Intraperitoneal fluid therapy in cholera and non-cholera diarrhoea

Bull. Org. mond. Sant) 1970, 42, 837-846 Bull. Wld Hlth Org. Intraperitoneal Fluid Therapy in Cholera and Non-cholera Diarrhoea With Special Emphasis on the Treatment of Infants and Children* D. MAHALANABIS, R. B. SACK, J. KAPLAN, B. JACOBS & A. MONDAL Because ofthe relative difficulty in maintaining continuous intravenous infusions in small children suffering from cholera, a simpler method of maintenance fluid therapy would be useful. With this in mind, the role of intraperitoneal fluid administration was evaluated in 8 adults and 26 children (aged 6 years or less) having moderate to severe cholera or cholera-like diarrhoeal disease. In adults intraperitoneal fluid was found to be of no significant value in maintenance therapy because peritoneal absorption was not sufficiently rapid to replace expected stool losses. In children, however, this form of therapy was considerably more successful. In 16 of 19 children with cholera and in all 7 with non-cholera diarrhoea, intraperitoneally admi- nistered fluid was absorbed rapidly enough to replace a major part of the initial fluid deficit on admission and all subsequent stool losses. No complications of intraperitoneal puncture were encountered. Careful studies of water and electrolyte balances have provided the basis for rational and highly effective treatment of cholera both in adults (Watten et al., 1959) and in infants and children (Mahalanabis et al., 1970). The optimum replacement of fluid and electrolytes by the intravenous route combined with the administration of tetracycline by mouth reduces the mortality and morbidity in infants and children with clinically severe dehydration due to cholera to levels comparable to those in adults.' Because of the relative difficulty, however, of maintaining intra- venous infusions in small children, a simpler method of fluid administration would be useful in the many cholera-affected areas where sufficient medical and paramedical personnel are lacking. This study was designed to explore the scope of a simpler route of fluid administration-intraperitoneal-in the treat- ment of cholera in infants and children. * From The Johns Hopkins University Center for Medical Research and Training, the Infectious Diseases Hospital and the Calcutta School of Tropical Medicine, Calcutta, India. This investigation was supported by US Public Health Service Research Grant No. SR07TW0O141-08CIC and by funding under US Public Law 480, Section 104 (c), Agreement 5x43 17. 1 Mahalanabis, D., Brayton, J. E., and Pierce, N. F.- unpublished observations. Intraperitoneal fluid has been used for over 50 years as therapy in dehydrated children with diarrhoea in America and Africa (Blackfan & Maxcy, 1918; Carter, 1953; Huckstep, 1962). Because the present knowledge of therapeutic responses in children with cholera was somewhat meagre, it was decided to determine first the thera- peutic response to intraperitoneal fluid in adults, after which more extensive studies were done with children. This report summarizes our experience with the use of intraperitoneal fluids in both adults and children. MATERIALS AND METHODS Case selection and treatment procedures for adults The present study involved 8 adult males admitted to the Infectious Diseases Hospital, Calcutta, with profuse watery diarrhoea of less than 24 hours' duration, with marked saline depletion and in shock (systolic blood pressure below 80 mm Hg); none had received prior therapy. Initial therapy. In the first two patients studied (one of whom was bacteriologically negative for Vibrio cholerae) intraperitoneal fluids were given 2524 - 837 D. MAHALANABIS AND OTHERS early in the course of the illness to determine their efficacy in correcting initial saline depletion. In each patient intravenous therapy was given only for the first 30 minutes after admission, bringing the systolic blood pressure to above 90 mm Hg, but only partially correcting the saline depletion. The intra- venous fluids were then discontinued and 2.0 litres of intraperitoneal