PEDIATRIC DEHYDRATION

INTRODUCTION Less tolerance to fluid/lyte changes b/c of higher metabolic rate in kids versus adults Turnover of fluids and solute 3Xs that of adult Higher % TBW (75% in neonate, 65% in child, 60% in adult) APPROACH TO DEHYDRATION: THE FIVE POINT ASSESSMENT... What is the volume deficit? Estimation by clinical assessment of % dehydration X body weight Does an osmolar deficit exist? Hyponatremic (hypotonic) dehydration = Na < 130 Isonatremic (isotonic) dehydration = Na 130 - 150 Hypernatremic (hypertonic) dehydration = Na > 150 Does an acid - base deficit exist? Loss of bicarbonate in diarrhea ----> normal anion gap metabolic acidosis Ketoacidosis (lipolysis- poor oral intake --> increased anion gap met acidosis Lactic acisosis (tissue hypoperfusion) > increased anion gap met acidosis Respiratory alkalosis as compensation for above Does a potassium disturbance exist? K+ loss in diarrheal stools Typical deficits: isonatremic (8-10 mEq/kg), hypoonatremic (8-10 mEq/kg) hypernatremic (0-4 mEq/kg) Serum K+ not reflective of total bd K+ b/c of shifts (acid/base disturbance) High K+: K+ replacement needs to be cautious, watch for renal failure What is the renal function? Pre-renal versus renal failure: Urine Na, FE Na, urine sediment, etc MAINTENANCE REQUIREMENTS Fluid losses 50% urine 50% insensible (2/3 derm, 1/3 resp) Fluid requirement 4:2:1 rule per hour or 100:50:20 rule per 24hr 4cc/kg/hr for 0 - 10kg: 2cc/kg/hr for 10 - 20kg: 1cc/kg/hr for > 20kg 100cc/kg/24hr for 0-10: 50cc/kg/24hr for 10-20: 20cc/kg/hr for > 20kg Caloric requirement Same 4:2:1 rule to determine Kcal/kg/hr or 100:50:20 rule for daily caloric requirement Electrolyte requirements Na+ requirement is 3mEq/kg/24hr K+ requirement is 3mEq/kg/24hr Kidney produces enough bicarbonate therefore not required Glucose: 5g glucose per 100ml maintenance fluid enough to prevent ketosis

 Requirements will increase with fever, ventilation, inc. activity, etc DEFICITS/DEHYDRATION Loss is mainly from ECF Estimate by: (wt b/f - wt a/f)/wt b/f = % dehydration. Rarely have accurate wt b/f :. must estimate clinically History Intake: what, how much? Output: urine, sweat, feces, vomiting? how much? Lethargic, activity level

MILD % Appearanc e Vitals < 5%

Thirsty, alert, restless Normal radial pulse and RR, BP normal Normal fontanelle Moist mucous mem Normal eyes Tears

MODERATE 6 - 10%
Thirsty, drowsy, orthostatic Rapid but strong radial pulse, increased RR, BP normal Sunken fontanelle Dry mucous mem Sunken eyes Absent tears

SEVERE > 10%

Lethargic, limp, cold

Rapid and weak radial pulse, increased RR, BP normal or low Very sunken fontanelle Parched mucous mem Very sunken eyes Absent tears Cap > 5 sec Marked tenting Reduce or no urine Loss of > 100 ml/kg

H/N

SKIN GENERAL

Cap refill < 2sec No tenting Normal urine Loss of 40 - 50 ml/kg

Cap refill 3 - 4 sec Mild tenting Reduced, dark urine Loss of 60 - 100 ml/kg

History + NO physical Findings

History + physical findings

History + severe findings

Physical Examination Gen: irritable, restless, lethargic, looks unwell Vitals: temp, RR, HR, BP, cap refill, wt H/N: mucous mem, eyes sunken, fontanelle, tearing Derm: skin turgor PEARL Isotonic: lethargy with severe dehydration Hypotonic: coma or seizure with severe dehydration Hypertonic: irritability or seizure with severe dehydration Clinical Estimation (note that 1cc = 1gm) Mild: 0 - 5% X body weight (5% X 10kg = 500cc) Moderate: 5 - 10% X body weight (10% X 10kg = 1000cc) Severe: 10 - 15% (15% X 10 kg = 1500cc)

