Dehydration and its Therapy

DEHYDRATION
• The first step in caring for a child with dehydration is to assess the degree of dehydration.
dehydration Approach to Severe Dehydration :
• The degree of dehydration dictates :
1- Urgency of the situation & 1- Resuscitation phase to treat shock (to
to ensure that there is adequate tissue perfusion)
perfusion :
2- Volume
olume of fluid needed for rehydration. • Types of fluid:
- Crystalloid solution: Isotonic solution normal saline (NS) or Ringer's lactate (RL).
- %of body weight lost is less in older children & adult because water is a higher percentage of body weight in infants.
infants - Blood for a child with acute blood loss.
- The
he patient must be continually re re-evaluated during therapy. • The child is given a fluid bolus, 20 mL/kg of the isotonic soluBon, over about 20 minutes.
- The degree of dehydration is underestimated in hypernatremic dehydration because the osmotically A child with severe dehydration may require multiple fluid boluses AND may need to receive fluid at a faster rate.
driven shift of water from the intracellular to extracellular space helps to preserve intravascular volume. • End of resuscitation :
- The initial resuscitation until an adequate intravascular volume clinically child shows,:
lower heart rate, normalization of blood pressure, improved perfusion, better urine output, a more alert affect.
SYMPOTMS Mild dehydration Moderate dehydration Severe dehydration
Colloids :
% of body <5% in an infant; 5–10% in an infant; >10% (15%) in an infant; - Blood is indicated in the child with significant anemia or acute blood loss.
weight lost <3% in older child or adult 3–6% in older child or adult >6% (9%) in older child or adult - Plasma is useful for children with a coagulopathy.
- 5% albumin used in a child with hypoalbuminemia may benefit from 5% albumin
Mental status - Well - Restless - Apathetic, lethargic,
The volume and the infusion rate for colloids are generally modified compared with crystalloids .
- alert - irritable/lethargic - unconscious
2- Calculate Deficit : The fluid deficit = Percentage of dehydration X patient's weight
Thirst - Drinks normally - Thirsty - Drinks poorly; Severity Infant (<10 Kg) Children (>10kg)
- might refuse liquids - Eager to drink - unable to drink
Mild dehydration 50 ml/kg 30 ml/kg
Heart rate Normal Tachycardia , weak pulse - Tachycardia, weak pulse Moderate dehydration 100 ml/kg 60 ml/kg
- with bradycardia in Sever Dehydration 150 ml/kg 90 ml/kg
most severe cases 3- Maintenance :
Quality of Normal Normal to decreased - Weak, thready, or BODY WEIGHT FLUID PER DAY
pulses - impalpable
0–10 kg 100 mL/kg
Blood pressure Normal Orthostatic hypotension Hypotension 11–20 kg 1,000 mL + 50 mL/kg for each kg > 10 kg
Breathing Normal Deep, may be rapid Deep and rapid >20 kg 1,500 mL + 20 mL/kg for each kg > 20 kg[*]
fontanels Normal Slightly sunken Deeply sunken • The maximum total fluid per day is normally 2,400 mL
With adequate intravascular volume
volume:
Eyes Normal Slightly sunken Deeply sunken
- In isonatremic or hyponatremic dehydration rapid correction (corrected over 24 hr)
Tears Present Decreased Absent - In hypernatremic dehydration Slow correction to avoid brain edema (corrected over 2-4
4 days)
• To assure that the in
intravascular
travascular volume is restored the patient receives:
Mouth & tongue Moist Dry Very dry
(Mucous mem.) (Parched) addiBonal 20-mL/kg
mL/kg bolus of an isotonic fluid over 2 hr.
• The child's total fluid needs are added together (maintenance + deficit).
Skin fold Instant recoil Mild delay in elasticity delayed elasticity • The volume of isotonic fluids that the patient has received is subtracted from this total.
(Skin turgor) Recoil in <2 sec Recoil in >2 sec • The remaining fluid volume iis then administered over 24 hr.
Capillary refill Normal delayed capillary refill very delayed capillary refill • The potassium concentration may need to be decreased or, less commonly, increased, depen depending
ding on the
clinical situation ((Potassium
Potassium is not usually included in the intravenous fluids until the patient voids)
voids
(>1.5 sec) (>3 sec);
• Children with significant ongoing losses need to receive an appropriate replacement solution (see below )
Extremities Warm Cool & pale Cold;mottled;cyanotic Table 33
33-6.