fluids were rapidly administered. Thereafter, for the next 2 hours, vital signs were monitored every 30 minutes and the plasma specific gravity (PSG) was measured hourly. Maintenance therapy. Seven patients (including the one vibrio-negative patient mentioned above) were subsequently studied to determine whether intraperitoneal fluids might be useful for main- tenance therapy during cholera. In these patients normal hydration was restored and maintained with intravenous fluids until an accurate rate of stool output could be determined (usually within 6-10 hours of admission). At this time intravenous fluids were discontinued and intraperitoneal fluids (1.5 litres-2.5 litres) were given every 10-14 hours. Vital signs and stool volumes were measured hourly and the PSG every 4 hours. If the PSG increased to greater than 1.030, additional intravenous fluids were given. Parenteral fluids. Fluids used for intraperitonea administration in adults were isotonic sodium chlo- ride and sodium lactate in a 2: 1 ratio with the addition of 5 mEq/l of potassium chloride. Fluids were given through a No. 18 needle into the left lower quadrant at a rate of approximately 100 ml per minute. Intravenous therapy consisted also of saline and lactate in a 2: 1 ratio, but without addi- tional potassium. None of these patients received antibiotics; only water was given by mouth. Case selection and treatment procedures for children Children aged 6 years or under, usually male, with a history of severe " rice-water " diarrhoea of less than 24 hours' duration, with moderate to severe dehydration at the time of admission to the Infectious Diseases Hospital, Calcutta, were chosen for study. After a brief history had been taken and a physical examination carried out, the child was weighed and placed on a metabolic bed. Blood from the femoral artery was collected in a heparin- rinsed syringe for immediate determination of pH, PSG and total CO2 content. The plasma was frozen for subsequent determination of sodium, potassium, and chloride. Rehydration was promptly started according to the protocols described below. Ringer's lactate solution was used for intraperi- toneal administration. It was given from a bottle by gravity using an 18-gauge needle and a routine intravenous administration set. After preparation of the skin with iodine and alcohol, the needle was inserted in the midline 2 cm below the umbilicus and fluid was allowed to run at maximum speed. Ten to 15 minutes were usually required to admi- nister 500 ml of fluid. Dextrose (5 Y.) in water was started by mouth as soon as patients tolerated oral fluid. This was given liberally, aiming to achieve a rate of approximately 120 ml per kg per 24 hours, thereby supplying free water requirements. Oral potassium was given at a rate of 4 mEq per kg per 24 hours in 4 divided doses in the form of an aqueous solution of potassium hydrogen citrate. Oral tetracycline was started 6 hours after admission at 50 mg per kg per 24 hours in 4 divided doses for 48 hours. Capillary blood was obtained hourly for the first 6 hours, then every 6 hours for determination of the PSG. Arterial blood was collected for determination of pH and total CO2 at 12 hours, 24 hours and 48 hours after admission. Body-weight was determined every 6 hours thereafter in all patients. Children's treatment groups Group I (7 children). Rehydration in these patients was begun with intravenous Ringer's lactate solution at 20 ml per kg body-weight over the first hour, followed by an electrolyte solution containing sodium chloride and bicarbonate in 5 % dextrose (composi- tion: Na 106 mEq/l, Cl 74 mEq/l, HCO-3 32 mEq/l) at 30 ml per kg body-weight over the next 2 hours. Three hours from the onset of rehydration, intra- venous fluids were stopped and Ringer's lactate solution was administered intraperitoneally, 50 ml per kg body-weight, thereby replacing 5% of the body-weight by the intravenous route and 5% intra- peritoneally. Stool losses were measured at 6-hour intervals or earlier if indicated, and additional intraperitoneal fluids given in