Water imbalance

● Dehydration
● Overhydration
Dehydration
 Dehydration
Hyponatremia Hypernatremia
Diarrhoea Diarrhoea
Vomiting Vomiting
Blood loss Nasogastric drainage
Diuretic agents Enterocutaneous fistula
Osmotic diuresis (glucose, urea, mannitol) Use of osmotic cathartic agents
Excessive sweating (e.g. in marathon (e.g. lactulose)
runners) Loop diuretics
Fluid sequestration in ‘third space’ (bowel Osmotic diuresis (glucose, urea, mannitol)
obstruction, peritonitis, pancreatitis, Polyuric phase of acute tubular necrosis
muscle trauma, burns) Postobstructive diuresis
Adrenal insufficiency Intrinsic renal disease
Excessive sweating
Burns
Central diabetes insipidus
Nephrogenic diabetes insipidus
Unreplaced insensible losses ((dermal and
respiratory)
Hypodipsia
 Clinical Evaluation of Dehydration
Normal or increased pulse,
Mild decreased urine output, thirsty,
(3-5%) normal physical examination

Tachycardia, little or no urine output, irritable/

Moderate lethargic, sunken eyes and fontanel, decreased
(7-10%) tears, dry mucous membranes, mild tenting of
the skin, delayed capillary refill, cool and pale
Rapid and weak pulse, decreased blood pressure, no urine
Severe output, very sunken eyes and fontanel, no tears, tenting
(10-15%) of the skin, very delayed capillary refill, cold and mottled,
decreased consciousness, Kussmaul breathing
Signs of volume depletion/dehydration
● Dry mucous membranes (dry mouth)
● Decreased skin turgor
● Increased thirst
● Altered mental status (confusion, lethargy)
● Dizziness, lightheadedness
● Headache
● Tachycardia, palpitations
● Hypotension, orthostasis
● Presyncope or syncope
● Weakness, fatigue
● Decreased urine output, concentrated urine (deep
yellow or amber color)
 Assessment of Dehydration
● Look for a recent weight change
Fluid deficit (L) = Pre-illness weight (Kg) - illness weight (Kg)

● Gauge clinical appearance

(Pre-illness weight - Illness weight)
% Dehydration = x 100%
Pre-illness weight

● Sodium content
< 130 mEq/L = Hypotonic
130 - 150 mEq/L = Isotonic
150 mEq/L = Hypertonic
 Clinical signs and symptoms of
dehydration in children
Some Severe
No dehydration
dehydration dehydration

Restless, Lethargic or
Condition Well, alert
irritable unconscious

Eyes Normal Sunken Very sunken

Tears Present Absent Absent

Mouth and
Moist Dry Very dry
tongue
Drinks Drinks poorly,
Thirsty, drinks
Thirst normally, not or not able to
eagerly
thirsty drink

Springs back Goes back Goes back very

Skin
quickly slowly slowly
 Signs and symptoms of dehydration
in infants and children
Mild Moderate Severe
Finding
(3-5 percent) (6-9 percent) (≥10 percent)
Pulse Full, normal rate Rapid Rapid and weak
Systolic pressure Normal Normal to low Very low
Deep, rate may be
Respirations Normal Deep, rapid rate
increased
Tacky or slightly
Oral tissues Dry Parched
dry
Infant fontanelle Normal Sunken Markedly sunken
Eyes Normal Sunken Markedly sunken
Cool, mottled,
Skin Normal Cool blue-tinged
hands/feet
Urine output Mildly reduced Markedly reduced Absent
Listlessness, Grunting,
Systemic signs Increased thirst
irritability lethargy, coma
 WHO guidelines for assessment of dehydration
Predicted degree of dehydration
Clinical feature Some Severe
None
dehydration dehydration
(<5 percent)
(5-10 percent) (>10 percent)
General Lethargic or
Well, alert Restless, irritable
appearance unconscious
Eyes Normal Sunken Sunken

Drinks normally, Thirsty, drinks Drinks poorly or

Thirst
not thirsty eagerly unable to drink

Goes back very

Skin pinch Goes back quickly Goes back slowly
slowly
Estimated fluid
<50 mL/kg 50-100 mL/kg >100 mL/kg
deficit
World Health Organization. The treatment of diarrhea: A manual for physicians
and other senior health workers, 4th revision. WHO/FCH/CAH/05.1. World Health
Organization, Geneva 2005.
Fluid management of Dehydration
● Fluid Resuscitation (restore intravascular
volume)
● Calculate daily water requirement
(maintenance, deficit replacement)
● Calculate daily electrolyte (sodium and K+)
requirement (maintenance, deficit
replacement)
● Select an appropriate fluid (based on total
water and electrolyte requirement)
● Administer base on the type of dehydration
● Replace ongoing losses as they occur
Approach to fluid
management in adult
with hypovolemia
Initial management of
shock in children
Calculation of daily water requirement
• Maintenance
Holliday-Segar formula
First 10 kg = 100 ml/kg daily or 4 ml/kg/hr
Second 10 kg = 50 ml/kg daily or 2 ml/kg/hr
Additional kg = 20 ml/kg daily or 1 ml/kg/hr

