Management of cholera in malnourished patients - PowerPoint Presentation

1. Management of cholera in malnourished patients 29 September 2022Presented by:Dr. Betty LanyeroTechnical officer, Nutrition, WHO, Ethiopia

2. Situation overview – Cholera outbreak, Bale zone as of 25 September 2022

3. Precautions when managing cholera in children with severe acute malnutrition

4. Introduction Two possible scenarios;Child with severe acute malnutrition is referred from the stabilization centre to CTC for cholera management ORB. Child with cholera presents with severe acute malnutrition when admitted to the cholera treatment facility.

5. Key messages: Precautions when managing cholera in children with severe acute malnutrition All patients with SAM and cholera MUST be treated at a Cholera Treatment Centre (CTC) as rehydration should be addressed before nutrition care and treatment is initiatedNutritional status of patients with cholera should be assessed as rehydration differs if the patient has SAMPatients with SAM have different physiology so they must be rehydrated slowly. IV fluids should only be used for SAM patients in shock because of the high risk of fluid overload and heart failureChildren with SAM and cholera must be treated for dehydration using low-osmolarity Oral Rehydration Solution (ORS). Do not use ReSoMal.

6. Key messages: Precautions when managing cholera in children with severe acute malnutrition During rehydration, closely monitor signs of fluid overload Re-assess and re-classify nutritional status after rehydration. Adjust management if needed Patients with SAM and cholera should be treated with therapeutic feeds, following the feeding protocol for patients with SAM and medical complications As soon as the patient has recovered from cholera, nutritional status should be reassessed and the child referred to the Stabilization Centre (SC) Breastfed infants should continue with breastfeeding

7. STEP 1: Determine nutritional status Does the patient have severe acute malnutrition (SAM)? Determine the nutrition status of the patient using a MUAC tapeAssess for presence of bilateral pitting edemaIf no SAM, use the Standard Rehydration Procedures for cholera and refer to the cholera Clinical Guidelines If yes, follow step 2 (assess for dehydration and shock in the SAM patient)Procedure of MUAC measurement

8. STEP 2: Assess dehydration and shock in patients with SAM

9. STEP 3: Treatment for non-dehydrated patients with SAM and cholera Continue breastfeeding and age-appropriate food Administer ORS to replace ongoing losses: If < 2 years old, 50-100 ml per loose stool If > 2 years old, 100-200 ml per loose stool As soon as the patient is stable, refer to the SC for the management of SAM

10. STEP 4: Treatment for dehydrated patients with SAM and cholera - CONSCIOUS and able to drink 5 ml/kg of ORS every 30 minutes for the first 2 hours 5-10 ml/kg per hour of ORS, alternating with F-75, for a maximum of 10 hours or until the fluid deficit is corrected Adjust ORS intake during rehydration phase to compensate for on-going fluid loss in high-output stooling After rehydration give: If < 2 years and wasted, 50-100 ml of ORS orally after each watery stool. If > 2 years and wasted, 100-200 ml of ORS orally after each loose stool. If the child has bilateral pitting oedema, give 30 ml of ORS orally per each loose stool. If the patient cannot drink adequately or is unable to drink, administer ORS via NGT.

11. STEP 5: Treatment for dehydrated patients with SAM and cholera - in shock Give IV treatment as follows: Give IV Ringer lactate with 5% dextrose. 15 ml/kg/h for the first hour then reassess, if there is improvement (a decrease in respiratory and pulse rates), same amount repeated for another one hourAfter 2 hours of IV fluids, give 10 ml/kg per hour of ORS orally or via NGT until the deficit is corrected or until the patient is fully rehydrated Adjust IV flow rate during the rehydration phase to compensate for ongoing fluid loss in high-output stoolingCheck every 10 minutes for heavy or laboured breathingIn case of presence of one or more signs of fluid overload or cardiac failure (heavy, laboured breathing, engorged jugular vein pressure or increased oedema) then stop the IV and consult a physician.

12. STEP 6: Ongoing monitoring Continue to check the patient’s status. Reassess the following after 1 hour: If the breathing status worsens, then stop IV infusion. If you do not see improvement, consider septic shock. If you do see improvement, continue the same amount of IV fluid for the next one hour.

13. STEP 7: Rehydration complete Rehydration is complete when: Patient is no longer thirsty. Urine production has normalized. Other signs of dehydration have resolved. Once hydration is re-established, measure MUAC. If MUAC is still less than 11.5 cm, continue with treatment for non-dehydrated children with SAM. Initiate feeding and treat medical complications such as hypothermia and/or hypoglycaemia.

14. Key points Knowledge and skill in the management of cholera in malnourished patients is critical The national guideline for the management of acute malnutrition includes an annex with protocol for management of cholera in malnourished patients The revised national cholera guideline has included protocol for management of cholera in malnourished patients – case management sectionGlobal Taskforce on cholera control (GTFCC) app Preparedness for the management of cholera in malnourished patients is essential Capacity building, guidelines, job aides Availability of essential commodities; MUAC tapes, nutrition commodities

15. Thank youFor more information, please contactBetty Lanyero,lanyerob@who.int.