a volume equivalent to 75% of the measured stool loss. Group II (9 children). Because of the satisfactory response of the patients in group I, an attempt was made in these patients to replace a larger portion of the initial fluid deficit by the intraperitoneal route. They were initially given Ringer's lactate solution intravenously (20 ml/kg-30 ml/kg) over 1 hour. Immediately after commencement of the intra- venous infusion, intraperitoneal Ringer's lactate (60 ml/kg-70 ml/kg) was administered. All sub- 838 INTRAPERITONEAL FLUID THERAPY IN CHOLERA AND NON-CHOLERA DIARRHOEA sequent diarrhoeal stool losses were replaced in the same way as for group I. Six children were success- fully treated by this protocol, and are designated group II (a). Two " treatment failures " and one death among children treated by this protocol are designated group II (b). Group III (3 children). These children, who had manifestations of moderate to severe dehydration but normal blood pressure, were not given intra- venous fluid. The total estimated volume deficit on admission was replaced by intraperitoneal Ringer's lactate solution (70 ml/kg-100 ml/kg). All stool losses were replaced by intraperitoneal fluid in the same way as in the other two groups. Group IV (7 children). Seven patients who were bacteriologically negative for V. cholerae were placed in this group; 5 of these were treated as for group II, 1 child as for group III, and 1 as for group I. Analytical methods The arterial pH was determined on anaerobically handled blood by a Radiometer pH meter 27 with capillary microelectrode. Plasma specific gravity was measured by a temperature-corrected refractometer (TS meter; American Optical Company). Plasma standard bicarbonate was measured by an Astrup Microtonometer or calculated from blood pH and plasma total CO2 content measured by a Natelson microgasometer. Sodium and potassium were deter- mined by a Patwin flame photometer with internal lithium standard. Chloride was determined by a Buchler-Cotlove chloridometer. Bacteriological studies Standard techniques described elsewhere (Sack et al., 1970) were used for isolation and identification of V. cholerae and other enteric pathogens. Stool samples were collected on admission by sterile rectal catheter. Thereafter daily samples were collected by rectal swabs. RESULTS Adults Initial therapy. In neither of the 2 patients receiving intraperitoneal fluid as initial therapy was the saline depletion significantly corrected. The PSG remained abnormally high during the period of observation, and additional intravenous fluids were required to bring it to within the normal range. Maintenance therapy. Intraperitoneal fluids were successful as maintenance therapy in 5 of 7 patients. A summary of the data from these 7 patients is given in Table 1. Stool output varied from 86 ml/h to 450 ml/h during the study periods. In the 2 patients with stool rates exceeding 400 ml/h, additional intra- venous fluids were required to maintain normal hydration. In all other patients, stool output was below 200 ml/h, and adequate hydration was main- tained with intraperitoneal fluids alone. TABLE 1 SUMMARY OF INTRAPERITONEAL FLUID THERAPY IN 7 ADULT CHOLERA PATIENTS Toutput (I) Duration( Rate of(stiol Duration Highest PSG a Total fluids given (I)Patien No. utput mllh) during study pro Intra- Intra-outut 1) f ilnes () drin stdy f sudy(h) perod venous peritoneal 967 18.3 117 191 88 1.029 8.5 14.5 984b 19.1 89 450 5 1.031 C 186 31 1.030 17.3 7.5 996 42.6 116 402 76 1.034" 33.0 15.8 20 2.3 20 115 20 1.027 4.0 2.0 25 16.5 100 169 60 1.030 9.7 8.1 43 3.6 40 86 36 1.028 5.0 4.0 48 4.5 38 152 14 1.028 4.0 3.4 a PSG= plasma speciflc gravity. b A second study was made in this patient after the stool rate had decreased. c When plasma specific gravity rose to above 1.030 during the study period additional intravenous fluids were required. 