenishing the BCC at the rate of 10-20 ml / kg.

A 5% glucose solution is used as an aqueous solution for hypertonic and isotonic dehydration, and 10% glucose solution for hypotonic dehydration. Its use requires the addition of insulin at the rate of 1 unit per 50 ml of 10% glucose.

Crystalloids, saline solutions - Ringer's solution, disol, trisol, lactosalt, saline solution. For children in the first months of life, saline solutions are administered in a volume of no more than 1/3 of the IT volume.

Solutions-correctors (electrolyte supplements) are introduced taking into account the physiological daily requirement to compensate for the identified deficiency of K + .

Correction of hypokalemia can be carried out taking into account the physiological need of the body for potassium under the control of the ionogram and ECG. For intravenous drip, a 1% solution of potassium chloride is used. A 7.5% solution of KC1 must be diluted approximately 8 times (no more than 13 ml of a 7.5% solution of KC1 is added to 100 ml of glucose). Potassium preparations are contraindicated in anuria and bradycardia. Enter with a solution of glucose in the middle and last portions. The rate of administration should be no more than 30 drops / min, i.e. no more than 0.5 mmol/kg per hour. The need for K +: up to 3 years - 2-3 mmol / kg per day; from 3 years old - 1.5 mmol / kg per day. 1 ml of a 7.5% solution of KC1 contains 1 mmol of K + and Ca +2.

The need for Ca+ is 0.5 mmol/kg per day. In practice, a 10% solution of CaCl is used, 1 ml of which contains 1 mmol of Ca +, or a 10% solution of Ca + gluconate, 1 ml of which contains 0.25 mmol of Ca +. Gluconate Ca + can be administered intravenously, intramuscularly, Ca + chloride - only intravenously (!).

Magnesium requirements are 0.1-0.2 mmol/kg per day. A 25% solution of magnesium sulfate is used, 1 ml of which contains 1 mmol of magnesium.

The rate of administration of solutions can be calculated using the following formula:

1 cap/min= IT volume: 3 × time (in hours).

Transfusion time in hours:

t=IT volume:3×number of drops/min

IT control

1. Weighing the child 2 to 4 times a day. Adequate is considered to be an increase in body weight with IT by 7-9% in 24 hours or up to 50 g per day.

2. CVP. Normally, in newborns - 2-4 cm of the water column, up to 3 years - 3.5-4.5; older than 3 years - 5.5-6.5. The optimal CVP is equal to 8 cm of water column. With an increase in CVP to 13 and above, the development of pulmonary edema is possible.

3. Dynamics of hematocrit.

4. Biochemical indicators of blood.

5. Measurement of hourly diuresis.

6. Measurement of the relative density of urine.

Various drugs can be added to infusion media (cardiac glycosides, aminofillin, heparin, vitamins, cocarboxylase, etc.). With the development of infectious-toxic and / or hypovolemic shock, glucocorticoids are administered at the rate of 5-10 mg / kg per day according to prednisolone.

Hospitalization of children infectious diarrhea with 1-2 degrees of dehydration to the infectious department, with exicosis of 3 degrees - to the intensive care unit of the infectious diseases hospital after emergency care. Ambulatory treatment it is possible (in the absence of other contraindications) with exsicosis of the 1st degree with oral rehydration.

Rehydration therapy underlies the pathogenetic essence of acute intestinal infections and is aimed at restoring the loss of water pi electrolytes.

Rehydration therapy underlies the pathogenetic essence of acute intestinal infections and is aimed at restoring the loss of water pi electrolytes. In patients with toxicosis I and II degree, in the absence of indomitable vomiting and severe anorexia, the method of oral administration of liquid is used for rehydration therapy. Ease of use, low cost of drugs, convenience for patients and medical staff make this method the best way treatment of patients with mild and moderate forms of the disease. Solutions for oral rehydration (Oralit, Orezol, Orazol, Chlorazol, Litrozol, Tlyukosolan, Regidron, etc.) consist of 3.5 g of sodium chloride, 2.5 g of potassium chloride , 2.9 g of sodium citrate and 10 g of glucose, dissolved in 1 liter of freshly boiled water. III generation for rehydration, which also contain nutrients (super-ORS, etc.). Oral rehydration is carried out in two stages.

The first stage is aimed at restoring the deficit of salts and water that existed before the start of treatment. It lasts 4-6 hours. Approximately the volume of glucose-salt solutions at the first stage of rehydration is 200-400 ml for mild and moderate forms of the disease in children weighing up to 6 kg, 400-600 ml up to 9 kg, 400-600 ml up to 12 kg. 600-800ml. During oral rehydration, the liquid is administered in small doses (10-20 ml) every 10-15 minutes.

The second stage of treatment - rehydration is carried out in order to compensate for the loss of fluid and electrolytes with stool, vomiting, perspiration. It is necessary to measure these losses every 6 hours and make a correction to the ongoing therapy. Approximately for maintenance therapy with mild degree exicosis requires 50 ml of solution / kg of body weight of the child, with a moderate degree - 100 ml of solution / kg of body weight.

With insufficient consideration of the loss of water and electrolytes, especially sodium, against the background of rehydration therapy, tissue pastosity may develop, diuresis may decrease. In order to avoid these complications (especially in children with concomitant pneumonia, neurotoxicosis, with severe colitis), it is advisable to replace half of the injected liquid with fruit decoction (apple, raisin), sweetened with tea with lemon juice.

