Fluidtherapyindehydration

Howsevereisthedehydration?

Cold Hands plus, weak / absent pulse, and one of: Capillary refill > 3 secs Not alert, AVPU < A

Shock

Howsevereisthedehydration?
Cold Hands plus, weak / absent pulse, and one of: Capillary refill > 3 secs Not alert, AVPU < A

Sh k Shock

Pulse easy to feel, but unable to drink or AVPU < A plus: Sunken Eyes Skin pinch 2 secs

Severe Dehydration

Howsevereisthedehydration?
Cold Hands plus, weak / absent pulse, and one of: Capillary refill > 3 secs Not alert, AVPU < A Pulse OK but unable to drink plus: Sunken Eyes Skin p pinch 2 secs?

Sh k Shock

Severe Dehydration

Able to drink plus 2 of: Sunken Eyes and / or Skin p pinch 1 - 2 secs Restlessness / Irritability

Some S Dehydration

Howsevereisthedehydration?
Cold Hands plus, weak / absent pulse, and one of: Capillary p y refill > 3 secs Not alert, AVPU < A Pulse OK but unable to drink plus Sunken Eyes Skin pinch 2 secs? Able to drink plus 2 or more of: Sunken Eyes and / or Skin p pinch 1 - 2 secs Restlessness / Irritability

Shock

Severe Dehydration Some Dehydration No Dehydration

Not classified above?

Whydoweusethesesigns?
Shockrequires q immediatemanagement g Theabilitytodrinkisanimportantindicatorof severity.Iftheycandrinkthenuseoralororal+ngt fluids. fluids SunkenEyesandSkinPincharethemostreliable signsofdehydration Signswhichworkpoorlyinclude:
Dry ymucousmembranes Absenceoftears Poorurineoutput

TreatingShock/SevereDehydration
Thegreatestconcernisthelossoffluidfromthe circulation. Torestorecirculationthefluidreplacedatfirstneeds, id ll to ideally, t b belik likeplasma l

Sodium, Na+ Potassium K+ Potassium,

140 mmol/l 4 0 mmol/l 4.0

Whichcommonivfluidshaveasimilar composition i i toplasma? l ?

Allconcentrationsarein mmol/l

Na+ 154 130

K+ 0 5.4

NormalSaline(0.9%) RingersLactate (Hartmanns)

Useoflowsodiumcontentfluids
Fluid deficit If the fluid deficit is first replaced with a low sodium fluid then body sodium is diluted. These low sodium fluids are much less good at restoring the circulation and can cause hyponatraemia leading to convulsions

Existin ng fluid

Na+, 140 mmol/l

Lowsodiumconcentrationfluidsthatshouldnot be usedtocorrectshockorseveredehydrationunless thereisseveremalnutrition

All concentrations are in mmol/l

Na+
Half Strength Darrows (& 5% Dextrose)

K+ 17

61

Lowsodiumconcentrationfluidsthatshouldnot be usedtocorrectshockorseveredehydrationinany situation.

Allconcentrationsarein mmol/l Dextrose(4%)/Saline (0.18%) 5%Dextrose

Na+ N 31 0

K+ 0 0

Treatmentofhypovolaemicshock
Shock identified Airway & B Ai Breathing thi (oxygen) ( ) effectively managed

Establish iv / io access Signs persist 20 mls / kg bolus of fluid (<15 mins) Re-assess clinical signs of shock

Treatmentofseveredehydrationwithoutshock
Full Strength Ringers
(Normal Saline if unavailable)

Age < 12 months 30 mls / kg over 1 hour 70 mls / kg over 5 hours

Age 12 months to 5 years 30 mls / kg over 30 mins 70 mls / kg over 2.5 hours

Step 1 Step 2

Then re-assess child if still signs of severe dehydration repeat step. If signs improving treat for some dehydration This is equivalent to correcting 10% dehydration in 3 6 hours

ReassessafterSteps1and2 3 6hours
Cold Hands plus, weak / absent pulse, and one of: Capillary p y refill > 3 secs Not alert, AVPU < A Pulse OK but unable to drink plus Sunken Eyes Skin pinch 2 secs? Able to drink plus 2 or more of: Sunken Eyes and / or Skin p pinch 1 - 2 secs Restlessness / Irritability

Shock

Severe Dehydration Some Dehydration No Dehydration

Not classified above?

Somedehydrationisbesttreatedwith ORS
Oralrehydration(bymouthorngt)worksjust aswellasivrehydration rehydration.
Inonedetailedreviewof>1500childrendeaths andconvulsionswerefewerintheorallytreated groupthanintheivtreatedgroup. IftherateofdrinkingisnotadequateORScan safelybegivendownanngtube.

Howmuchtogive?
ORS++ ORSplenty FrequentORS ORSuntil ilb better

PrescribingORS
75mls/kgofORSover4hours. After4hoursreassessandreclassify;
Severe,Someornodehydration?

Counselingthemother/caretaker? Whatdoyoutellthemotherofan8kgchild?

ORSinpractice.

300 mls l

200 mls l

PrescribingORS
75mls/kgforan8kgchild?
600mls in4hours 2largecups/2soda bottlesin4hours 3small llcupsi in4h hours.

Vomitingandfeeding?
VomitingisNOTacontraindication tooral lrehydration h d i Carefulcounselingabout,slow, steady d administration d of fORSis helpful. Breastfeedingandotherformsof feedingcanandshould continue Thereisnoevidenceofbenefit fromusinghalfstrengthfeedsor gradualreintroductionoffeeding feeding.

Roleofantibiotics&Zinc.
Onlyblooddiarrhoeaistreatedwithantibiotics Ciprofloxacinfor3days Butifachildisshockedorhassignsofanother severeillnessthentreatwithappropriate antibiotics Zincshouldbegiventoallchildrenwithdiarrhoea asitspeedsresolutionofsymptoms:
10mgod(halftab)for14daysifage<6months 20mgod(onetab)for14daysifage>=6months

Questions?

Summary
Asmallnumberofsignsaremostusefulin classifyingtheseverityofdehydration. Shock&severedehydrationmustbe treatedusingfluidswithphysiological sodiumconcentrations. Classifyseverity,treatbyspecifyingfluid, volumeandinfusionduration. Then reassess.