839 D. MAHALANABIS AND OTHERS Children The 26 patients, divided into 4 groups as described, will be discussed separately. All patients in groups I, II and III had bacteriologically confirmed cholera. Of these 19 stool cultures positive on admission, 12 were Inaba and 7 Ogawa, all biotype El Tor, as determined by polymyxin-B resistance (Gan & Tjia, 1963). Of the 7 children negative for cholera, 1 harboured non-cholera vibrios of uncertain patho- genicity; no enteric pathogens were isolated from the remaining 6 patients. Group I. Admission data and the course of illness for each patient are shown in Table 2. Their mean age was 3.4 years and mean duration of diarrhoea before admission was 9 hours. On admission an altered consciousness, low blood pH, low standard bicarbonate and elevated PSG were noted. Stool output over the first 12 hours ranged from 3.7 ml/kg/h to 7.3 ml/kg/h. Patient No. 5, who lost nearly 17% of his body-weight in 24 hours, required 4 separate intraperitoneal fluid administrations. Patients No. 2 CLINICAL DATA and 4 needed 3 administrations each, and all the others either 1 or 2. All 7 patients recovered without complications and none required additional intra- venous therapy after initial rehydration. All had an adequate oral intake of glucose water which ranged from 4% to 13% of their body-weight over the first 24 hours. Fig. 1 illustrates the course of illness in patient No. 5, who was successfully treated by this regime despite large losses of diarrhoeal stools. He lost about 600 g of watery stools during the first 6 hours which were replaced by 500 ml of intra- peritoneal Ringer's lactate solution. Two more intraperitoneal administrations were required to replace his continuing stool losses during the first 24 hours. Group II (a and b). Table 3 gives the relevant information on individual patients in this group. In group II (a) are 6 children who were successfully treated by this regime. The age and admission data are similar to those for the previous group. Stool output over the first 12 hours was less than in TABLE 2 FOR 7 MALE CHILDREN WITH CHOLERA, GROUP I Patient No. 1__ _ __ _2 _3 1 4 f 5 - 6 - 7 Age (years) 3 3 2'/12 36/,i 211/12 5 4 Duration of diarrhoea prior to admission (h) 3 8 19 8 10 11 3 Findings on admission: Sensorium Stupor Drowsy Drowsy Coma Drowsy Drowsy Alert Loss of skin turgor (Oto + + +) + + + + + + + + ++ + +++ 0 Body-weight (kg) 8.57 9.43 7.58 11.37 9.40 10.24 10.07 Systolic blood pressure (mm Hg) 40 50 80 60 0 85 65 Blood pH 7.01 7.20 7.23 7.22 7.14 7.11 7.34 Plasma specific gravity 1.035 1.036 1.035 1.034 1.031 1.033 1.037 Standard bicarbonate (mEq/l) 9.5 9.4 11.1 12.8 13.6 10.8 16.6 Stool output (ml): 0 h-24 h 641 666 394 989 1 573 685 1 056 24 h-48 h 88 291 360 0 647 0 0 Total intravenous fluid given (ml) 480 460 350 590 505 520 500 Total intraperitoneal fluid given (ml) 600 1 070 690 1000 1 840 1 080 1 330 Intake of oral glucose water over first 24 h (ml) 737 885 810 495 1 230 810 1 300 840 INTRAPERITONEAL FLUID THERAPY IN CHOLERA AND NON-CHOLERA DIARRHOEA group I, ranging from 1.4 ml/kg/h to 6.2 ml/kg/h. Oral glucose intake over the first 24 hours was similar to that in group I, ranging from 7% to 15 % of body-weight. One or two intraperitoneal admi- nistrations were necessary for each patient. Reco- very was uneventful except in patient No. 2 who had transient signs of peritoneal irritation, i.e., guarding and rebound tenderness. Peritoneal fluid cultures were negative, however, and signs of irritation disappeared within 12 hours. Fig. 2 illustrates the course of illness over the first 24 hours in patient No. 1. He lost over 500 ml of diarrhoeal stools during the first 6 hours after admission, which were replaced by intraperitoneal Ringer's lactate solution. The child responded well, maintaining a normal blood pressure; his PSG and blood pH were normal at 6 hours and remained so thereafter. Patients 1 and 2 in group II (b) represent treat- ment failures. Both had stool outputs over the first 12 hours considerably greater than the other 24 pa- tients studied (9.4 ml/kg/h and 9.5 ml/kg/h) and each had a fall in blood pressure with deteriorating clinical signs, despite the administration of large volumes of intraperitoneal fluid. Both were given additional