In case of acute intestinal infections occurring with toxicosis II-III degree and accompanied by vomiting, anorexia, refusal to drink, resort to parenteral rehydration. At the beginning of therapy, it is necessary to calculate the daily volume of fluid to be administered. It consists of the volume of acute weight loss on the eve of illness, daily requirement in water and electrolytes, ongoing pathological losses. If the body weight before the disease is unknown, then the degree of dehydration is determined by clinical signs (Table 2).

table 2 Clinical assessment severity of exsicosis in children

In this case, the loss of body weight is taken as 10%. The daily requirement for fluid and electrolytes is determined using the Aberdeen nomogram. Current pathological losses are taken into account either by weighing dry and used diapers, determining the volume of vomit, or using calculations proposed by E.Yu. Veltischev, according to which the volume of infusions is increased by 10 ml/kg of body weight for each degree of elevated temperature, by 20 ml/kg of body weight - with vomiting, by 20-40 ml/kg of body weight - with intestinal paresis, by 25-75 ml/ kg of body weight - for losses with a chair.

From the resulting volume, subtract the volume of food eaten and the solution required for oral rehydration. Intravenous fluid should not exceed 70-80%, and in the presence of pneumonia - 50% of the total necessary solutions. The liquid is administered in a state warmed up to 37 ° C through a disposable intravenous drip system. Completely refrain from oral administration nutrients not recommended, as it helps to restore the epithelium of the intestinal mucosa and maintain the motor-enzymatic function at the proper level gastrointestinal tract.

Table 3 Approximate calculation of liquid according to Denis (according to the degree of exicosis)

In the following days, when calculating rehydration therapy, the remaining unfilled body weight deficit, daily fluid requirement and current pathological losses are taken into account. Replenishment of body weight deficit is carried out gradually - 2-3% per day. It is desirable to inject the calculated volume of liquid into the central veins during the day. If it is impossible to master the central vein, the liquid is injected into the peripheral veins within 4-8 hours, repeating the infusion if necessary after 12 hours. Accordingly, the patient receives intravenously that part of the calculated daily volume of fluid that falls on this period of time (1/4 of the daily volume for 6 hours, 1/3 for 8 hours, etc.). The remaining volume of liquid is administered through the mouth.

When conducting parenteral rehydration, it is necessary to take into account the anatomical and physiological characteristics of infants - their filtration by the kidneys is 5 times less than that of an adult. As a result, during dehydration in infants, conditions are created for the development of hypernatremia, due to the restriction of glomerular filtration of sodium ions, as a protective reaction to hypovolemia.

The resorption of sodium ions from the cells is faster than the resorption of potassium ions.
A tendency to hyperosmia develops in the "first hours of toxicosis, when sympathicotonia (stress reaction) is expressed. This phase is accompanied by thickening of the blood; loss of oxygen by tissues; hyperglycemia; ketonemia; hypernatremia; an increase in the content of urea, amino acids; limiting the ability to release sodium ions into the intestine.

Thus, infusion fluid for rehydration in acute stage toxicosis should contain a limited amount of sodium ions (no more than 3-7 mmol / kg of body weight per day). Therefore, in initial stage intestinal toxicosis, infusion mixtures are used with a predominance of glucose over saline and colloidal solutions and are used in a ratio of 3:1:1, and in children of the first six months of life - 4:1:1. In subsequent periods, the composition of the infusate is corrected, taking into account the reaction of the body and the results of additional research methods.

Damage to the cell due to the action of toxins in acute intestinal infections (hypoxia, acidosis) is accompanied by a violation of the function of the potassium-sodium pump, which leads to the movement of potassium ions from the cell, and sodium ions into the cell. Despite developing hyperkalemia and oliguria, potassium losses increase. It is necessary to take into account the large need for potassium in infants due to intensive growth. Therefore, potassium is a mandatory component in infusion therapy.

Before introducing potassium into the infusate, it is necessary to achieve a satisfactory diuresis and then inject it after 1.5-2 hours at the rate of 0.1-0.4 g of dry matter / kg of body weight. Potassium preparations (mainly potassium chloride) are administered intravenously in a 10% glucose solution with insulin. The concentration of potassium chloride in the infusate should not exceed 0.3-0.5%. With ongoing diarrhea, potassium chloride is administered at the rate of 1-6 mmol/kg body weight per day. Most often, a 7.5% solution of potassium chloride is used. It should be remembered that glucocorticoids, GHB, seduxen, chlorpromazine, insulin, diuretics, nystatin, repeated vomiting, frequent gastric lavages contribute to the excretion of potassium from the body. The presence of anuria and severe oliguria is a contraindication for intravenous administration potassium. Intracellular potassium deficiency recovers slowly (up to 2-3 weeks), so it must be administered after the abolition of infusions in the form of potassium orotate, panangin, asparkam. The correctness of rehydration therapy is controlled by the child's condition, body weight dynamics, diuresis, urine specific gravity, blood rheological properties, assessment of blood viscosity factors (BP, hematocrit, proteinogram, ionogram, immunoglobulin concentration). In children early age preference should be given to electro-coagulography (coagulograph H-333), and not to biochemical coagulogram. The indicators of the coagulographic curve allow you to quickly determine the general coagulation direction of the blood, which helps to identify the threat of the onset and development of DIC.

CLINICAL PICTURE

Symptoms depend on the degree and type of dehydration, which determine the tactics of rehydration.

Isotonic type: the loss of water is proportional to the loss of salts, the concentration of potassium and sodium in the blood is normal. With a loss of body weight up to 5%, diuresis is preserved, hemodynamic disturbances and metabolic acidosis compensated.

The hypertonic type (sodium concentration in the blood exceeds 150 mmol / l) is accompanied by a loss of intracellular fluid. With it, pastosity of the skin, a decrease in intraocular pressure, dryness of the mucous membranes, a scarlet shriveled tongue, thirst, and hemodynamic disturbances are noted.

The hypotonic type (sodium concentration in the blood below 130 mmol / l) usually develops with prolonged diarrhea. With this type of exsicosis, shock often occurs. Patients complain of severe weakness, refuse to drink. Vomiting, cold clammy skin, decreased tissue turgor, dry skin and mucous membranes, pronounced hemodynamic disturbances, decompensated metabolic acidosis, decreased diuresis, and CNS disorders are noted. There is a decrease in volume

extracellular fluid. The loss of salts exceeds the loss of water, which leads to a decrease in plasma osmolarity and the occurrence of intracellular edema.

