DEHYDRATION

M K DENIS
BCM, MCM – A & E
MKU
OVERVIEW
• Dehydration is a common complication of illness observed in pediatric
patients presenting to the emergency department.
• Early intervention are important to reduce risk of progression to
hypovolemic shock and end-organ failure.
• Volume depletion in children is caused by fluid losses from vomiting or
diarrhea
• Mild or moderate volume depletion should be treated with oral
rehydration when possible.
• Intravenous fluid therapy is necessary when oral therapy fails or volume
depletion is severe.
EPIDEMIOLOGY
• Majority of cases are due to gastroenteritis
• Approximately 30 million children are affected annually, with 1.5
million presenting to outpatient care, 200,000 requiring
hospitalizations, and 300 dying in the United States (King et al)
• For children younger than 5 years, the annual incidence of diarrheal
illness is approximately 1.5 billion, while deaths are estimated
between 1.5 and 2.5 million per year (Centers for Disease Control and
Prevention (CDC)
• Morbidity varies with the degree of volume depletion and the
underlying cause.
ETIOLOGY
• Dehydration is frequently the result of increased output from condition characterized by vomiting and
diarrhea. i.e.
• GI causes of vomiting include the following:
• Gastroenteritis
• Obstruction
• Hepatitis
• Liver failure
• Appendicitis
• Peritonitis
• Intussusception
• Volvulus
• Pyloric stenosis
• Drug toxicity (ingestion, overdose, drug effects)
ETIOLOGY
• CNS causes of vomiting include the following:
• Infections
• Increased intracranial pressure
• Psychogenic vomiting is not seen in infants and is rare in
children
• Endocrine causes of vomiting include the following:
• Diabetic ketoacidosis (DKA)[4]
• Congenital adrenal hypoplasia
• Addisonian crisis
ETIOLOGY
• Renal causes of vomiting include the following:
• Infection
• Pyelonephritis
• Renal failure
• Renal tubular acidosis
• GI causes of diarrhea include the following:
• Gastroenteritis
• Malabsorption (e.g. milk intolerance, excessive fruit juice)
• Intussusception
• Irritable bowel syndrome
• Inflammatory bowel disease
• Short gut syndrome
ETIOLOGY
• Endocrine causes of diarrhea include the following:
• Thyrotoxicosis
• Congenital adrenal hypoplasia
• Addisonian crisis
• Diabetic enteropathy
• Volume depletion from increased output NOT caused by vomiting or diarrhea may be
divided into renal or extrarenal causes.
• Renal causes of volume depletion include:-
• Use of diuretics
• Renal tubular acidosis
• High output renal failure
ETIOLOGY
• Extrarenal causes of volume depletion include the following
examples:-
• Third-space extravasation of intravascular fluid (e.g.
pancreatitis, peritonitis, sepsis, heart failure, nephrotic
syndrome, protein-losing enteropathy)
• Hemorrhage
Pathophysiology
• Volume depletion denotes reduction of effective circulating volume in the
intravascular space, whereas dehydration denotes loss of free water in greater
proportion than the loss of sodium.
• 2 major fluid compartments: the intracellular fluid (ICF) and the extracellular
fluid (ECF).
• ECF is further divided into the interstitial fluid (75%) and plasma (25%). The
TBW comprises approximately 70% of body weight in infants, 65% in
children, and 60% in adults
• Infants' and children’s higher body water content, along with their higher
metabolic rates and increased body surface area to mass index, contribute to
their higher turnover of fluids and solute.
• Therefore, infants and children require proportionally greater volumes of water
than adults to maintain their fluid equilibrium and are more susceptible to volume
depletion.
• Significant fluid losses may occur rapidly, leading to depletion of the intravascular
volume.
• In hyponatremic volume depletion, the patient may appear more ill clinically than
actual fluid losses would otherwise indicate.
• The degree of volume depletion may be clinically overestimated. Serum sodium
levels less than 120 mEq/L may result in seizures
• If intravascular free water excess is not corrected during volume replenishment, the
shift of free water to the intracellular fluid compartment may cause cerebral edema
PRESENTATION
• The goal of the history and physical examination is to determine the
severity and etiology of the child's condition.
• Accurate classification of the degree of dehydration as mild, moderate, or
severe allows for appropriate therapy
• Obtaining a complete history from the parent or caregiver is important
because it provides clues to the type of dehydration present
• History taking:- • Feeding pattern and fluids given
• Fluid loss (e.g. vomiting, diarrhea)
• Number of wet diapers compared with normal, suggesting
oliguria or anuria
PRESENTATION
• Activity level
• Possible ingestions that may cause vomiting
• Heat and sunlight exposures for insensible losses
• Current illness pattern, fever, ill contacts
• Recent weight prior to current illness
• Physical Examination:-
• Steiner et al found that the most useful signs (i.e. highest likelihood ratios) for
recognizing 5% dehydration are the following:
• Abnormal capillary refill time
• Abnormal skin turgor
• Abnormal respiratory pattern
Differential Diagnoses
• Diabetic Ketoacidosis
• Hypernatremia
• Hyperosmolar Hyperglycemic Nonketotic Coma
• Hypokalemia
• Hyponatremia
• Hypovolemic Shock
• Metabolic Acidosis
• Pediatric Gastroenteritis
• Pediatric Pyloric Stenosis
Diagnosis
• RBS – Esp. if there is change in mental status
• Serum electrolytes - all children with severe dehydration and in those receiving
intravenous fluids
• Comprehensive metabolic panel to include electrolytes, BUN, Cr, glucose, iCa,
Phosphate, Magnesium,
• Albumin.