intravenous fluids and recovered uneventfully. Fig. 3 demonstrates the course of illness in the first of these treatment failures. On admission he was given Ringer's lactate solution intravenously TABLE 3 CLINICAL DATA FOR 9 CHILDREN WITH CHOLERA, GROUP II Patient No. Group 11 (a) Group 11 (b) I 1 2 3 4 |_5 J 6 1 2 |_3 Age (years) 36/12 6 2 2'/,t 2 6l/2 3 6/12 5 4 3 Vn Sex M M F F F M F M F Duration of diarrhoea prior to admission (h) 6 Not known 10 9 5 6 17 6 17 Findings on admission: Sensorium Alert Drowsy Drowsy Drowsy Drowsy Alert Drowsy Drowsy Stupor; decerebrate Loss of skin turgor(Oto+++) ++ ++ +++ +++ +++ + ++ +++ ++ Body-weight (kg) 9.32 11.98 5.82 7.37 8.23 7.43 12.30 9.10 8.90 Systolic blood pressure(mm H) 90 40 0 55 50 80 75 45 0 Blood pH 7.28 7.21 7.03 7.24 7.21 7.33 7.13 7.13 7.20 Plasma specific gravity 1.030 1.037 1.037 1.036 1.034 1.030 1.033 1.039 1.033 Standard bicarbonate(mEq/l) 16.2 4.5 6.6 6.2 9.4 5.6 8.5 4.6 9.3 Stool output (ml): 0 h-24 h 681 204 435 525 444 233 1 917 1 239 929 24 h-48 h 271 0 300 0 0 0 0 0 0 Total intravenous fluid given(ml) 200 250 150 210 250 150 2 270 1 290 700 Total intraperitoneal fluid given(ml) 1 290 1 080 740 940 540 540 1 620 1 080 1 260 Intake of oral glucose water over flrst 24 h (ml) 1 400 870 675 1 065 1 060 1110 270 840 0 841 D. MAHALANABIS AND OTHERS FIG. I COURSE OF ILLNESS DURING THERAPY IN PATIENT No. 5, GROUP I (9.4 kg) 7.' 7.5 7-1it72LI. FIG. 2 COURSE OF ILLNESS DURING THERAPY IN PATIENT No. 1, GROUP 11 (a) (9.32 kg) G 0% 724f.4 ,I I. IrAdPER/rOffDNI FUIO, v V.r NTRArVoOUS FLUID iSoo V 0 0 6 It Is 24 30 HOURS AFTER ADMISSION a After initial therapy he was maintained on intraperitoneal fluid alone, which was given in 4 separate administrations. Diarrhoeal stools over the first 24 hours amounted to 17%o of his body-weight. (24 ml/kg) and intraperitoneally (88 ml/kg.) In spite of this, his general condition remained poor, his blood pressure dropped and his PSG increased. He was given another administration of 500 ml Ringer's lactate solution intraperitoneally although the first lot of intraperitoneal fluid did not appear to have been absorbed fully. During this time he continued to produce large volumes of diarrhoeal stools. After 6 hours he was given additional intravenous fluids and he thereafter made an uneventful recovery. The third patient in group 11 (b) died 24 hours after admission. However, her death was considered unrelated to the fluid therapy. On admission, this child was in shock, gasping and unresponsive. Blood pressure was corrected within 25 minutes of admission with intravenous Ringer's lactate solu- tion and remained normal thereafter. Intraperito- neal fluids (80 ml/kg) were given at this time. Within 2 hours of admission and without ever regaining consciousness, the patient developed decerebrate 7.0 it U1030I0. 1. 5 ,% to1s t *t I-Oils 0. 1'020 _ 750 u4 500 61.X ; 2S0 0 "x0..~ 0. ORAL GLUCOSE WATERHA- /.P. IM/4Tg rONpALf tZflU/I, I P fiT//RI PIAtWS fLD'/ zSo 0 6 12 Is 24 HOURS FROM AIDMISSION a The calculated fluid deficit on admission was replaced by Ringer's lactate solution, 20 ml/kg, over the first hour and 80 ml/kg Ringer's lactate solution intraperitoneally. Subsequent stool loss was replaced by a second intraperitoneal infusion. posturing and tonic-clonic seizures. Oral fluids were thought to be contra-indicated and the child was removed from the study and given intravenous replacement therapy only. Examination of cerebro- spinal fluid was normal and CSF cultures were sterile. Despite anticonvulsants, intravenous calcium gluconate and dextrose, the child's seizures could not be adequately controlled and she died suddenly 24 hours after admission. Permission for autopsy was not granted. Group III. Data from these 3 patients are given in Table 4. On admission each had an adequate systolic blood pressure, but marked base deficit and 842 .k a 0 ;4 INTRAPERITONEAL FLUID THERAPY IN CHOLERA AND NON-CHOLERA DIARRHOEA FIG. 3 COURSE OF ILLNESS DURING THERAPY IN PATIENT No. 1, GROUP 11(b) (12.3 kg)0 FIG. 4 COURSE OF ILLNESS DURING THERAPY IN PATIENT No. 3, GROUP III (12.47 kg) a 71.' fjt r24 <_1___ a. r.vW _*0. t 1-035 4),I'L:41t0 " v 'f .5 a l, 0l0 L4. IT*MAPERIIr7di FLID10, ISO 0 0 6 12 14 SOURS FROM ADMISSION a This patient was normotensive on admission, although moderately severely dehydrated. He was given only Intra- peritoneal Ringer's lactate solution, approximately 80 ml/kg, to correct initial deflcits. Subsequent stool loss was replaced by a second intraperitoneal infusion. 