Degree of exsicosis

Isotonic exsicosis is more common: sodium loss in this type of dehydration is calculated by multiplying the water deficit by the normal sodium concentration (140 mmol/l). A decrease in the level of potassium in the blood by 1 mmol / l indicates a loss of 5-10% total potassium in the body. With exsicosis I and II degree apply per oral rehydration, at III degree intravenous rehydration.

The child's need for water and salts

Per 1 kg of body weight, the need for water decreases with age, with an increase in temperature, severe shortness of breath, the need increases by 20-40%.

The newborn has a relatively higher proportion of water (78% of body weight compared to 60% at 1 year of age and older).

The proportion of intracellular water at all ages is about 40% of body weight, plasma volume - 4.5-5%, the volume of interstitial fluid in a newborn - 35%, at the age of 1 year - 25%. The last two volumes add up to extracellular water (40% in a newborn and about 30% at the age of 1 year and older).

The main ions of the extracellular fluid are sodium (140-150 mmol / l) and chlorine (95-105 mmol / l), while the intracellular fluid is potassium and phosphates. The need for sodium ions in a child is 2.5-3 mmol / kg of body weight, for potassium ions - 2 mmol / kg of body weight. These quantities should be included together with 5% glucose solution in the composition of rehydration solutions. The daily requirement for calcium (1 g is 25 mmol) at the age of up to 6 months is 350 mg, 6-12 months - 550 mg, over 1 year - 800 mg.

METHOD OF APPLICATION AND DOSES OF MEDICINES

Gastric lavage - 0.9% solution of sodium chloride or 2% solution of sodium bicarbonate in volume up to 1 year 10 ml / month of life, up to 3 years - 1.5-2 l

Hydration - 5-10% dextrose (glucose) solutions, 0.9% sodium chloride solution, potassium chloride solutions, colloidal solutions in/in or orally

Correction of acidosis - 4% solution of sodium bicarbonate

CLINICAL PHARMACOLOGY OF DRUGS

Gastric lavage is performed with signs of gastroenteritis (repeated vomiting).

Oral hydration with glucose-salt solutions is indicated for exsicosis I-II degree. In 2001, WHO recommended reducing the osmolarity of standard glucose-salt solutions from 311 to 245 mOsm/l by reducing the content of sodium chloride from 3.5 g/l to 2.6 g/l (sodium ions from 90 to 75 mmol/l) . Glucose-salt solutions are administered in the initial phase of rehydration with diarrhea to compensate for the loss of sodium ions. In the main phase (as in other diseases), solutions with a lower sodium content are prescribed (adding water, tea to glucose-salt solutions). When refusing to drink, glucose-salt solutions are injected into the stomach by drip through a nasogastric tube. The volume of liquid is determined by the degree of dehydration. For watery diarrhea, add 10 ml/kg of body weight per bowel movement to the deficit (200 ml in children over 3 years of age). Oral rehydration is carried out in 2 phases.

The initial phase of rehydration: in the first 4-6 hours, in order to eliminate the deficiency of water and salts, glucose-salt solutions are given at the rate of 50 ml / kg of body weight at degree 1 and 80-100 ml / kg of body weight at degree II of exsicosis. The liquid is injected fractionally, 0.5-1 teaspoon every 10 minutes.

The main phase of rehydration: in the next 18-20 hours, the remainder of the estimated daily volume (including liquid food) is administered in the form of a glucose-salt solution diluted with tea, water, rice water in a ratio of 1:1 with watery diarrhea, 2:1 - with vomiting, 1:2 - with hyperthermia and enterocolitis syndrome. With the improvement of the state and expansion of nutrition, the volumes of the solution are respectively reduced.

Parenteral rehydration is indicated for the ineffectiveness of per-

ral rehydration and exsicosis III degree. Infusion therapy is combined with oral hydration in case of exsicosis of II degree in the ratio 1:1, in case of exsicosis of III degree - 4:1.

The volume of injected fluid on the 1st day is determined by the formula: daily water requirement + pathological losses + fluid deficiency. The daily need for water is determined by the table. 20 or, simplified: for children weighing up to 10 kg - 4 ml / kg of body weight per hour or 100 ml / kg of body weight per day + 2 ml / kg of body weight per hour for each kg more than 10 kg. Pathological losses include unrecorded losses with stool and vomiting (20 ml/kg body weight per day), with tachypnea

(10 ml/kg of body weight per day for every 10 respiratory movements per minute more than the age norm), elevated temperature body (10 ml/kg of body weight per day for each degree above 37 °C).

The qualitative composition of rehydration solutions depends on the type of exicosis. The main infusion solution: with hypertonic and isotonic type of exsicosis, 5% dextrose solution is considered the main one, with hypotonic - 10%. Colloidal solutions should be 25% of the volume of the injected fluid (10-20 ml/kg of body weight). Potassium chloride solutions are used to correct the potassium level: 100 ml of 1% solution contains 13.4 mmol of potassium, 1 ml of a 7.5% solution - 1 mmol of potassium).

Initial phase: Rapid replacement of extracellular fluid losses is essential to prevent hypovolemic shock. In the absence of data on the type of exsicosis, as well as in cases of shock due to trauma, acute blood loss V emergency situations it is enough to introduce a mixture of 0.9% sodium chloride solution and 5% dextrose solution at a dose of 20-30 ml / kg body weight for 1 hour, if necessary, repeatedly (preferably with 10 ml / kg body weight of plasma or high molecular weight solution).