• Venous blood gases
• Serum lactic acid
• Complete blood cell count (CBC)
• Urinalysis
* If in hypovolemic shock
Rationale:-

• Bicarbonate and potassium levels also are important to assess the degree of metabolic
acidosis from volume depletion and tissue hypoperfusion as well a screen for
coexisting hypokalemia.
• Blood urea nitrogen and creatinine levels measure renal function and intravascular
volume.
• The glucose measurement may reveal hyperglycemia or hypoglycemia.
• Serum lactate elevation is indicative of tissue perfusion and oxygenation resulting in
anaerobic metabolism. It may be helpful in cases of severe dehydration or sepsis.
• The CBC may be helpful in cases in which volume depletion is due to sepsis or
hemorrhage.
• On urinalysis, the urine specific gravity indicates the degree of volume depletion and
may also reveal an underlying infectious etiology.
Obtaining Vascular Access
• Prior to vascular access attempts, consider oral rehydration in mild and moderate
dehydration
• Sites for intravenous access include superficial veins in the dorsum of the hand, the
antecubital fossa (median cephalic or basilic veins), dorsum of the foot, and scalp
veins.
• Use intraosseous access if attempts to start percutaneous intravenous lines are
unsuccessful
• For central venous access, typical sites are as follows:
• Femoral vein
• Internal jugular vein
• Subclavian vein
TREATMENT
General Approach:
• Address emergent airway, breathing, and circulatory problems first. Obtain
intravenous access, and give a 20 mL/kg isotonic fluid bolus (Ringer lactate
or normal saline) to children with severe volume depletion. This should not
delay transport to the appropriate facility.
• Reassessment of perfusion, cardiac function, mentation should take place
after each intervention. At times, cardiac failure can mimic volume depletion
leading to further deterioration of clinical findings after fluid administration.
• Failure to diagnose appendicitis, intussusception, or small bowel obstruction
places patients at risk of serious complications (including death).
SOME DEHYDRATION
Presentation: • Management: (Plan B)
• Able to drink adequately but 2 or • ORS by mouth at 75 ml/kg over
more of: 4 hrs., plus,
• Sunken eyes • Continue breast feeding as
• Return of skin pinch 1 - 2 secs tolerated
• Restlessness / irritability • Reassess at 4 hrs. & treat
according to classification.
NO DEHYDRATION
Presentation:
• Diarrhea with fewer than 2 of the
following signs of dehydration:-
• Sunken eyes
• Return of skin pinch 1 - 2 secs
• Restlessness / irritability
Management: (Plan A)
• 10mls/kg ORS after each loose
stool
• Continue breast feeding and
encourage feeding if > 6 months
• Encourage to continue an age-appropriate diet and adequate intake of
oral fluids.
• Oral rehydration solution (ORS) should be used.
• Children should be given sips of ORS (5 mL or 1 teaspoon) every 2
minutes.
• As an estimate for the amount of fluid to replace, the goal should be to
drink 10 mL/kg body weight for each watery stool and estimate
volume of emesis for each episode of vomiting.
• ORS is not available:-
• In 1 L of water, add 2 level tablespoons of sugar or honey, a quarter
teaspoon of table salt (NaCl), and a quarter teaspoon of baking soda
(bicarbonate of soda)
• If baking soda is not available, use another quarter teaspoon of salt
instead
• If available, add one-half cup of orange juice, coconut water, or a
mashed ripe banana to the drink
• Guidelines from the American Academy of Pediatrics on fruit juice in
infants, children and adolescents recommend against the use of fruit
juice in the treatment of dehydration or the management of diarrhea.
Severe Volume Depletion
• Use Intravenous isotonic fluid boluses (20-60 mL/kg)
• In children with difficult peripheral access, perform intraosseous or central
access promptly.
• Fluid boluses should be repeated until vital signs, perfusion, and capillary
refill have normalized.
• If a patient reaches 60-80 mL/kg in isotonic crystalloid boluses and is not
significantly improved, consider other causes of shock (e.g. sepsis,
hemorrhage, cardiac disease).
• Consider administering vasopressors and instituting advanced monitoring,
such as a bladder catheter, central venous pressure, and measuring mixed
venous oxygen saturation.
HYPOVOLEMIC SHOCK
Presentation:
• Weak/absent pulse;
• AVPU < A;
• Cold hands + Temp gradient;
• Capillary refill > 3 secs
• PLUS sunken eyes and slow skin
pinch
NB:I f Hb < 5 g/dl, transfuse
urgently
Treatment:
• Ringer’s 20ml/Kg bolus
• A second bolus may be given if
required before proceeding to:
Step 2 of Plan C:
• 70ml/kg – ringer’s over 2.5 hrs. if
aged 12m and above or 5 hrs. if
aged <12 months.