24 a Admission deficits were replaced by Ringer's lactate solution, 24 ml/kg Intravenously and 88 ml/kg intraperitoneally. In spite of this, his general condition remained poor, blood pressure dropped, and plasma specific gravity rose. His condition did not improve despite a second intraperitoneal infusion, and at 6 hours, he was started on intravenous fluids. He thereafter made an uneventful recovery. elevated PSG. Stool output over the first 12 hours ranged from 1.2 ml/kg/h to 5.6 ml/kg/h. Each had an adequate oral intake of glucose water, ranging from 12% to 15% of body-weight in 24 hours. Recovery in each was uneventful. The course of illness in patient No. 3 is illustrated in Fig. 4. On admission, this child was not in shock but had moderately severe dehydration and metabolic acidosis, as evidenced by loss of skin turgor, high PSG and low plasma standard bicarbonate. He was given intraperitoneal Ringer's lactate solution (approximately 80 ml/kg) to replace the initial deficit. Stool loss during the first 6 hours was replaced by a second administration of intraperitoneal fluid 7 hours after admission. His clinical response was satisfactory; the PSG and blood pH gradually returned to normal. Group IV. Results from these 7 patients, who had a severe cholera-like illness in spite of vibrio-negative stool cultures, are summarized in Table 5. The severity of illness is comparable to that in the Q 90 70. i o 1-40 t 4 so0 LI v 0 5.1040 74 1-035 ft lu V030 1025 I.P. Ia'TR4PERTrD#IEA FLUID l.K aIN*/ravNo#S flUID 25fi0 o000. %a.It 1fi0 0 2.750 500 i.:6 toe i%go ± 0 6 it ls HOURS FROM ADMISSIOK 843 t. - D. MAHALANABIS AND OTHERS TABLE 4 CLINICAL DATA FOR 3 MALE CHILDREN WITH CHOLERA, GROUP IlIl Patient No. 1 1 2 3 Age (years) 2 7/12 2 6/12 4 Duration of diarrhoea prior to admission (h) 24 7 7 Findings on admission: Sensorium Alert Alert Drowsy Loss of skin turgor (oto + + +) + + 0 + Body-weight (kg) 6.88 9.875 12.47 Systolic blood pressu re (mm Hg) 80 90 85 Blood pH 7.29 7.20 7.37 Plasma specific gravity 1.029 1.036 1.035 Standard bicarbonate (mEq/l) 10.6 7.7 10.6 Stool output (ml): 0 h-24 h 98 566 1 212 24 h-48 h 0 70 8 Total intravenous fluid given (ml) 0 0 0 Total intraperitoneal fluid given (ml) 540 1 380 1 680 Intake of oral glucose water over first 24 h (ml) 855 1 450 1 890 patients with cholera. Many of them passed large amounts of stools-between 1.1 ml/kg/h and 7.4 ml/kg/h during the first 12 hours. The treatment responses in each of them were satisfactory; no additional intravenous fluids were necessary. The rapid administration of 70 ml-80 ml of intra- peritoneal fluid per kg of body-weight did not cause any discomfort or respiratory embarrassment to any child. Transient signs of peritoneal irritation in one child, as described, were not regarded as being of major significance. DISCUSSION Adults Because of the slow rate of absorption, the administration of intraperitoneal fluid is unlikely to be of any significant value in initial rehydration of adult cholera patients. After the initial deficit has been corrected by intravenous fluids, however, adequate hydration can be maintained by intra- peritoneal infusion, provided that the rate of stool output does not exceed approximately 200 ml/h. Since the majority of cholera patients have stool rates considerably greater than this, intraperitoneal therapy has little or no practical usefulness in adults. Children Intraperitoneal fluid and electrolyte administra- tion in children, however, was found to be a simple, safe and effective method for partial initial rehydra- tion and replacement of concurrent stool losses in the majority of patients. In 