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Dehydration is the excessive loss of body water, with an accompanying disruption of metabolic processes.
1. 2.
I.
3.
I.
Translocation
II.
Burns Ascites
Mild : <3 % of body weight Moderate: 5-9 % of body weight Severe: >10 % of body weight
Physical
The following table highlights the physical findings seen with different levels of
pediatric dehydration. Symptom Mental status Heart rate Mild (<3% body weight lost) Normal, alert Normal Normal Normal Normal Normal Normal Moderate (3-9% body weight lost) Restless or fatigued, irritable Normal to increased Normal to decreased Normal to increased Slightly sunken Slightly sunken Normal to decreased Severe (>9% body weight lost) Apathetic, lethargic, unconscious Tachycardia or bradycardia
Quality of pulse
Breathing Eyes Fontanelle s Tears
Capillary refill
Extremities Symptom Mental status Heart rate
<2 seconds
Warm Mild (<3% body weight lost) Normal, alert Normal
Prolonged
Cool Moderate (3-9% body weight lost) Restless or fatigued, irritable Normal to increased
Minimal
Mottled, cyanotic Severe (>9% body weight lost) Apathetic, lethargic, unconscious Tachycardia or bradycardia
Weak, thready, impalpable Tachypnea and hyperpnea Deeply sunken Deeply sunken
Normal Moist
Instant recoil <2 seconds Warm
Absent Parched
Recoil >2 seconds Minimal Mottled, cyanotic
Prolonged cap refill Sunken eyes Poor overall appearance Sunken fontanelle Absent tears Increased HR Weak Pulse Dry mucous membranes Abnormal resp pattern Abnormal skin turgor or tenting
By far the most common Equal losses of Na and Water Na = 130-150 No significant change between fluid compartments No need to correct slowly
Water loss > sodium loss Na >150mmol/L Water shifts from ICF to ECF Child appears relatively less ill
More intravascular volume Less physical signs Alternating between lethargy and hyperirritability
Physical findings
Dry doughy skin Increased muscle tone
Correction
Correct Na slowly If lowered to quickly causes massive cerebral edema intractable seizures
Sodium loss > Water loss Na <130mmol/L Water shifts from ECF to ICF Child appears relatively more ill
Less intravascular volume More clinical signs Cerebral edema Seizure and Coma with Na <120
Correction
Must again be performed slowly unless actively
seizing Rapid correction of chronic hyponatremia thought to contribute to. Central Pontine Myelinolysis
Fluctuating LOC Pseudobulbar palsy Quadraparesis
Oral Rehydration Therapy (ORT) vs Intravenous therapy (IVT) To poke or not to poke, that is the question
Contraindications to ORT
Severe dehydration (10%) Ileus or intestinal obstruction Unable to tolerate (Persistent vomiting) Signs of shock Decreased LOC or unconscious Unclear diagnosis Psychosocial situations
Commercial preparations
Pedialyte Infalyte Rehydralyte WHO rehydration salts
Osmoles mOsm/L
Glucose mmol/L
Na mEq/L
Cl mEq/L
HCO3 mEq/L
K mEq/L
WHO formulation
330
110
90
80
30
20
Pedialyte
AJ
270
730
140
690
45
5
35
x
30
x
20
32
Sports drink
D5W / 0.45% saline
330
454
255
300
20
77
x
77
3
0
3
0
Management of severe dehydration requires IV fluids Fluid selection and rate should be dictated by
The type of dehydration The serum Na Clinical findings
D5NS is fluid of choice ( deficit the bolus) over the first 8hrs
Add maintenance and any ongoing losses to above Further the deficit replaced over the next 16hrs
Na deficit =
Divide above by Na in mEq/L within the replacement fluid
154 mEq in NS 77 mEq in D5 NS 513 in 3% saline
If seizing
Correct with 3% Saline bolus Target a Na of 120 Further correction beyond this with D5 NS Correct with D5 NS Target a Na of 130
If not Seizing