6. Fluid Management of DehydraBon :
Urine output Normal to decreased Oliguria Anuria and severe oliguria Restore intravascular volume
Laboratory Findings Normal saline: 20 mL/kg over 20 minutes
…Normal
• Hemoconcentration as a result of dehydration causes an increase in : …..Repeat
Repeat as needed
CBC
Hematocrit, Hemoglobin, Serum
erum proteins repletion: 20 mL/kg normal saline (maximum = 1 L) over 2 hours
Rapid volume rep
• These values normalize with rehydration. 24-hour fluid needs: maintenance + deficit volume
Calculate 24
• A normal hemoglobin concentration during acute dehydration may mask an underlying anemia. Subtract isotonic fluid already administered from 24
24-hour
hour fluid needs
• A decreased albumin level in a dehydrated patient suggests a chronic disease, such as
Administer remaining volume over 24 hours using D5 ½ normal saline + 20 mEq/L KCl
malnutrition, nephrotic syndrome, or liver disease, or an acute process, such as
a capillary leak.
• Acute
cute or chronic protein
protein-losing
losing enteropathy may also cause a low serum albumin concentration. Replace ongoing losses as they occur
Serum Na Determines
etermines the type of dehydration ( Types of dehydration can be estimated clinically )
Table 33
33-7. Monitoring Therapy :
Hypokalemia : Vital signs Intake and output Physical examination Electrolytes
• The serum potassium concentration may be low as a result of diarrheal losses. Pulse Fluid balance Weight
• In children with dehydration due to emesis, gastric potassium losses, metabolic alkalosis, and Blood pressure Urine output and specific Clinical signs of depletion
urinary potassium losses all contribute to hypokalemia. gravity or overload
serum K Hyperkalemia :
• Metabolic acidosis,
cidosis, which causes a shift of potassium out of cells, and renal insufficiency may lead Hyponatremic dehydration
to hyperkalemia. • Hyponatremic dehydration occurs in children who :
• A combination of mechanisms may be present; thus, it may be difficult to predict the child's acid-
acid 1-- have diarrhea
base status or serum potassium level by the histor
history alone. 2-- consume a hypotonic fluid (water or diluted formula).
Metabolic Metabolic acidosis may be due to : - Volume depletion stimulates secretion of ADH,, preventing the water excretion that should correct hyponatremia.
1- stool bicarbonate losses in children with diarrhea,
acidosis - Some patients develop symptoms, predominantly neurologic, from the hyponatremia
2- secondary renal insufficiency, or
3- lactic acidosis from shock. hyponatremic dehydraBon do well with the same general approach outlined in Table 33
33-6.
The anion gap is useful for differentiating among the various causes of a metabolic acidosis. N.B: Overly rapid correc on of hyponatremia (>12 mEq/L/24 hr) should avoided risk of central pontine myelinolysis.
Metabolic Hypernatremic dehydration
Due to : 1- Emesis or 2- Nasogastric losses
alkalosis • Hypernatremic dehydration occurs is usually as a consequence of an inability to take in fluid, because of :
• BUN & serum creatinine concentration are useful in assessing the child with dehydration. 1-- Lack of access chanism (neurologic impairment) 3- intractable emesis 4-
2- poor thirst mechanism 4 anorexia.
• Volume depletion without parenchymal renal injury may cause a disproportionate increase in the
- The movement of water from the intracellular space to the extracellular space during hypernatremic dehydration
BUN with little or no change in the creatinine concentration.
partially protects the intravascular volume. Urine output may be preserved longer, and there may be less tachycardia.
tachycardia
• This is secondary to increased passive resorption of urea in the proximal tubule due to
appropriatee renal conservation of sodium and water. - Children with hypernatrem
hypernatremic dehydration Are often lethargic and irritable with :
• This increase in the BUN with moderate or severe dehydration may be absent or blunted in the *Hypernatremia may cause: fever, hypertonicity, and hyperreflexia.
child with poor protein intake because urea production is dependent on protein degradation. - Idiogenic osmoles are generated within the brain during the development of hypernatremia
hypern which increase the osmolality within
• The BUN may be disproportio
disproportionately
nately increased in the child with increased urea production, as the cells of brain, providing protection against brain cell shrinkage 2ry to movement of water out of cells into the hypertonic ECF
occurs with a gastrointestinal bleed or with the use of glucocorticoids, which increase catabolism. - These idiogenic osmoles dissipate slowly duri
during
ng correction of hypernatremia With rapid lowering of the extracellular osmolality
BUN & during correction of hypernatremia, there may be a new gradient created that causes water movement from the extracellular spa space
• A significant elevation of the creatinine concentration suggests renal insufficiency, although
alth a
creatinine small, transient increase can occur with dehydration. Acute tubular necrosis (see Chapter 535 )
into the cells of the brain, producing cerebral edema. (manifestations
manifestations of cerebral
cerebral edema include seizures, brain herniation, death )
- N.B. To minimize the risk of cerebral edema the serum Na concentration should not decrease more than 12 mEq/L every 24 hours. hours
due to volume depletion is the most common etiology of renal insufficiency in a child with
volume depletion, but occasionally, the child may have previously undetected chronic renal • The initial resuscitation
resuscitation-rehydration
rehydration phase of therapy remains the same as for other types of dehydration
insufficiency or an alternative explanation for the ac
acute
ute renal failure. • The choice & rate of fluid are not nearly as important as vigilant monitoring of the serum sodium concentration and
• Renal vein thrombosis is a well
well-described
described sequela of severe dehydration in infants; possible adjustment of the therapy based on the result.
