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The initial approach in rehydration during severe cholera differs substantially from the approach to patients with gastroenteritis
- severe cholera patients presents with greater degree of initial dehydration and electrolyte losses than in non-cholera gastroenteritis
- this should be kept in mind to avoid underestimation of the speed and volume of fluids required in these patients
- in severe cholera within the first 24 h of therapy an average of 200 mL/kg of isotonic oral or intravenous fluids is typically required (although in some cases may require more than 350 mL/kg ) (1)
In severe cholera,
- the initial fluid replacement should be done within 3-4 h of presentation
- route of administration depends on the severity of the dehydrations
- in patients with severe dehydration (>10%) who are in hypovolaemic shock
- require immediate intravenous rehydration, as rapidly as possible until circulation is restored
- patients should be switched to oral rehydration as soon as they are able to have liquids (typically 3-4 h) since more potassium bicarbonate, and glucose are available in oral rehydration solutions (ORS) than in standard intravenous fluids,
- in patients with some dehydration (5-10%)
- rapid replacement of the initial deficit with ORS and monitoring of patients until signs of dehydration have resolved
- in the presence of some dehydration with profound vomiting or continuing stool losses, concomitant intravenous and oral rehydration should be provided
- in patients without signs of dehydration, management consists of oral fluids to replace continuing losses (1)
Estimation and replacement of ongoing losses is crucial even when replacing initial fluid deficit (1)
- rate of continuing fluid loss might exceed 20 mL/kg/hour
- cholera cots could be used to estimate continuing volume losses but in the absence estimations can be calculated as 10-20 mL/kg of bodyweight for each diarrhoeal stool or episode of vomiting (1)
After rehydration signs of dehydration should be reassessed at least every 1-2 hours (more often if there is profuse ongoing diarrhoea).
- if signs of dehydration appears ORS solution should be given more rapidly
- if patients become tired, vomit frequently or develop abdominal distension
- ORS solution should be stopped and rehydration should be given IV with Ringer's Lactate Solution (50 ml/kg in three hours), with added potassium chloride
- after this it is usually possible to resume treatment with ORS solution (2)
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