💧 Chapter 83: Diarrhoea in PICU

Nosocomial Diarrhoea · C. difficile · Antibiotic-Associated · ORS · Zinc · Severe Dehydration vs Shock · De-resuscitation

💧 Diarrhoea in PICU: Nosocomial, Infectious, and Enteral Feeding-Related

📊 Definitions
• Nosocomial diarrhoea: onset ≥3 days after admission
• Severe dehydration: signs of shock, altered sensorium, feeble pulses
• Antibiotic-associated diarrhoea (AAD): common complication of antibiotics
🦠 Clostridium difficile
• Anaerobic, spore-forming, Gram-positive bacillus
• Risk factors: recent antibiotics, prolonged ICU stay, PPI use, enteral nutrition
• Diagnosis: stool ELISA for toxins A/B or PCR
• Treatment: oral vancomycin (125-500 mg q6h) or metronidazole (mild)
⚠️ Severe Dehydration vs Decompensated Shock
• Severe dehydration: sensorium usually maintained, low BP late
• Decompensated shock: unconscious, feeble/absent pulses, hypotension early
• Shock requires rapid IV fluid boluses (20 mL/kg)
💊 ORS and Zinc
• Reduced-osmolality ORS: Na 75, glucose 75, total osmolarity 245
• Zinc: 3-6 months → 10 mg × 14 days; >6 months → 20 mg × 14 days
• Reduces duration and severity of diarrhoea
🍽️ Enteral Feeding-Related Diarrhoea
• Causes: fast advancement, high osmolality, hypoalbuminaemia, medications
• Management: slow rate, change formula, check for C. diff, probiotics
⚠️ C. difficile Severity Grades
• Mild: diarrhoea, minimal systemic symptoms
• Moderate: IV fluids needed, WBC 10-20k, fever
• Severe: ICU, hypotension, WBC >20k, ileus, peritonitis → colectomy may be needed
⚠️ Critical Pearls: C. difficile is a major nosocomial threat — strict hand hygiene and isolation required. Zinc and ORS are first-line for community-acquired diarrhoea. Distinguish dehydration from shock — shock requires aggressive IV fluids.

🩺 Step-by-Step: Diarrhoea Management in PICU

1
Assess severity — dehydration vs shock
Mild/moderate dehydration: ORS. Severe dehydration with shock: IV fluids 20 mL/kg bolus. Decompensated shock: rapid boluses, consider inotropes.
2
Determine aetiology
• Community-acquired: viral, bacterial, parasitic. Check stool culture, O&P.
• Nosocomial (≥3 days admission): suspect C. difficile, medication-associated, enteral feeding-related.
3
Evaluate enteral feeding causes
• Fast advancement, high osmolality, low fibre, medications (antibiotics, laxatives, PPIs)
• Management: slow rate, change to fibre-containing or lower-osmolality formula, consider post-pyloric feeding
4
Suspected C. difficile — isolate patient
Contact precautions (gloves, gown, hand washing with soap and water — alcohol not sporicidal). Send stool for C. diff toxin/PCR.
5
Treat C. difficile
• Mild-moderate: oral metronidazole 30 mg/kg/day × 10-14 days
• Severe: oral vancomycin 40 mg/kg/day (max 500 mg q6h) × 10-14 days
• Fulminant: IV metronidazole + oral/rectal vancomycin, surgical consult
6
Supportive care
• ORS (hypotonic) for mild-moderate dehydration
• IV fluids for severe dehydration
• Zinc supplementation (10-20 mg/day × 14 days)
• Probiotics (S. boulardii, L. rhamnosus GG) may reduce AAD
7
Prevention
• Strict hand hygiene, contact precautions for C. diff
• Avoid unnecessary antibiotics
• Slow advancement of enteral feeds, use fibre-containing formulas when appropriate