Hyperemesis :- What
will be ideal kind of fluid therapy in women with Hyperemesis or diarrhoea
pending Na, K are available? The ideal & safe policy in case of severe
vomiting where Lc is lost too much:-We should always say “NO DNS”:
It should be should be
forewarned to ward sisters that they should not initiate 5% Dextrose also (as
it is readily available in nurses table) in a hurry for first 1-2 days of Tr.:-
- 1)
to start I
.V. drip (no restriction on oral feeds-foods as per her choice but better
restrict carbohydrate rich oral food ...
3)
Issue
8:-Rural settings: - Be it acute diarrhea & vomiting. And she is admitted at a SD
/Taluka level hospital where neither Na, K estimation is available, what should be initial drip? Message to Gynae members working in remote
areas with meager lab back up, particularly after 4 p.m.
4)
To start drip at earliest opportunity
without waiting for acetone & electrolyte reports & immediately IV Vit
B1 supplementation:-What kind of drip?? It should be NS (NaCl=0.9%=150 m.mol/L
Na+)-replace K as per serum electrolyte reports later (electrolyte estimation
to be done at least on daily basis --for usually first 3-4 days) if she is on
TPN as happens in serious cases of diarrhea. As I appealed to all of U:-Say NO DNS: Say NO to
5% Dextrose àNo PLEASE. Such types of fluids may kill her à may yield Wernicke’s encephalopathy.
5)
No double strength saline please-even if document hyponatraemia.4)
supplement Vit B1 by parental route:-if available-otherwise oral tab (in our
country Vit B1 is available as BENALGIS – (Tab form 25-50 mg TDS) -U may keep
it at your own stalk-because at Kolkata there is limited supply. It is -for
best interest of your pts.) . I V dose will be thiamine 100mmg diluted in NS
again –over 30-60 mts. If not available
one can administer Inj Multivitamin as we commonly use in P.ileus.
Firstly simply Hyperemesis is not to be
confused with Hyperemesis which is a serious condition decussating
hospitalization.
In cases simple nausea chewing ginger, give
chewable chocolates, ginger., honey &
some
dry foods before leaving bed and taking small foods at a time will help. Only
few women with progress to Hyperemesis who will warrant antiemetic Ry. If one
antiemetic is not sufficed then one can quickly add another one or even two
more antiemetic to relive her as all antiemetic are safe and nonteratogenic.
This dictum should be in the mind of practioners .To added other types of
antiemetic: - at least 3 agents concurrently to combat incessant vomiting-. No
hesitation / No apprehension about teratogens :-My preferences are 1) Tab B6 -10 mg QDS-preceded by
Ondansteron 4/ 8 mg or phenergan
sublingual(MD is now available) each time sublingually 30 mts prior to B6 tab ,2) liberal Chewing
ginger pieces --.& 3) Doxyalamine &
4) promethazine-MD antihistamincs ( Extra Pyramidal effects can appear
with promethazine ( Phenothiazines) can cause drowsiness / Extrapyramidal sump
–with Reglan are rare possibilities)à then switch over to some other agents. My
experience is that one may have to combine as many as four kinds of antiemetic
for initial 3-4 days if this is real Hyperemesis and nothing can be taken by
mouth (simple nausea vomiting is not be confused with Hyperemesis-which warrant
hospital admission) à may have to
be prescribed à gradually
taper off. Antiemetic should not be stopped too early. Not to discharge home from Hosp/N Home too
early. Corticosteroids I V very rarely prescribed. Hydrocortisone 100 mg I V BD
basis. All IV drips slowly –too rapid Na replacement May harm her. If
persistent vomiting then to rule out other pathology may try benefited with single shot
of injection phenergan ,failing which hydrocortisone
100mg iv bd
. What are the other causes of Hyperemesis in Preg?
To think of any Surgical
causes? If vomiting is not
controlled by 72 hrs with above quoted regime:-One should explore other causes of vomiting (GB Stone,
UTI, Subacute App hyperthyroidism..
Hiatus hernia.
Deworm the patient if
recent H/O passage of R worm.
What investigations? How best to gauze metabolic changes but
rpt vomiting?? 1) Urine for acetone Urine alb, ketones, pus cells etc, Sp Gr may be high, & blood biochemistry
right on admissionàlater USG.-not Obstet but whole abd
as GB may be cause of vomiting. Also to .rule out twin & rarely
molar pregnancy. 2) Blood
biochemistry:-serum electrolytes, &
vary rarely when her condition is very critical on admission àone may rarely opt for ABG( arterial blood gas-which
will by 2 minutes time yield information on 10-32 characteristics of blood
,Resp & metab component mainly including serum lactate) . Metabolic
Hyperchloraeic alkalosis is common. Whole abd USG if not earlier. Meanwhile
either maintains Intake output OUTPUT chart, or else weigh the woman at daily /
alt day 3) LFT, RFT, compl Heamogram…
Follow up of Hyperemesis:- Weight the women daily, Vomitus chart , similarly, Na, Ka,
Creatinine, Uric acid, LFT, & PCV daily or alt day depending on the severity.
