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 Diarrhea results in large losses of water and
electrolytes sodium and potassium
 frequently is complicated by severe systemic
acidosis
Symptoms Associated with Dehydration
MILD TO
MINIMAL OR NO MODERATE SEVERE
DEHYDRATION (<3% DEHYDRATION (3– DEHYDRATION (>9%
LOSS OF BODY 9% LOSS OF BODY LOSS OF BODY
SYMPTOM WEIGHT) WEIGHT) WEIGHT)
Mental status Well;alert Normal, fatigued or Apathetic, lethargic,
restless, irritable unconscious
Thirst Drinks normally; Thirsty;eager to drink Drinks poorly; unable
might refuse liquids to drink
Heart rate Normal Normal to increased Tachycardia, with
bradycardia in most
severe cases
Quality of pulses Normal Normal to decreased Weak, thready, or
impalpable
Breathing Normal Normal;fast Deep
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Mouth and tongue Moist Dry Parched
Skinfold Instant recoil Recoil in <2 sec Recoil in >2 sec
Capillary refill Normal Prolonged Prolonged;minimal
Extremities Warm Cool Cold;mottled;cyanotic
Urine output Normal to decreased Decreased Minimal
 Electrolyte Imbalance
 Hyponatremia
 Hypernatremia
 Hypokalemia
 Hyperkalemia
Management
Correction
DEGREE OF REHYDRATION REPLACEMENT OF
DEHYDRATION THERAPY LOSSES NUTRITION
Minimal or no Not applicable <10 kg body weight: 60– Continue breast-feeding,
dehydration 120 mL oral rehydration or resume age-
solution (ORS) for each appropriate normal diet
diarrheal stool or after initial hydration,
vomiting episode; >10 kg including adequate
body weight: 120–240 mL caloric intake for
ORS for each diarrheal maintenance[*]
stool or vomiting episode

Mild to moderate ORS, 50–100 mL/kg body Same Same

dehydration weight over 3–4 hr
Severe dehydration Lactated Ringer solution Same;if unable to drink, Same
or normal saline in 20 administer through
mL/kg body weight nasogastric tube or
intravenous amounts administer 5% dextrose ¼
until perfusion and normal saline with 20
mental status improve; mEq/L potassium
then administer 100 chloride intravenously
mL/kg body weight ORS
over 4 hr or 5% dextrose
½ normal saline
intravenously at twice
maintenance fluid rates
Fluid Management of Dehydration
 Restore intravascular volume
 Normal saline: 20 mL/kg over 20 min
 Repeat as needed
 Rapid volume repletion: 20 mL/kg normal saline or
Ringer Lactate (maximum = 1 L) over 2 hr
 Calculate 24-hr fluid needs: maintenance + deficit
volume
 Subtract isotonic fluid already administered from 24 hr
fluid needs
 Administer remaining volume over 24 hr using D5 ½
normal saline + 20 mEq/L KCl
 Replace ongoing losses as they occur
  Monitoring Therapy
 VITAL SIGNS
 Pulse
 Blood pressure
 INTAKE AND OUTPUT
 Fluid balance
 Urine output and specific gravity
 PHYSICAL EXAMINATION
 Weight
 Clinical signs of depletion or overload
 ELECTROLYTES
Treatment of Hypernatremic Dehydration
 RESTORE INTRAVASCULAR VOLUME
 Normal saline: 20 mL/kg over 20 min
(Repeat until intravascular volume restored)
 DETERMINE TIME FOR CORRECTION BASED ON INITIAL
SODIUM CONCENTRATION
 [Na]:145–157 mEq/L:24 hr
 [Na]:158–170 mEq/L:48 hr
 [Na]:171–183 mEq/L:72 hr
 [Na]:184–196 mEq/L:84 hr
 ADMINISTER FLUID AT CONSTANT RATE OVER TIME FOR
CORRECTION
 Typical fluid: D5 ½ normal saline (with 20 mEq/L KCl unless
contraindicated)
 Typical rate: 1.25–1.5 times maintenance
 FOLLOW SERUM SODIUM CONCENTRATION
 ADJUST FLUID BASED ON CLINICAL STATUS AND
SERUM SODIUM CONCENTRATION
 Signs of volume depletion: administer normal saline (20
mL/kg)
1. Sodium decreases too rapidly
 Increase sodium concentration of intravenous fluid, or
 Decrease rate of intravenous fluid
2. Sodium decreases too slowly
 Decrease sodium concentration of intravenous fluid, or
 Increase rate of intravenous fluid
 REPLACE ONGOING LOSSES AS THEY OCCUR
 Continued enteral feeding in diarrhea aids in
recovery from the episode and a continued
age-appropriate diet after rehydration is the
norm.
 The usual energy density of any diet used for
the therapy of diarrhea should be around 1
kcal/g, aiming to provide an energy intake of
a minimum of 100 kcal/kg/day and a protein
intake of between 2 and 3 g/kg/day
Clinical Manifestations of Abnormalities in Serum
Sodium
Body System Hyponatremia

Central nervous system Headache, confusion, hyper- or

hypoactive deep tendon reflexes,
seizures, coma, increased intracranial
pressure
Musculoskeletal Weakness, fatigue, muscle
cramps/twitching
Gastrointestinal Anorexia, nausea, vomiting, watery
diarrhea
Cardiovascular Hypertension and bradycardia if
significant increases in intracranial
pressure
Tissue Lacrimation, salivation

Renal Oliguria
PREVENTION

 Promotion of exclusive breast-feeding.

 Improved complementary feeding practices
 Rotavirus immunization
 Improved water and sanitary facilities and
promotion of personal and domestic hygiene.
 Improved case management of diarrhea.