findings include thrombocytopenia and hematuria (see Chapter 519 ). • The deficits in severe hypernatremic dehydration may need to be corrected over 2 to 4 days (Table 33-8).
33
• The baseline normal creatinine concentration increases with age; thus, a normal
n adult creatinine Restore intravascular volume
concentra9on of 1 mg/dL may indicate significant renal insufficiency in an infant. Normal saline: 20 mL/kg over 20 minutes (repeat un9l intravascular volume restored)
• The BUN and creatinine concentration are dependent on the timing of the disease process. Urea Determine time for correction based on initial sodium concentration
and creatinine are waste products that build up gradua
gradually
lly with decreased renal excretion. [Na] 145-157 mEq/L: 24 hr
• A child with acute, severe dehydration may have only a minimal elevation of the serum creatinine [Na] 158-170 mEq/L: 48 hr
concentration despite marked renal insufficiency; the creatinine concentration will increase over time.
[Na] 171-183 mEq/L: 72 hr
• Urinalysis is most helpful in the measurement of urine specific gravity, which is usually elevated
in cases of significant dehydration, but returns to normal after rehydration. [Na] 184-196 mEq/L: 84 hr
• Although infants have a reduced ability to concentrate the urine, even those who w are a few Administer fluid at a constant rate over the time for correction
weeks of age can show a clear elevation in specific gravity with significant dehydration. Typical fluid: D5 1/2 normal saline (with 20 mEq/L potassium chloride unless contraindicated)
• A specific gravity <1.020 indicates mild or no dehydra9on or indicates a urinary concentra9ng Typical rate: 1.25-1.5 9mes maintenance
defect, as in chronic renal disease or primary or second
secondary
ary diabetes insipidus. With dehydration, Follow serum sodium concentration
Urinalysis urinalysis may show hyaline and granular casts, a few white cells and red cells, and 30–100
30 mg/dL Adjust fluid based on clinical status and serum sodium concentration
of proteinuria.
Signs of volume deple9on: administer normal saline (20 mL/kg)
• These findings are not usually associated with significant renal pathology, and they remit with
therapy. Sodium decreases too rapidly
• The urine specific gravity is usually elevated ((≥1.025)
≥1.025) in cases of significant dehydra9on but Increase sodium concentration of IV fluid or
decreases after rehydration. With dehydration, a urinalysis may show hyaline and granular casts, Decrease rate of IV fluid
a few white blood cells and red blood cells, and 30 to 10 1000 mg/dL of proteinuria. Sodium decreases too slowly
• These findingss usually are not associated with significant renal
al pathology,
patho and they remit with Decrease sodium concentration of IV V fluid or
therapy. Increase rate of IV fluid
• Hemoconcentration
tration fr
from dehydration causes an increase in the hematocrit
hem and hemoglobin. Replace excessive ongoing losses as theyey occur
 Oral Rehydration Solution (ORS) Treatment of electrolytes disturbances
• In 70–80% of pa9ents isotonic dehydration develop : Electrolyte Treatment
- Occurs when the losses of water & sodium are proportionate. • Emergency treatment of symptomatic hyponatremia, such as seizures, uses:
• In 10–15% of pa9ents Hyponatremic dehydration develop :
IV 1 milliliter/kg of 3% NaCl (hypertonic saline)
- Occurs when large amounts of electrolytes, especially sodium, are lost in the stool out of
proportion to fluid losses. - This increases the serum Na by approximately 1 mEq/L.
- It occurs more frequently with "bacillary dysentery or cholera" - A child often improves after receiving 4 to 6 mL/kg of 3% sodium chloride.