Not to estimate TSH & T4 - as TSH will falsely exhibit low figure due to
gest hyperthyroidism an effect of increased HCG. Vit B12 def may also
follow better to suppl inj Vit B12 as safety margin is high. Like vit D.
What is Korsakoff psychosis Such psychotic
changes in Hyperemesis cases is not impossible if one mistakenly administer 5% D-5% or DNS à then what will go wrong?? Administered glucose will consume
existing Vit B1 in tricarboxy Acid cycleà and utilize
whatever Vit B1 is there àresulting into quick
depletion of serum Vit B1 def. As such there will be 6 Th nerve palsy,
Nyastagmus, gaze palsy (Wernicke’s encephalopathy).
Additionally as
because due to rpt vomiting her liver F. is already abnormalà so
conversion of existing B1 by liver to its active substance i.e. Thiamine
pyrophosphate IS INTERFERD WITH. Low level of RBC transketolase will
confirm such diag of acute B1 def. If not cared at this early phase she will
proceed to a more dangerous phase of then this encephalopathy will proceed to
Korsakoff psychosis.
To exclude Iatrogenic Korsakoff psychosis?? It may so happen DNS or 5% Dextrose plain have been administered by nurses
inadvertently on admission at ER with severe vomiting or say diarrhoea-this
drip can invite trouble in the form of: Korsakoff psychosis.
Take home message :- to admit all Hyperemesis cases
& estimate rft lft tft , haemogram, & urine for acetone ,alb & msu .
To maintain vomitus chart , initiate iv
fluids which is a must Normal saline 2 lit bottle-with inj B1B6 B12 (Inj MVI
will, serve the purpose) ,as explained
later it will help to revert Wernicke’s
encephalopathy . Second step is to send her to USG Deptt or Portable USG:-
exclude other causes for vomiting like GB,hiatus hernia, molar, twin etc. Given
parenteral antiemetic and antacids too (patoprazole) , Inj Phenergan,
/chlorpromazine initially will yield good result. After 2-4 days she usually
will be symptom free .If starts vomiting again inspite of above quoted two
agentys then there should not be any hesitation to start hydrocortisone.
1-10-19 .Then what will
be ideal kind of fluid therapy in women with Hyperemesis or diarrhoea
pending Na, K are available? The ideal & safe policy in case of severe
vomiting where Lc is lost too much:-We should always say “NO DNS”:
It should be should be
forewarned to ward sisters that they should not initiate 5% Dextrose also (as
it is readily available in nurses table) in a hurry for first 1-2 days of Tr.:-
- 1)
to start I
.V. drip (no restriction on oral feeds-foods as per her choice but better
restrict carbohydrate rich oral food ...
6)
Issue
8:-Rural settings: - Be it acute diarrhea & vomiting. And she is admitted at a SD
/Taluka level hospital where neither Na, K estimation is available, what should be initial drip? Message to Gynae members working in remote
areas with meager lab back up, particularly after 4 p.m.
7)
To start drip at earliest opportunity
without waiting for acetone & electrolyte reports & immediately IV Vit
B1 supplementation:-What kind of drip?? It should be NS (NaCl=0.9%=150 m.mol/L
Na+)-replace K as per serum electrolyte reports later (electrolyte estimation
to be done at least on daily basis --for usually first 3-4 days) if she is on
TPN as happens in serious cases of diarrhea. As I appealed to all of U:-Say NO DNS: Say NO to
5% Dextrose àNo PLEASE. Such types of fluids may kill her à may yield Wernicke’s encephalopathy.
8)
No double strength saline please-even if document hyponatraemia.4)
supplement Vit B1 by parental route:-if available-otherwise oral tab (in our
country Vit B1 is available as BENALGIS – (Tab form 25-50 mg TDS) -U may keep
it at your own stalk-because at Kolkata there is limited supply. It is -for
best interest of your pts.) . I V dose will be thiamine 100mmg diluted in NS
again –over 30-60 mts. If not available
one can administer Inj Multivitamin as we commonly use in P.ileus.
Firstly simply Hyperemesis is not to be
confused with Hyperemesis which is a serious condition decussating
hospitalization.
In cases simple nausea chewing ginger, give
chewable chocolates, ginger., honey &
some
dry foods before leaving bed and taking small foods at a time will help. Only
few women with progress to Hyperemesis who will warrant antiemetic Ry. If one
antiemetic is not sufficed then one can quickly add another one or even two
more antiemetic to relive her as all antiemetic are safe and nonteratogenic.