• Deficit replacement
Water deficit replacement
Water deficit = % dehydration x weight (kg) x 10 mL
Hypertonic dehydration
Free water deficit = 4 ml/Kg for each mEq Na+ excess
 Replacement fluid volume for
patients with dehydration
Age Weight Fluid
<4 months <5 kg 200 to 400 mL
4 to 12 months 5 to 8 kg 400 to 600 mL
1 to 2 years 8 to 11 kg 600 to 800 mL
2 to 4 years 11 to 16 kg 800 to 1200 mL
5 to 14 years 16 to 30 kg 1200 to 2200 mL
>14 years >30 kg 2200 to 4400 mL
World Health Organization. The treatment of diarrhea: A manual for physicians
and other senior health workers, 4th revision. WHO/FCH/CAH/05.1. World Health
Organization, Geneva 2005.
 Calculation of electrolytes requirement
Maintenance
Na+ =2-4 mEq/kg/day
K+ =1-2 mEq/kg/day

Sodium deficit calculation

[(normal Na(mEq/L)) – (measured Na(mEq/L)] X TBW (L)

· Use 135mEq/L as normal Na

· Estimate TBW as 0.6 L/kg X body weight (kg)
· Determine the patient’s overall fluid status to help clarify cause of hyponatremia
Formula for use in managing
hyponatraemia and hypernatraemia
Clinical use
Estimate the effect of 1 L of any infusate containing Na+
and K + on serum Na+
Formula

[infusate Na+ + infusate K+] - serum Na+

Change in serum Na =
total body water + 1

Total body water (in litres) is calculated as a fraction of body weight: 0.6 in children; 0.6 and 0.5 in non-
elderly men and women, and 0.5 and 0.45 in elderly men and women, respectively. Normally, extracellular
and intracellular fluids account for 40 and 60 per cent of total body water, respectively
 The characteristics of infusates
Infusate Na+ ECF distribution
Infusate
(mmol/l) (%)
5% NS 855 *100
3% NS 513 *100
0.9% NS 154 100
Ringer’s lact sol 130 97
0.45% NS 77 73
0.2% NS-D5W 34 55
D5W 0 40
* In addition to its complete distribution in the extracellular compartment,
this infusate induces osmotic removal of water from the IC compartment.
 Fluid Administration Schedule
Isotonic dehydration
● First 8 hr : 1/3 maintenance + 1/2 deficit
● Next 16 hr : the remainder
Hypotonic dehydration
● Same as isotonic dehydration
● Or 24 hours treatment period
Hypertonic dehydration
● Avoid dropping the serum Na+>15 mEq/L per 24 hr to
minimize the risk of cerebral edema
● Free Water deficit replacement should be spread over 48
hours
● Follow Na+ level at least every 4 hours initially
Oral re-hydration therapy safe and
effective as first line treatment for
dehydration due to acute diarrhea
in children
● Arch Pediatr Adol Med 2002;156:1240-3
● Pediatrics 2002;109:566-72
● Arch Pediatr Adol Med 2004;158:483-5
● BMC Medicine 2004;2:11-5
Overhydration
 Overhydration
(water excess or water intoxication)

The body contains too much water*

● Primary polydipsia
● Dilute infant formula
● Accidental intake of large amounts of
water (e.g. during swimming lessons)
● Multiple tap-water enemas
● Congestive heart failure
● Cirrhosis
● Nephrotic syndrome
● Renal failure (acute or chronic)
*Mostly with hyponatremia
 Sign of overhydration
Early signs Advanced signs Far-advanced signs
Anorexia Impaired response to Decorticate or decerebrate
Headache verbal stimuli posturing
Nausea Impaired response to Bradycardia
Emesis painful stimuli Hypertension or hypotension
Hypotension Bizarre behavior Altered temperature regulation
Tachycardia Hallucinations Dilated pupils
Weakness Obtundation Seizure activity
Muscular Incontinence Respiratory arrest
cramps Respiratory insufficiency Coma
 Treatment
● Mild: fluid restriction
● In more severe cases:
● Diuretics/furosemide, to increase urination
● Hypertonic saline/3% NaCl is not routinely
recommended
● Vasopressin receptor antagonists/
Demeclocycline is rarely indicated
● Emergent dialysis if indicated