PATHOPHYSIOLOGY Isonatremic (Isotonic) Dehydration: 80% [Na] between 130 - 150 Roughly equal losses of Na and water NO change in body tonicity or redistribution of fluid between extra and intravascular spaces Hyponatremic (hypotonic) Dehydration: 5% [Na+] is < 130 mmol/L Sodium loss > water loss Most common cause is sodium poor replacement of GI loss Child appears relatively more ill than expected b/c water shifts from ECF to ICF :. there is less intravascular volume and more physical signs Na < 120: seizures, coma Cerebral edema can lead to seizures Hypo-osmolar demyelination syndrome,most commonly seen as central pontine myelinolysis, can occur. Uncertain whether these are due to hyponatremia itself or too rapid correction of Na+. Pathophysiology unknown. Thought to be due to rapid correction in chronic hyponatremia. Neurological findings include fluctuating LOC, behavioral disturbances, convulsions progressing to pseudobulbar palsy and quadraparesis. Hypernatremic (Hypertonic) Dehydration: 15% [Na+] > 150 mmol/L Water loss > sodium loss or increased Na+ intake (incorrect formulas) Child appears relatively less ill than it is b/c water shifts from ICF to ECF :. there is more relative intravascularvolume and less physical signs Risk: brain hemorrhage, SZ, coma, death Do NOT correct rapidly w/ hypotonic solution b/c of brain shifts which can cause massive brain swelling May have alternating LOC b/w lethargy and hyperirritability PE: dry, rubbing, doughy skin w/ inc muscle tone (doughy skin b/c hypertonicity of body fluids in subcutaneous tissues) Risk: intracellular dehydration :. water shifts out of the brain cells. This stress causes production of idiogenic osmols (glycine and taurine) which prevents ongoing water loss from neurons. If serum Na is lowered too quickly, these idiogenic osmols will then attract water into brain cells

causing swelling, massive cerebral edema, and intractable seizures. MUST correct serum Na slowly, and remember that tissue/renal perfusion is maintained w/ high Na MANAGEMENTOF SEVERE DEHYDRATION Approach is ABCs with emphasis on iv access ALL types of severe dehydration require a fluid bolus of 20 cc/kg of 0.9% NaCl or Ringers Theoretical risk of acidosis with normal saline: infusion of NaCl dilutes the extracellular HC03- creating a dilutional acidosis. Ringers lactate has some HCO3 in it. Reassess q 5-10 min after bolus and repeat as needed X 2 Avoid glucose containing solutions for initial resuscitation of severe dehydration If hypoglycemic: give 2ml/kg D25W (children) or 4ml/kg DW10 (infants)if hypoglycemic Consider colloids (albumin, FFP, synthetics) if renal, cardiac, or pulmonary dz Consider differential dx of shock if nonresponsive to 3 boluses (>60 ml/kg): septic, spinal, hypovolemic, hemorrhagic, obstructive, cardiogenic, anaphylactic, other ISONATREMIC DEHYDRATION Phase I (0 - 20min): Bolus 20 cc/kg X 3 prn of normal saline, lactate ringers Phase II (0 - 8hrs): Infusion with D5W 0.45% normal saline (D5W NS) Add 20 mEq/L KCL after urine output established Rate cc/hr = ( deficit - bolus) + maintenance X 8hrs + ongoing losses 8 hours Phase III (8-24hrs): Infusion with D5W 0.45%NS Adjust according to urine output if neccessary; monitor lytes Rate cc/hr = deficit + maintenance X 16hrs + ongoing losses 16 hours

HYPONATREMIC DEHYDRATION Phase I (0-20min): Bolus 20 cc/kg X 3 prn of NS or LR Phase II (0-8hrs) If not seizing ... administer D5W NS with objective to raise serum Na by no more than 12 mEq/L over 24hrs no NaCl bolus necessary rate cc/hr = ( deficit - bolus) + maintenanceX8hrs + losses 8 hours If seizing... Na deficit = (desired - current [Na]) X TBW X weight (kg) Na deficit = (120 - [Na]) X 0.6 X kg replace with 3% saline (0.5 mEq/ml or 513 mEq/L) use 120 as desired Na to prevent rapid overcorrection rough estimate is 4 ml/kg of 3% saline rate of administration: 1 ml/kg/hour proceed with fluids to raise Na by no more than 12 mEq/L over next 24hrs; monitor lytes after 3% saline, use D5W NS rate cc/hr = ( deficit - bolus) + maintenanceX8hrs +

losses

8 hours

Phase III (8-24hrs) DW5 NS Rate cc/hr =1/2 deficit + maintenance X 16hrs + ongoing losses 16 hours

HYPERNATREMIC DEHYDRATION Phase I: Bolus 20 cc/kg NS X 3 prn Phase II/III Treat shock and give fluids to replace deficits over 48hrs (vs 24hr) Reduce serum Na by no more than 10 mEq/L/24hrs Dialysis for SeNa > 210 mEq/L Acceptable solutions: D5W0.45%NS or D5W0.2%NS NOTE that rate of solution more important than type of solution Rate cc/hr = ( deficit - bolus) + maintenanceX24hrs + ongoing losses 24 hours SPECIAL SITUATIONS Acidosis Regardless of type of dehydration, pt may b/cm acidotic from lactate secondary to poor perfusion, ketone production, or bicarbonate loss in diarrhea Most recover spontaneously with rehydration Consider HCO3- for pH < 7.0 or HCO3 < 10 (debatable) NaHCO3 deficit = 20 - SeHCO3 X 0.6 X kg Remember that HCO3 can cause severe K+ shifts and paradoxical CSF acidemia Do not fully correct acidosis Potassium Remember shifts; ddx is mainly GI vs renal loss Always ensure urine output and renal function before replacing K+ Replace with 20 - 40 mEq Kcl/L Maximum is 60 mEq/L in peripheral iv Replace potassium gradually over 2 days ORAL REHYDRATION THERAPY (ORT) Contraindications to oral rehydration therapy Severe dehyration/shock Lethargy Acute abdomen Intestinal obstruction Underlying complicating illness Failure of oral rehydration therapy Circulatory collapse Increasing deficit despite ORT Deterioration during ORT Intractable vomiting Failure to rehydrate in 8hrs Technique Rehydrate in ED over 4hrs, reassess Review contents of pedialyte, WHO solution, gatorade, apple juice, soup,