This dictum should be in the mind of practioners .To added other types of
antiemetic: - at least 3 agents concurrently to combat incessant vomiting-. No
hesitation / No apprehension about teratogens :-My preferences are 1) Tab B6 -10 mg QDS-preceded by
Ondansteron 4/ 8 mg or phenergan
sublingual(MD is now available) each time sublingually 30 mts prior to B6 tab ,2) liberal Chewing
ginger pieces --.& 3) Doxyalamine &
4) promethazine-MD antihistamincs ( Extra Pyramidal effects can appear
with promethazine ( Phenothiazines) can cause drowsiness / Extrapyramidal sump
–with Reglan are rare possibilities)à then switch over to some other agents. My
experience is that one may have to combine as many as four kinds of antiemetic
for initial 3-4 days if this is real Hyperemesis and nothing can be taken by
mouth (simple nausea vomiting is not be confused with Hyperemesis-which warrant
hospital admission) à may have to
be prescribed à gradually
taper off. Antiemetic should not be stopped too early. Not to discharge home from Hosp/N Home too
early. Corticosteroids I V very rarely prescribed. Hydrocortisone 100 mg I V BD
basis. All IV drips slowly –too rapid Na replacement May harm her. If
persistent vomiting then to rule out other pathology may try benefited with single shot
of injection phenergan ,failing which hydrocortisone
100mg iv bd
. What are the other causes of Hyperemesis in Preg?
To think of any Surgical
causes? If vomiting is not
controlled by 72 hrs with above quoted regime:-One should explore other causes of vomiting (GB Stone,
UTI, Subacute App hyperthyroidism..
Hiatus hernia.
Deworm the patient if
recent H/O passage of R worm.
What investigations? How best to gauze metabolic changes but
rpt vomiting?? 1) Urine for acetone Urine alb, ketones, pus cells etc, Sp Gr may be high, & blood biochemistry
right on admissionàlater USG.-not Obstet but whole abd
as GB may be cause of vomiting. Also to .rule out twin & rarely
molar pregnancy. 2) Blood
biochemistry:-serum electrolytes, &
vary rarely when her condition is very critical on admission àone may rarely opt for ABG( arterial blood gas-which
will by 2 minutes time yield information on 10-32 characteristics of blood
,Resp & metab component mainly including serum lactate) . Metabolic
Hyperchloraeic alkalosis is common. Whole abd USG if not earlier. Meanwhile
either maintains Intake output OUTPUT chart, or else weigh the woman at daily /
alt day 3) LFT, RFT, compl Heamogram…
Follow up of Hyperemesis:- Weight the women daily, Vomitus chart , similarly, Na, Ka,
Creatinine, Uric acid, LFT, & PCV daily or alt day depending on the severity.
Not to estimate TSH & T4 - as TSH will falsely exhibit low figure due to
gest hyperthyroidism an effect of increased HCG. Vit B12 def may also
follow better to suppl inj Vit B12 as safety margin is high. Like vit D.
What is Korsakoff psychosis Such psychotic
changes in Hyperemesis cases is not impossible if one mistakenly administer 5% D-5% or DNS à then what will go wrong?? Administered glucose will consume
existing Vit B1 in tricarboxy Acid cycleà and utilize
whatever Vit B1 is there àresulting into quick
depletion of serum Vit B1 def. As such there will be 6 Th nerve palsy,
Nyastagmus, gaze palsy (Wernicke’s encephalopathy).
Additionally as
because due to rpt vomiting her liver F. is already abnormalà so
conversion of existing B1 by liver to its active substance i.e. Thiamine
pyrophosphate IS INTERFERD WITH. Low level of RBC transketolase will
confirm such diag of acute B1 def. If not cared at this early phase she will
proceed to a more dangerous phase of then this encephalopathy will proceed to
Korsakoff psychosis.
To exclude Iatrogenic Korsakoff psychosis?? It may so happen DNS or 5% Dextrose plain have been administered by nurses
inadvertently on admission at ER with severe vomiting or say diarrhoea-this
drip can invite trouble in the form of: Korsakoff psychosis.
Take home message :- to admit all Hyperemesis cases
& estimate rft lft tft , haemogram, & urine for acetone ,alb & msu .
To maintain vomitus chart , initiate iv
fluids which is a must Normal saline 2 lit bottle-with inj B1B6 B12 (Inj MVI
will, serve the purpose) ,as explained
later it will help to revert Wernicke’s
encephalopathy . Second step is to send her to USG Deptt or Portable USG:-
exclude other causes for vomiting like GB,hiatus hernia, molar, twin etc. Given
parenteral antiemetic and antacids too (patoprazole) , Inj Phenergan,
/chlorpromazine initially will yield good result. After 2-4 days she usually
will be symptom free .If starts vomiting again inspite of above quoted two
agentys then there should not be any hesitation to start hydrocortisone.
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