The main phase is the restoration of the volume of liquid, taking into account its losses. With exicosis II-III degree, 50% of the volume is administered for the first 6 hours, 25% for the next 6 hours, and 25% for the next 12 hours. In case of hypovolemic shock, after the initial phase of emergency correction from the 2nd to the 8th hour, 50% of the calculated volume is injected, from the 9th to

24th hour - the rest of the calculated volume of liquid.

With the isotonic type of exsicosis, 65% of the water and sodium deficit (including the volumes of the initial phase) is compensated for in 20-24 hours with 0.9% sodium chloride solution and 5% glucose solution. Potassium deficiency is compensated for 3-4 days. With salt-deficient exicosis, rehydration is carried out in the same way, but the loss of sodium ions is compensated for in 2-3 days, without prescribing hy-

potonic solutions. The loss of sodium ions (in mmol) is calculated based on the following formula: (135 - [blood sodium]) x 0.6 x body weight (in kg).

With hypernatremia, due to the possibility of developing seizures, a decrease in the concentration of sodium in the blood is carried out by 10-12 mmol / l / day. In view of the decrease in diuresis due to the release of antidiuretic hormone, the supporting fluid volume should be reduced by 25%. With the introduction of 5% glucose solution at a dose of 60-80 ml / kg of body weight per day, the dose of sodium is 20-25 mmol / l.

The final phase of rehydration is the transition to enteral fluid intake.

Correction of acidosis is carried out on the basis of: 4% sodium bicarbonate (in ml) \u003d [body weight (in kg) x BE (excess of bases)]? 2.

Monitoring the effectiveness of infusion therapy: stabilization of blood pressure, positive central venous pressure, adequate diuresis, elimination of acidosis.

Hospitalization in the infectious or intensive care unit is indicated.

Intestinal exsicosis is understood as pronounced violations water-mineral exchange predominantly in the cellular and intercellular sectors, developing in acute watery diarrhea in children.

From this article, you will learn the main causes and symptoms of exsicosis in children, how exsicosis is treated in children, and what preventive measures you can take to protect your child from this disease.

Treatment of exsicosis in children

Intensive therapy exicosis in children

The main principle of intensive care of intestinal exsicosis is the rapid replacement of losses. Typically, the doctor has three tasks:

Compensation for lost water and salts;

Increase in the buffer capacity of the blood (correction of metabolic acidosis);

Reduction of pathological losses with the help of etiotropic therapy.

The first and second tasks are solved with the help of infusion therapy with a glucose-polyion solution, which contains necessary complex basic electrolytes and buffer bases. Its composition corresponds to the concentration of electrolytes in the diarrheal masses of the child.

The solution is isotonic, its pH is close to 7.4. Correction doctor water-salt disorders, must determine the total amount of fluid the child needs, and how much of it should be administered intravenously. The needs of patients with grade 2-3 exsicosis are shown in the table below. In practice, they are the result of three terms: fluid deficiency plus the physiological needs of the child plus ongoing losses (vomit and diarrheal masses), the volume of which is determined gravimetrically (weighing).

Table. Requirements for fluid and basic electrolytes in patients with intestinal exicosis of 2-3 degrees at the stages of treatment

It is necessary to observe a certain rate of intravenous administration. If the patient's condition allows, the fluid deficiency is compensated fairly quickly (within 6 hours). In the first 2 hours, 50% of the deficit is introduced (the rate of fluid administration is about 40-50 drops per minute), the second half of the volume is administered in 4 hours. After that, the introduction of the liquid goes at a rate of 10-14 drops per minute - to compensate physiological needs and pathological losses. The infusion rate at this stage varies depending on the amount of pathological losses, which are defined as follows:

Severe diarrhea - up to 3 ml / kg / hour;

severe diarrhea- from 3 to 5 ml/kg/h;

Cholera-like profuse diarrhea -> 5 ml / kg / hour.

At the moment when the child loses no more than 1.0-1.2 ml / kg / hour with stool, and consumes 80-90% of the proper volume of fluid enterally, infusion rehydration therapy can be completed, provided that the concentration of basic electrolytes in plasma is normalized and reduction of metabolic acidosis. The criteria for the adequacy of rehydration therapy are: an increase in body weight for the first day from 3 to 9%, a decrease in temperature, cessation of vomiting, an increase in urine output of more than 10 ml/hour, an increase in central venous pressure, and a regression of clinical symptoms of exsicosis. This is usually achieved within the first day.

Medications for the treatment of intestinal exsicosis in children

Reducing the volume of ongoing pathological losses is possible not only due to etiotropic antibiotic therapy, but also with the help of enterosorbents. In acute intestinal infections in children, we consider Mikrosorb and Smecta to be the most effective enterosorbents, the doses of which are given in the table below.

Table. Doses of enterosorbents depending on the age of the child

Therapy with enterosorbents for acute intestinal infections usually does not exceed three to four days.

The use of a glucose-polyionic solution for rehydration therapy in combination with enterosorbents in the indicated doses can reduce the time of intensive treatment of patients with intestinal exicosis to 2 days.

Treatment of exsicosis with oral rehydration

Diarrhea therapy is carried out depending on the predominant syndrome, however, rehydration and antibiotic therapy(not necessarily antibiotics) are the main destinations. When a patient with diarrhea is admitted, the doctor first of all decides on the degree of dehydration and chooses how to treat:

• exsicosis I: usually used by OP;
• exsicosis II: OR or conventional fluid therapy;
• exsicosis III: intensive infusion therapy until the patient is removed from hypovolemic (dehydration) shock, and then therapy as in exsicosis II.

Treatment of intestinal exsicosis by oral rehydration was developed by WHO specialists for underdeveloped countries, since infusion therapy is costly. It turned out that the water-electrolyte and acid-base disturbances that occur during diarrhea can be compensated by oral administration of fluids and salts. The essence of the development was the optimal selection of the ratio of electrolytes (sodium and potassium), glucose and bicarbonate, which would provide absorption in the intestine, despite the ongoing diarrhea.