16 of 19 children with proven cholera and in all 7 with non-cholera diar- rhoea, intraperitoneal fluid was absorbed rapidly enough to replace a major part of the initial deficit on admission and all subsequent stool loss. In all 23 successfully treated patients, the blood pressure remained normal after the first hour of therapy, the general clinical state steadily improved and most patients were eating a regular diet after 24 hours. Three children (group III) who had moderate to 844 INTRAPERITONEAL FLUID THERAPY IN CHOLERA AND NON-CHOLERA DLARRHOEA CLINICAL DATA FOR 7 MALE CHILDREN TABLE 5 WITH SEVERE NON-CHOLERA DIARRHOEA, GROUP IV a Patient No. 1 1 2 3 | 4 5 6a 7 a Age (years) 2 '/12 3 1 4/12t 3 10/11 11112 3 Duration of diarrhoea prior to admission (h) 5 24 21 12 11 18 6 Findings on admission: Sensorium Coma Alert Drowsy Drowsy Alert Drowsy Drowsy Loss of skin turgor (Oto + + +) + + + + + + + + + + + + + Body-weight (kg) 10.315 7.820 7.08 3.90 9.32 7.64 9.117 Systolic blood pressure (mm Hg) 48 75 65 85 75 90 20 Blood pH 7.12 7.17 7.17 7.23 7.23 7.21 7.17 Plasma specific gravity 1.032 1.028 1.032 1.024 1.035 1.028 1.030 Standard bicarbonate (mEq/l) 10.6 9.8 11.8 4.35 6.2 6.27 4.8 Stool output (ml) 0 h-24 h 208 942 330 240 698 487 0 24 h-48 h 0 50 120 170 0 32 0 Total Intravenous fluid given (ml) 280 210 150 100 270 0 450 Total intraperitoneal fluid given (ml) 540 1 080 540 350 1 040 540 540 Intake of oral glucose water overfirst24 h (ml) 570 810 825 1 065 1080 1080 1 065 a All treated as for group 11, except patient No. 7, who was treated as for group 1, and Patient No. 6, treated as for group Ill. severe dehydration but who had no associated hypo- tension were successfully rehydrated with intra- peritoneal fluid alone. Two of these passed con- siderable volumes of diarrhoeal stools after admis- sion. On the basis of this small experience, it would appear that rehydration can be effected by intraperi- toneal fluid alone, if treatment is given before the onset of hypovolaemic shock. Two failures in the study point to the basic limita- tion of intraperitoneal fluid therapy. The rate of stool loss may be greater than the rate of effective fluid absorption, so that normal hydration cannot be maintained. These two children had the highest rates of stool loss among the 26 study patients (9.4 ml/kg/h-9.5 ml/kg/h over the first 12 hours after admission). It would appear-although this was not directly measured-that stool rates below about 8 ml/kg/h can be successfully replaced by intraperitoneal fluids alone, whereas those above this value exceed the capacity for intraperitoneal absorption. Ringer's lactate solution, which was used as maintenance replacement fluid, has a 25% higher sodium concentration than the mean concentration of sodium in children's cholera stools (Mahalanabis et al., 1970). Therefore, only 75% of the stool output was replaced by intraperitoneal Ringer's lactate solution. The resultant water deficit, in addition to obligatory water loss through the lungs and kidneys, was met by the liberal intake of oral glucose water. It is possible that the large quantities of glucose water given by mouth may have influenced the reabsorption of sodium within the small bowel, and therefore may have contributed to the therapeutic results. Plans to study this possibility in more detail are contemplated. Maintaining intravenous infusions over any length of time in small children requires skilled personnel, specialized equipment and expert supervision. Moreover, if proper facilities and supervision are not available, overhydration can easily occur in a small child. Both of these difficulties can be largely over- 845 846 D. MAHALANABIS AND OTHERS come if the majority of children in a cholera ward could be maintained on intraperitoneal fluid therapy. The safety of this method, as previously shown in children with infantile diarrhoea (Blackfan & Maxcy, 1918; Carter, 1953; Huckstep, 1962; Ransome- Kuti et al., 1969), has been confirmed in children with cholera. The need for aseptic precautions and for using sterile pyrogen-free