- Hyponatremia may develop or worsen if there is a considerable oral intake
intak of low-electrolyte
or electrolyte-free
free fluids during diarrhea (see Chapter 54 ). • Non-Emergency
Emergency Correction of Hyponatremia :
• In 10-20% of pa9ents hypernatremic dehydration 1- hypovolemic hyponatremia
hyponatremi :
- Occurs when disproportionately large net losses of water compared with losses of electrolytes
Treatment of hypovolemic hyponatremia requires administration of IV fluids
- May occur during the course of diarrhea when :
with sodium to provide maintenance requirements and deficit correction, as
1- oral homemade electrolyte solutions with high concentrations of salt are administered well as to replace ongoing losses
2- when infants are fed boiled skim milk, which produces a high renal solute load and HYPONATREMIA
-
increased urinary water losses. - The child with hypovolemic hyponatremia has a deficiency in sodium and
3- increased evaporative water loss as a result of fever, high environmental temperatures, may have a deficiency in water.
and hyperventilation, and with decreased availability of free water. - Cornerstone
ornerstone of therapy is to replace the sodium
s deficit & any water deficit.
DEGREE OF REPLACEMENT OF - The 1st step in trea9ng any dehydrated pa9ent is to restore the intravascular
DEHYDRATION REHYDRATION THERAPY LOSSES NUTRITION volume with isotonic saline.
- This is frequently needed in hyponatremic dehydration because the low
<10
10 kg body weight: - Continue breast-
serum osmolality causes water to move intracellularly,
intracellularly, further depleting the
60–120 mL ORS feeding, or intravascular volume.
Minimal or no for each diarrheal stool - resume age-
- Ultimately, complete restoration of intravascular volume suppresses ADH
dehydration Not applicable or vomiting episode; appropriate normal production, which permits excretion of the excess water.
diet after initial (See above the management of hyponatremic dehydration)
dehydration
>10 kg body weight: hydration, including
120–240
240 mL ORS N.B.
adequate caloric - Rapid correction of hyponatremia can produce central pontine myelinolysis.
myelinolysis
for each diarrheal stool intake for - Avoiding more than a 12-mEq/L/24
12 increase in the serum Na every, especially
[*]
or vomiting episode maintenance if the hyponatremia developed gradually.
Mild to Same
moderate ORS, 50–100
100 mL/kg over 33–4 hr Same In a child with hypernatremic dehydration, ass in any child with dehydration :
dehydration 1- The first priority is restoration of intravascular volume with isotonic fluid.
IV Lactated Ringer or normal saline same Same 2- Table 33-8
8 outlines a general approach for correc9ng hypernatremic
20 mL/kg over 20 min. dehydration secondary
econdary to gastroenteritis (see above).
if unable to drink,
Severe until perfusion
sion and mental status - administer through NG N.B.
dehydration improve; then administer : or HYPERNATREMIA - Because of the dangers of overly rapid correction, hypernatremia should be
- 100 mL/kg ORS over 4 hr or - administer 5% D ¼ corrected slowly.
- 5%D ½ normal saline IV at twice normal saline with 20 - The goal is to decrease the serum sodium by less than 12 mEq/L every 24
maintenance fluid rates mEq/L KCl IV hours, a rate of 0.5 mEq/L/hr.
- The most important component of correcting moderate or or severe
KCL NaHCO3 NaCl Glucose hypernatremia is frequent monitoring of the serum sodium to :
1- allow adjustment of fluid therapy and
ORS 1.5 gm 2.5 gm 3.5 gm 20 gm 2- provide adequate correction that is neither too slow nor too fast.

- If a child develops seizures from brain edema secondary to rapid correction,

+ - + 2+ -
Composition of IV Solutions [Na ] [Cl ] [K ] [Ca ] [Lactate ] administration of hypotonic fluid should be stopped and infusion of 3%
NaCl (hypertonic saline) should be used to increase the serum sodium acutely.
Normal saline (0.9% NaCl) 154 154
½ normal saline (0.45% NaCl) 77 77 - Severe, symptomatic hypokalemia requires aggressive treatment.
- Supplementation is more cautious if renal function is decreased because of the
0.2 normal saline (0.2% NaCl) 34 34 kidney's limited ability to excrete excessive potassium.
- The plasma potassium level does not always provide an accurate estimation of
Ringer lactate 130 109 4 3 28 the total body potassium deficit :
• because there may be shifts of k from the intracellular space to plasma.
Mild to moderate dehydration : • Clinically, this shift occurs most commonly with metabolic acidosis and as a result of the
insulin deficiency of diabetic ketoacidosis;
- Mild to moderate dehydration from diarrhea of any cause can be treated effectively using a
• the plasma potassium underestimates the degree of total
total body potassium depletion.
simple, oral rehydration solution (ORS) containing glucose and electrolytes.
electrolyte • When these problems are corrected, potassium moves into the intracellular space, and
- These solutions rely on the coupled transport of sodium & glucose in the intestine. these patients require more potassium supplementation to correct the hypokalemia.