As a result of this work, a solution called Oralit was created. IN practical work, in particular in Russia and the CIS countries, the drug Regidron, similar in composition, is used (Orion, Finland). Both preparations are dry powders, which are diluted with boiled water in a volume of 1 liter before use. The composition and quantity of ingredients in Regidron are indicated directly on the bag containing the powder, and instructions for diluting the drug are also given there. In the absence of Regidron, a similar solution is prepared in a hospital pharmacy or directly in a hospital department. IN outpatient practice You can order an oral rehydration solution from a pharmacy using the prescription below:

Prescription solution "Regidron":

• KCl - 1.5 g,
• NaCl - 3.5 g,
• Na citrate - 2.9 g,
• Glucose - 20 g,
• Water - 1l,
• Glucose solution 10% - 44.0 ml,
• Solution KCl 7.5% - 6.0 ml,
• Solution NaCl 10% - 7.0 ml,
• Solution NaHCO 3 4% - 14.0 ml,
• Water dist. – up to 200.0 ml

Diluted solutions can be used during the day.

Advantages of oral rehydration method in the treatment of exsicosis

It should be emphasized the fundamental provisions and advantages of oral rehydration in comparison with other methods of treatment:

• oral rehydration is the main therapy, especially in patients with mild or moderate disease;
• oral solutions quickly normalize water-electrolyte and acid-base balance organism, preventing the development severe conditions;
• the previously practiced water-tea break is not used;
• natural nutrition through the mouth is used as early as possible, against the background of ongoing therapy;
• oral rehydration combined with dietary therapy is sufficient to eliminate clinical manifestations diseases, often without the use of antibacterial drugs.

Treatment of exsicosis 1 degree

Exsicosis is treated with oral rehydration. It is carried out in 2 stages:

Emergency rehydration within 4-6 hours aims to eliminate the water-salt deficiency (up to 5% of body weight) that arose before the start of treatment. Accordingly, the volume of liquid at this time will be 30-50 ml / kg;

Supportive rehydration is carried out taking into account the daily need of the child for water, electrolytes and to eliminate ongoing pathological losses with diarrhea and vomiting.

emergency rehydration: in the first stage, the child drinks one of these oral solutions at will, if thirsty. small child drink 1-2 teaspoons every 10 minutes. In case of vomiting after a 10-minute pause, rehydration therapy continues in the same way.

It should be noted that the estimated amount of "Rehydron" for the period of emergency oral rehydration may vary both in the direction of decrease and increase, depending on the dynamics of the patient's condition.

Criteria for the effectiveness of rehydration:

• cessation or reduction of diarrhea;
• cessation or reduction of vomiting;
• disappearance of thirst;
• moisturizing mucous membranes;
• the appearance of tears when crying;
• improvement of tissue turgor.

Therapy of the disease

How successfully the exsicosis of the 1st degree will be treated depends largely on the choice further tactics. After 4-6 hours from the start of treatment, it is necessary to evaluate the effect of therapy and choose one of the following options:

• transition to maintenance therapy, since with proper oral rehydration, dehydration and diarrhea quickly stop;
• if dehydration persists, the treatment is repeated for the next 4 to 6 hours;
• with an increase in dehydration, therapy is carried out as with exicosis II.

Supportive oral rehydration: until the end of the first day of treatment, the child receives a volume of fluid equal to FP + Pat. losses (PP = 20-30 ml/kg/day), i.e. maintaining a normal hydration regimen. Half of this amount is "Regidron", and the other - diluted 2 times with boiled water breast milk(for children under 1 year). After 1 year, "Regidron" alternates with diluted kefir or diluted cow's milk.

From the second day of treatment, the patient is transferred to fractional nutrition: 5-7 times a day, giving fluids more than usual. Sometimes on the second day they use milk diluted by 2/3. Thus, according to the method of oral rehydration, the child is transferred to natural nutrition by the second or third day of treatment.

Treatment of exsicosis 2 degrees

Recall that the disease is characterized by impaired peripheral microcirculation and, above all, by the appearance of oliguria. Fluid therapy at this stage can be administered in two ways: by oral or intravenous rehydration.

Oral rehydration. Since the loss of body weight in exsicosis II is greater (60 - 100 ml / kg), then more significant and metabolic disorders in water sectors (intracellular, intercellular, intravascular). Emergency oral rehydration is carried out for 6 hours, but the volume of liquid at this time will already be 100 ml / kg. Only oral rehydration solutions are used.

Tube rehydration is used when the child refuses to drink or has persistent vomiting (sometimes the probe is used for exsicosis I). The oral solution is dropped into a thin stomach tube that is inserted through the nose. The length of the probe should be equal to the distance from ear to nose + from nose to xiphoid process sternum. At first glance, it seems illogical to try to introduce solutions into the stomach in the presence of vomiting, but practice shows that with this approach, vomiting often stops after 1-3 hours. Probe rehydration is carried out continuously (without a night break). It is possible to administer the oral solution with a jet syringe, but it is better to do it by drip using an intravenous injection system, and the maximum injection rate should not exceed 10 ml / min.

The main criterion for the effectiveness of oral (tube) rehydration is diuresis of at least 50% of age-related hourly diuresis and the disappearance of signs of microcirculation disorders. Other criteria as for exsicosis I.

How to treat exsicosis II degree in children?

Exsicosis is a dangerous condition, so the success of treatment will depend on the choice of further medical tactics. After evaluating the effect of therapy for 6 hours, choose the following possible options for action:

• transition to maintenance oral rehydration (as in exsicosis I) with access to natural nutrition by the third day of treatment;
• transition to infusion therapy with an increase in dehydration, incessant vomiting, profuse diarrhea, an increase in symptoms of toxicosis.