infusion fluid and administration sets, however, should be emphasized, since the potential problem of intraperitoneal bacterial infection is always present. These and other complications, such as bladder or bowel perforation, however, have been rare, even under the most primitive of conditions (Carter, 1953; Huckstep, 1962). There is no substitute for the prompt administra- tion of intravenous fluids to combat hypovolaemic shock associated with severe dehydration in children with cholera. Intraperitoneal fluids are not recom- mended for initial treatment in patients with hypo- tension, owing to the variable peritoneal absorption associated with decreased mesenteric blood flow. Once hypotension is corrected, however, intraperi- toneal fluid may be a useful additional or alternative means of replacing a major proportion of the initial fluid deficits and the entire subsequent stool output during recovery. RISUMti ADMINISTRATION DE UQUIDE PAR VOIE INTRAPERITONEALE DANS LE TRAITEMENT DU CHOLERA ET DE LA DIARRHEE GRAVE D'ORIGINE NON CHOLERIQUE, SPECIALEMENT CHEZ LES NOURRISSONS ET LES JEUNES ENFANTS L'administration prolong6e de liquide par voie intra- veineuse chez les jeunes enfants atteint de cholera ne va pas sans poser certains problemes surtout dans les regions oiu les effectifs du personnel m6dical et para- medical sont insuffisants et oii une methode plus simple de r6hydratation serait appr6ci6e. On a etudie la possibilit de recourir a l'injection intraperitoneale de liquide pour compenser les pertes d'eau et d'electrolytes chez 8 adultes et chez 26 enfants ages de moins de 6 ans, atteints d'une forme moyenne ou grave de chol6ra ou d'une affection diarrheique chol6riforme. Les adultes ont recu une solution isotonique de chlorure de sodium et de lactate de sodium, addi- tionn6e de 5 mEq/litre de chlorure de potassium, et les enfants la solution lact6e de Ringer. Chez les adultes, I'administration intraperiton6ale de liquide de remplacement n'apparait pas comme un mode acceptable de therapeutique d'entretien, I'absorption, trop lente, ne permettant pas de compenser les pertes de liquides dans les selles. En revanche, chez les enfants, cette forme de r6hydratation s'est revelee beaucoup plus efficace. Chez 16 des 19 enfants atteints de cholera et chez les 7 enfants souffrant de diarrh6e choleriforme, le liquide introduit par voie intraperiton6ale a et6 r6sorbe suffisamment rapidement pour pallier la plus grande partie du deficit en liquide present au moment de l'admis- sion et les pertes ult6rieures. Trois jeunes choleriques qui presentaient un syndrome de deshydratation relativement grave, mais sans hypotension arterielle associ6e, ont et6 r6hydrates avec succes grace 'a la seule administration de liquide par voie intraperitoneale. Par contre, ce traitement nta pu assurer un 6quilibre normal chez 2 enfants, le rythme d'evacuation des liquides dans les selles, attei- gnant respectivement 9,4 et 9,5 millilitres par kilo et par heure pendant les 12 premieres heures, etant trop rapide. Dans ces deux cas, il a 6te n6cessaire d'appliquer en outre la rehydratation par voie intraveineuse. Un deces, sans relation apparente avec les modalites du traitement, a ete enregistre parmi les enfants. L'utilisation de la voie intraperitoneale n'a donne lieu a aucune complication. REFERENCES Blackfan, K. D. & Maxcy, K. F. (1918) Amer. J. Dis. Child., 15, 19-28 Carter, F. S. (1953) E. Afr. med. J., 30, 499-505 Gan, K. H. & Tjia, S. K. (1963) Amer. J. Hyg., 77, 184- 186 Huckstep, R. L. (1962) Typhoidfever and other salmonella infections, Edinburgh and London, Livingstone Mahalanabis, D., Wallace, C. K., Kallen, R. J., Mondal, A. & Pierce, N. F. (1970) Pediatrics, 45, 374-385 Ransome-Kuti, O., Elebute, O., Agusto-Odutola, T. & Ransome-Kuti, S. (1969) Brit. med. J., 3, 500-503 Sack, R. B., Cassells, J., Mitra, R., Merritt, C., Butler, T., Thomas, J., Jacobs, B., Chaudhuri, A. & Mondal, A. (1970) Bull. Wid Hlth Org. (in press) Watten, R. H., Morgan, F. M., Songkhla, Y. N., Vani- kiati, B. & Phillips, R. A. (1959) J. clin. Invest., 38, 1879-1889