• Start ORS at 5ml/kg/hr. once able
to drink
SEVERE DEHYDRATION
Presentation: Management: (Plan C)
• Unable to drink • Step 1: 30ml/kg Ringers over 30 min if
aged >12m or over 60 min if age <12m
• AVPU < A plus • Step 2: 70ml/kg Ringer’s over 2.5 hrs.
• Sunken eyes if aged 12m and above or 5 hrs. if aged
<12 months.
• Skin pinch over 2 secs
Start ORS at 5ml/kg/hr. once able to
drink
OR
• NG rehydration - 120 ml/kg ORS over
6 hrs.
• Re-assess at least hourly.
• After 3- 6hrs, re-classify as severe some or no dehydration and treat
accordingly
• All cases to receive Zinc.
• Antimicrobials are NOT indicated unless there is dysentery or proven
Amoebiasis or Giardiasis.
• Remember to check a bedside glucose level for patients who appear
lethargic or altered.
• Treat hypoglycemia promptly.
• The appropriate dose is 0.25 g/kg IV (2.5 mL/kg of 10% dextrose or 1
mL/kg of 25% dextrose) with reassessment of glucose level after
administration of dextrose.
• Once vital sign abnormalities are corrected, initiate maintenance fluid
therapy plus additional fluid to make up for any continued losses
• Daily requirements for maintenance fluids can be approximated as
follows:-
• If the patient weighs less than 10 kg, give 100 mL/kg/day
• If the patient weighs less than 20 kg, give 1000 mL/d plus 50 mL/kg/day for each
kilogram between 10 and 20 kg
• If the patient weighs more than 20 kg, give 1500 mL/day, plus 20 mL/kg/d for each
kilogram over 20 kg
NB: Divide the total by 24 to obtain the hourly rate
• Daily fluid requirements may be met using dextrose 5% in half-normal saline solution.
• For patients with significant hyponatremia or hypernatremia, it is preferable to use
dextrose 5% in normal saline.
• Dextrose is important to include because these patients generally have a notable
ketosis.
• Also consider daily sodium and potassium requirements as follows:
• Sodium 2-3 mEq/kg/d
• Potassium 2-3 mEq/kg/d
• The goal for correction rates for either hyponatremic or Hypernatremic
patients should be no more than 0.5 mEq/L/h or no more than 8mEq/L per
24 hour period
• This to prevent the devastating CNS complications of over-rapid
correction (central pontine myelinolysis and cerebral edema)
• Full correction of severe sodium abnormalities usually should be staged
over 24-48 hours or longer
• Failure to correct for hypokalemia during volume repletion may result in
clinically significant hypokalemia.
• Add potassium to fluids when the patient has documented hypokalemia.
• Avoid adding potassium to fluids until the patient has received
resuscitation and has demonstrated adequate urine output.
NB:
• Children with severe volume depletion, especially those with
hypernatremia or hyponatremia, require inpatient therapy.
• Children with severe hyperosmolar states, severe electrolyte derangements,
or associated renal failure may require admission to a critical care unit.
SEVERE MALNUTRITION WITH
DIARRHOEA
SHOCK:
• AVPU<A , plus absent, or weak pulse plus prolonged capillary refilling
(>3s) plus cold periphery with temperature gradient 20mls/kg in 2 hrs.
of Ringer’s lactate with 5% dextrose – add 50 ml 50% dextrose to 450
ml Ringer’s lactate.
• If severe anemia start urgent blood transfusion not Ringer’s.
IF NOT IN SHOCK OR AFTER TREATING SHOCK
• If unable to give oral/NGT fluid because of very poor medical condition
use/continue with iv fluids at maintenance regimen of 4mls/kg/hr.
• If able to introduce oral or ng fluids / feeds:
• For 2 hours: Give ReSoMal at 10mls/kg/hour
• Then: Give ReSoMal at 7.5ml/kg over 1 hour then introduce first feed
with F75 and;
• Alternate ReSoMal with F75 each hour at 7.5ml/kg/hr. for 10 hrs. –
can increase or decrease hourly fluid as tolerated between 5 –
10ml/kg/hr.
• At 12 hours switch to 3 hourly oral / NG feeds with F75
References
• Alex Koyfman, MD: Pediatric Dehydration: Nov 2017 medline
• Freedman SB, Willan AR, Boutis K, Schuh S.: Effect of Dilute Apple
Juice and Preferred Fluids vs Electrolyte Maintenance Solution on
Treatment Failure Among Children With Mild Gastroenteritis: A
Randomized Clinical Trial. JAMA. 2016 May 10.
• Barkin RM, Ward DG. : Infectious diarrheal disease and
dehydration. Marx JA. Rosen's Emergency Medicine: Concepts and
Clinical Practice. 6th ed. Philadelphia, Pa: Mosby/Elsevier; 2006.
• Pediatric management guidelines: 2016: Diarrhea/Gastroenteritis: pg.
20.