Treatment of exsicosis 3 degrees

Exsicosis is a life-threatening disease, so the treatment of patients is carried out in the intensive care unit. One or two veins (central and peripheral) are catheterized. During catheterization central vein caution should be exercised, since due to a deficiency of BCC, air can enter the catheter, leading to an air embolism. With collapsed veins, venesection is performed. Infusion therapy is carried out in two stages: emergency - until the child is taken out of anhydrous shock, and then supportive - as in exsicosis II.

Emergency intravenous rehydration lasts for 1-2 hours and aims to restore central hemodynamics. The criterion for this is an increase in blood pressure to normal age values, the restoration of consciousness and diuresis.

An essential point at the stage of emergency rehydration is the choice of solutions for infusion. Most often, volemic solutions are used: polyglucin, reopoliglyukin, albumin, etc. at a dose of 15-20 ml / kg, but it is advisable to use them only in the presence of cerebral edema.

The second way is the use of crystalloid solutions: Ringer's solution, Ringer's lactate, saline, etc. They are administered at a dose of 40-60 ml/kg in order to quickly restore the volume of extracellular fluid. The faster this water sector recovers, the faster and more reliably the BCC will recover. If the effect of crystalloid solutions is insignificant, the doctor can always switch to volemic preparations.

At the stage of emergency intravenous infusion, it is necessary to introduce alkaline solutions: 4% sodium bicarbonate at a dose of 5-7 ml / kg, and in the future - taking into account acid-base balance. Details on the correction of metabolic acidosis will be discussed below. It is advisable to introduce corticosteroids - prednisolone or methylprednisolone. Hormones normalize vascular tone, stabilize cell and lysosomal membranes, and facilitate the release of oxygen to tissues and its absorption. A single dose of hormones: 2-3 mg / kg, daily - up to 10 mg / kg. After stabilization of the central hemodynamics and obtaining diuresis, infusion therapy is carried out as in exsicosis II.

How to treat exsicosis III degree in children?

Correction of metabolic acidosis. As already mentioned, metabolic acidosis stands out in diarrhea as a separate syndrome, since it is constantly present with intestinal dysfunction. varying degrees expressiveness.

First of all, let us recall normal values main indicators of acid-base balance (table). Metabolic acidosis is an absolute or relative increase in the concentration of H in the blood. The relative increase in H + occurs due to a decrease in the level of HCO 3-, i.e. there is always a shortage of bases. With compensated metabolic acidosis, the pH does not go beyond 7.35 - 7.45. If compensatory possibilities buffer systems are exhausted, then decompensated metabolic acidosis develops with a drop in pH below 7.35.

Metabolic acidosis is always accompanied by an increase in protein catabolism. The content of hydrogen and sodium ions inside the cells increases, while the content of potassium and phosphorus ions decreases. Therefore, against the background of intracellular acidosis in the blood plasma, there is hyperkalemia, despite the general deficiency of K in the body. With the deterioration of renal blood flow, a vicious circle arises, where each link increases acidosis and hyperkalemia.

Table. Indicators of the acid-base state

Symptoms of exsicosis in children

Symptoms of intestinal exicosis in children

Decompensated metabolic acidosis is a mandatory sign of intestinal exicosis of any degree, when the pH can drop to 7.08 - 7.2, and the deficiency of buffer bases to - (-) 17- (-) 20 mmol / l. This permanent and unidirectional violation of the CBS is associated with hypovolemia and centralization of blood circulation, which usually accompany dehydration. Another factor is the action of bacterial toxins that cause spasm of metarterioles and precapillary sphincters.

As a result, there is an increase in the centralization of blood circulation, and tissue hypoxia, when oxygen delivery does not cover the increased needs of tissues, the oxygen content in the blood decreases. venous blood and there is an accumulation of acidic metabolic products. At the same time, violations of central hemodynamics are in the nature of reactions and fluctuate by no more than 20-25% towards hypo- or hyperdynamia.

An important role is also played by the accumulation of fatty acids and the absorption of hydrogen ions from the intestine in case of impaired cavitary digestion of carbohydrates.

Shortness of breath and hypocapnia with intestinal exicosis of 2-3 degrees partially compensate for metabolic disorders, but often the carbon dioxide tension approaches such low level(pCO2 is less than 24 mm Hg), which in itself becomes additional factor violations cerebral circulation.

The development of dehydration is not accompanied by severe tachycardia, as is the case with infectious toxicosis or infectious toxic shock. It is observed only in 32% of patients and usually does not exceed 160 beats per minute. Constant changes in exicosis include an increase in the concentration total protein in plasma, as a reflection of hemoconcentration, and the relative high density of urine.

Causes of exsicosis in children

Causes of intestinal exicosis

Acute intestinal infections (AII) can be caused by viruses, bacteria, protozoa, or combinations thereof. With any of them, patients have, to one degree or another, violations of the water-mineral balance.

Intestinal exsicosis occurs mainly in infants and young children due to big losses fluids and salts with diarrheal masses, when much water, sodium, potassium, chlorine, bicarbonate and some amino acids and albumin are lost. This is the main link in the pathogenesis of intestinal exsicosis. Diarrhea develops under the influence of toxins, the leading role among which is occupied by a thermolabile exotoxin of pathogenic enterobacteria, which causes the so-called "watery diarrhea".

Cholera and colienteritis are classic examples of acute intestinal infections with "watery diarrhea", although intestinal exsicosis in children can occur with any causative agent of AII. This syndrome occurs quite often and makes up 40-42% of all patients with acute intestinal infections admitted to the intensive care unit.