- ORS therapy is less expensive than intravenous therapy and has a lower complication rate. - Patients who have ongoing losses of potassium need correction
correction of the deficit and
replacement of the ongoing losses.
1- Rehydration therapy : HYPOKALEMIA Route:
As a guideline for ORS : - Because of the risk of hyperkalemia, (IV) potassium should be used cautiously.
• Patients with mild dehydration: 50 mL/kg within 4 hr - Oral potassium is safer, albeit not as rapid in urgent situations.
Dose :
• Patients with moderate dehydration: 100 mL/kg within 4 hr IV potassium is 0.5 to 1 mEq/kg, usually given over 1 hour.
2- Replacement ORS : The adult maximum dose is 40 mEq.
- is given to replace ongoing losses from diarrhea or vomiting.
• For patients with excessive urinary losses :
- An additional 10 mL/kg of ORS is given for each stoolstool. sparing diuretics are effective, but they need to be used cautiously in
Potassium-sparing
patients with renal insufficiency.
- Fluid intake should be decreased if the patient :
1- Appears
ppears fully hydrated earlier than expected or • When hypokalemia, metabolic alkalosis, and d volume depletion are present :
restoration of intravascular volume decreases urinary potassium losses.
2- Iff periorbital edema develops. - The first action in a child with a concerning elevation of plasma potassium is to
3- Maintenance ORS : stop all sources of additional potassium (oral and IV).
When rehydration is complete, maintenance therapy should be started. - If the potassium level is greater than 6 to 6.5 mEq/L,
mEq/L, an ECG should be obtained
• Patient with mild diarrhea : to help assess the urgency of the situation.
- Therapy of hyperkalemia has two basic goals:
- can be treated at home with 100 mL of ORS/kg/24 hr until the diarrhea stops.
1- Prevent life--threatening arrhythmias.
- Breast-feeding
feeding or supplemental water intake should be maintained.
2- Remove potassium from the body.
bo
• Patients with more severe diarrhea require continued supervision. 1- Rapidly decrease the risk of life-threatening
life arrhythmias
- The volume of ORS ingested should equal the volume of stool losses. a- Shift potassium
otassium intracellularly:
- If stool cannot be measured, intake of 10–15
tool volume can 15 mL of ORS/kg/hr • Sodium bicarbonate administration (IV)
4- Breast-feeding : Should be maintained not delayed for more than 24 hours HYPERKALEMIA - causes potassium to move intracellularly
- In breast-fed infants breast-feeding should be allowed after rehydration • Insulin and glucose (IV)
- The combina9on of insulin and glucose works within 30 min
- In other patients their usual formula, mil
milk, or feeding should be offered. • β-Agonist
Agonist (albuterol via nebulizer)
- Along with its nutritional benefits, early refeeding decreases the duration of diarrhea. - Nebulized albuterol, by stimulation of β1-receptors,
receptors, leads to rapid
- Most children can tolerate a lactose-containing formula, intracellular movement of potassium
ome children benefit from a lactose-free formula if malabsorption is present.
Some b- Cardiac membrane stabilization
- Vomi9ng may occur during the first 2 hr of administra9on of ORS, but it usually does not prevent successful oral • IV calcium
rehydra9on if the ORS is given in small amounts at short intervals (1 tsp every 11–22 min). - Calcium stabilizes the cell membrane of heart cells, preventing
- Emesis usually lessens over time. arrhythmias
- The volume of ORS can be increased slowly, with an increasing interval between feedings. c- Remove potassium from the body
- If sustained and severe vomiting occurs, intravenous therapy should be instituted. The patient's progress should a- Loop diuretic (IV or PO)
be assessed frequently and changes in body weight monitored, if pos
possible,
sible, to determine the degree of rehydration. • In patients who are not anuric, a loop diuretic increases renal excretion of
potassium.
Severe dehydration : b- Sodium polystyrene (PO or rectal)
- Intravenous therapy (see above) may be required for patients with : • is an exchange resin that is given either rectally or orally.
1- severe dehydration Sodium in the resin is exchanged for body potassium, and the potassium-
potassiu
containing resin is then excreted from the body
2- uncontrollable vomiting;
iting;
c- Dialysis
3- those unable to drink
nk becau
because of extreme fatigue, stupor,
r, or coma;
com • Dialysis is often
ten nece
necessary if there is severe renal failure or if there is
i an
4- those with gastric orr intestin
intestinal distention. especially high
igh rate o
of endogenous potassium release