It is generally accepted to divide exsicosis into three degrees: the first is a fluid deficiency in a patient up to 5% of body weight, the second is a fluid deficiency of 5 to 9%, and the third is a deficiency of 10% or more. Children with intestinal exicosis of 2 and 3 degrees need intensive care. Depending on the concentration of sodium in plasma, the isotonic form of exicosis is distinguished, when plasma sodium does not go beyond normal values, salt-deficient form, when sodium is reduced and water-deficient - plasma sodium is higher normal level. In children less than five years old, as a rule, there is an isotonic form of exsicosis.

Clinical and laboratory signs exicose are easily recognizable. The most characteristic of these are the "standing crease" symptom, retraction of the large fontanel, dry skin and mucous membranes, "sunken eyes", negative central venous pressure, and decompensated metabolic acidosis. These symptoms occur in the vast majority of patients. The exceptions are children with severe paratrophy or malnutrition, in whom it is difficult to interpret the state of the standing fold and patients with initial hydrocephalus, when the large fontanel is filled or even bulges.

Unlike patients with infectious toxicosis or infectious - toxic shock with intestinal exicosis, there is no pronounced tachycardia and gross violations of central hemodynamics.

Pathogenesis. Regardless of the causes of dehydration, exsicosis can be isotonic, hypotonic (salt-deficient), or hypertonic (water-deficient). In acute intestinal infection in children, any of the variants of dehydration may occur, but in infants and young children with intestinal exicosis of 2 or 3 degrees, only the isotonic variant of dehydration is observed. The type of dehydration is judged by the concentration of sodium in the plasma or guided by the level of osmolality. In patients with AII with intestinal exsicosis of 2-3 degrees, the sodium concentration in plasma ranges from 135 to 145 mmol / l, and the osmolality is within 270-300 mosm / l, that is, they do not go beyond normal values, which makes it possible to consider intestinal exsicosis in children isotonic. This fact is explained by the fact that in young children the stores of sodium in the body, in particular in the bones, are relatively larger than in older children and adults. At the same time, the diarrheal masses in young children contain sodium 50-80 mmol/l, that is, half as much as in plasma and less than in the diarrheal masses of an adult (140 mmol/l). After the age of five years, the electrolyte composition of the intestinal contents in patients with AII approaches in composition to the diarrheal masses of an adult. They may already have a salt-deficient type of exsicosis, especially if the child is rehydrated with salt-free solutions: tea, water, glucose, etc.

Patients with intestinal exicosis of 2-3 degrees always have relative or absolute hypokalemia, which increases with the development of dehydration and decompensated metabolic acidosis. The level of potassium in the plasma of patients can decrease to critical figures of 2-1 mmol / l, which leads to violations of cardiac activity and respiration.

Degrees of exsicosis in children

It should be noted that with intestinal infection there is no isolated extra- or intracellular dehydration. There is usually total dehydration. However, more fluid is lost from the extracellular sector than from the intracellular one, especially with secretory diarrhea (cholera, coli infection, etc.).

Since the total fluid is lost, the criterion for dehydration, of course, can be body weight. The first clinical symptoms of dehydration appear with a loss of fluid in the amount of 40-50 ml/kg of body weight. The body copes with fluid deficiency up to 100 ml/kg due to compensatory mechanisms of hemodynamics (centralization of blood circulation, tachycardia, etc.).

Decompensation occurs with a loss of 110-150 ml/kg, and a deficit of more than 200 ml/kg (20% of body weight) leads to death. Clinical symptoms exicosis increase in parallel with the patient's weight loss. In an adult patient, it is not difficult to determine the mass deficit, knowing the initial mass. Unfortunately, the doctor most often does not know the initial weight of the child, therefore it is better to focus on the clinical signs of dehydration (table), according to which degrees of exsicosis are distinguished in children and adults.

The main degrees of exsicosis:

degree of exicosis - loss of up to 5% of body weight (up to 50 ml / kg of liquid) - compensated dehydration without disturbing peripheral microcirculation. A sign of the transition to exsicosis II is the appearance of oliguria.

degree of exicosis - loss of 6-10% of body weight (60-100 ml / kg) - subcompensated dehydration of the body with impaired peripheral microcirculation, a synonym - compensated hypovolemic (dehydration) shock. A sign of the transition to exsicosis III degree is a violation of central hemodynamics.

degree of exicosis - loss of more than 10% of body weight (110 - 150 ml / kg) - decompensated dehydration with impaired central hemodynamics, a synonym - decompensated hypovolemic (dehydration) shock. Violations are manifested by a decrease in systolic blood pressure below 70 mm Hg, the absence of a pulse on peripheral vessels as well as oligoanuria or anuria.

Table. Evaluation of the severity of exsicosis in children and adolescents with acute intestinal infections

* CVP in children under 3 years old is normally 2-7 cm H 2 O, in adults - 5-12 cm H 2 0

Signs of dehydration

Clinical signs dehydration can be supplemented by the definition of extracellular fluid deficiency based on laboratory indicators. The volume of extracellular fluid is 20% of body weight (or 1/5), and in children under 1 year old - 30% (about 1/3). With isotonic and hypotonic dehydration, the deficit of extracellular fluid is calculated according to the Rachev formula using hematocrit:

Deficiency / liters \u003d Ht of the patient - Ht norm / 100 - Ht norm x Body weight in kg / 3 or 5

coefficient 3 in children under 1 year old;

coefficient 5 in children older than 1 year and adults.

With hypertensive dehydration, the Seifert formula is used:

Deficiency / liters \u003d Na of the patient - Na norm / Na norm x Body weight in kg / 3 or 5

Sodium is normal = 140 mmol / l.

Thus, the nature and degree of exsicosis are revealed by clinical and laboratory data. It is necessary to calculate the degree and nature of dehydration as carefully as possible, since in many respects they determine the volume and intensity of antidiarrheal therapy.

Diagnosis of exsicosis in children

From the totality of symptoms, it is necessary to single out the main ones that allow diagnosing a shock condition: compensated shock (exicosis of the II degree), decompensated shock (exicosis of the III degree), terminal shock (irreversible).

How is exsicosis diagnosed in children?

Consciousness.

It is an indicator of the functional activity of the central nervous system. With exicosis of the II degree due to the centralization of blood circulation, the cerebral blood flow is not disturbed, with exicosis of the III degree, decentralization of the blood circulation occurs, leading to cerebral ischemia and coma.

Color skin.

With exsicosis II degree, the skin is pale and cold, with moderate cyanosis of the extremities. Paleness of the skin is a consequence of compensatory vasospasm, which ensures the centralization of blood circulation. With exicosis III, vascular paresis occurs, leading to peripheral acrocyanosis, i.e. cyanosis of the protruding parts of the body (tip of the nose, ears, distal extremities).

Skin temperature.

It decreases with exsicosis II and III degree, which can be determined by palpation and using electrothermometry. IN last case the difference between the central and peripheral temperatures (∆t°) is measured. Central is measured in the rectum, peripheral - on the plantar surface thumb feet. Normally, ∆t° = 3-4 °C, with exicosis II it increases to 6-10 °C, with exicosis III - over 10 °C.

BP, pulse, Algover index.

According to the level of blood pressure, one can immediately distinguish between exsicosis II and III degrees. In the first case, systolic blood pressure may be at the lower limit of normal, in the second case it is always below normal.

The Algover index (shock index) is expressed by the ratio:

Diagnosis of exsicosis must necessarily include measurement of pulse rate / systolic blood pressure. They are an informative indicator of the severity of hypovolemic shock. Normally, in adults, the index is 0.5, and in children, depending on the age values ​​of blood pressure and pulse. With exicosis II, the index increases by 1.5-2 times, with exicosis III - more than 2 times.

circulation index.

Allows you to evaluate the intensity of blood circulation and is expressed by the product: systolic blood pressure x pulse rate. In adults, the norm is 10,000, in children - depending on the age values ​​of blood pressure and pulse. An increase above the norm is designated as hypercirculation (for example, with exsicosis of the II degree), below the norm - hypocirculation (exicosis of the III degree).

Central venous pressure (CVP).

It is measured in the superior vena cava in the presence of a catheter. Normally, the CVP value corresponds to 5-12 cm H 2 0, in children under 3 years old = 2-7 ​​cm H 2 0. CVP depends on three factors: the functional ability of the right ventricle, the volume of circulating blood, and venous tone. With exicosis II and III degree, CVP is reduced to the values ​​shown in the table. Heart failure or fluid overload leads to increased CVP.

Diuresis is an indicator of the adequacy of hemodynamics, and sometimes diuresis is figuratively called "cardiac output of a serious patient." With exsicosis of the II degree, the patient has oliguria, with exicosis of the III degree - oligoanuria or anuria. The absolute amount of urine excreted in a certain time must be correlated with the volume of fluid introduced into the body over the same time interval (1, 6, 12 or 24 hours).

daily diuresis. It is 60-70% of the human FP in water and for an adult is 1500-1800 ml. In addition, in children daily diuresis can be calculated using the following formulas:

• Up to 1 year = 300 + 25 x (n - 1), where n is the number of months.
• Up to 5 years = 600 + 100 x n, where n is the number of years.
• After 5 years = 400 + 100 x n, where n is the number of years.

Hourly diuresis in ml/hour and per 1 kg of body weight (ml/kg/hour):

• 1 month – 15.0(3.0) 7 years – 45.0(2.0);
• 6 months - 20.0(3.0) 10 years - 55.0(1.5);
• 1 year - 30.0(2.5) 14 years - 60.0(1.2);
• 3 years - 30.0 (2.0) - 80.0 (1.2).

Diuresis disorders are manifested by oliguria, oligoanuria and anuria:

1. Oliguria: diuresis less than 50% of the age norm (less than 0.5-1.5 kg / h);
2. Oligoanuria: diuresis less than 30% of the age norm (less than 0.3-1.0 ml / kg / h);
3. Anuria: complete absence of diuresis or an extremely small amount of urine - in an adult about 100 ml, in a child of 5-10 years old - no more than 50 ml.

DIC syndrome.

Often accompanies compensated and decompensated hypovolemic shock. In cases of diarrhea, DIC occurs less frequently than in other cases. hypovolemic states(traumatic, hemorrhagic, septic, anaphylactic shock). With exicosis II, clotting disorders are manifested only by laboratory tests in the form of compensated hypercoagulation (increase in fibrinogen, platelets, prothrombin index). With exicosis III degree, there may be a second, less often a third phase of DIC. In this case, separate "shock organs" appear: lungs or kidneys.

Terminal shock is an irreversible condition that occurs when dehydration progresses. The morphological substrate of terminal shock is total DIC, leading to the emergence of many "shock organs", in contrast to decompensated shock, in which DIC is partial. Clinical course characterized by extreme severity of the condition: the patient is in a deep coma (coma III degree), blood pressure is not more than 35-40 mm Hg, the pulse is determined only on carotid artery, heart failure is combined with respiratory failure of the III degree (the patient is on mechanical ventilation), diuresis is absent, despite the use of infusion solutions and diuretics ("Shock kidney").

Criteria for assessing the patient's condition

Universal status:

Gastrointestinal tract injury:

The symptoms included in these sections are scored, then summed up to select the optimal tactical solution. After summation, the doctor, based on the score, determines the degree of threatening condition (MS) of the child. The more positive points, the harder and more dangerous disease. When the diagnosis of exsicosis is carried out, having identified the degree of US, the doctor makes one of the following tactical decisions (Table):

Hospitalization in a hospital (optional, desirable, mandatory), and in severe cases- to the intensive care unit by an ambulance.

Intensive surveillance (IN) by the duty brigade.

Remote intensive surveillance (DIN) with registration.