etc D/C home at 4 hours if rehydrated, continue if not D/C home or admit at 8 hours Give 1/4 of target volume Q1hr X 4 Target volumes mild = 60 ml/kg, moderate = 80 ml/kg or: deficit + maintenance + ongoing losses Controversy/Discussion Why is glucose needed? the absorption of Na occurs by a Na/Glucose cotransporter which remains functional during diarrhea (even secretory) Is there a role for NG placement and rehydration vs oral vs iv rehydration Does it make sense to give frequent small volumes/sips to thirsty infant to try to prevent vomiting? Dehydration with Vomiting after every drink ....... some goes up, some goes down. Note studies with administration of drug followed immediately by ipecac: < 50% of drug is recovered thus at least is going down.

Na WHO Pedialyte Gatorade Pop 90 45 20 3

K 20 20 3 .1

Cl 80 35 0 0

HCO3/ citrate 10 30 0 7

Glucose (gm/dl) 2 2.5 2.1 10

mOsm 310 270

IV vs ORT in PEDIATRIC GASTROENTERITIS

Any signs of dehydration? Duration of illness? Pmhx? Decent ORT trial?

LOOKS DRY LOOKS UNWELL LETHARGIC DURATION >2-3d FAILED A GOOD ORT TRIAL

CONSERVATIVE APPROACH

MORE AGGRESSIVE

ORT IN ED AND OBSERVE 4HRS HOME IF SUCCESSFUL IV IF NOT SUCCESSFUL

ORT AT HOME REGARDLESS OF VOMITING IN ED

IV THERAPY

APPROACH TO PEDIATRIC DEHYDRAITON

1. Initial Resuscitation

Emphasis on iv access and bolus administration of 20 cc/kg prn X3 for severe dehydration/shock
2. Determine % Dehydration (volume of deficit)

Mild: <5% Moderate: 6 - 10% Severe: > 10%

3. Define Type of Dehydration: osmolar deficit?

Hyponatremic (hypotonic): Na < 130 Isonatremic (isotonic): Na 130 - 150 Hypernatremic (hypertonic): Na > 150
4. Determine Type and Rate of Fluids

Calculate deficit, maintenance, ongoing losses

5. Final Considerations

Does an acid - base deficit exist? Does a potassium disturbance exist? What is the renal function?

MAINTENANCE
4:2:1 RULE = 0 - 10 kg: 4cc/kg/hr 10 - 20 kg: 2cc/kg/hr > 20 kg: 1cc/kg/hr 100:50:25 RULE = 0 - 10 kg: 100cc/kg/24hr 10 - 20 kg: 50 cc/kg/24hr > 20 kg: 25 cc/kg/24hr

DEFICIT
HOW DO YOU ASSESS % DEHYDRATION

DEFICIT = % DEHYDRATION x BODY WEIGHT (1cc = 1gm) 5% dehydrated X 10 kg = 0.05 X 10000cc = 500cc 10% dehydrated X 10kg = 0.10 X 10000cc = 1000cc 15% dehydrated X 10 kg = 0.15 X 10000cc = 1500cc

PEDIATRIC DIARRHEAL DISEASE

INTRODUCTION Why are diarrheal illness more significant in children? Higher risk of fluid/electrolyte deficiecies b/c of size, physiology Generally less developed immune system Dependancy on adult for fluid rehydration Less stores of glycogen and electrolytes Etiology Viral 60% Bacterial 20% Parasites 5% Parental illness 10% Unknown 5% VIRAL GASTRO Rotavirus

Overall the MCC Winter and spring epidemics (50% at those times) Destroys the small intestinal villi Incubation is from 1-3 days Fecal excretion may be prolonged 5-50 days! Stool antigens can be done

BACTERIA Most common causes Shigella: MCC Salmonella: 2nd MCC

 Campylobacter jejuni: 3rd MCC Yersini Clostricum perfringes Staph aurues Vibrio Ecoli enterohemorrhagic and 0157H7 Shigella Starts watery then progresses to dysentery Most common 6 months - 10 years, rare < 3 months Septra X 10 days for signficiant illness Salmonella May be invasive or non-invasive Most common in < 1year but can be any age Can spread to bone, brain, joints, kidney, or pericardium Antibiotics only required for complications/spread Campylobacter Invasive; Mild requires no treatment Severe should be treated with erythromycin Clostridium diff Less common in kids but does occur Tx is flagyl or vancomycin po COMPLICATIONS Dehydration Acidosis Hypokalemia Hypovolemic shock Seizures: acid/base, hyponatremia DIAGNOSIS Indications for stool studies Duration > 5-7 days Bloody or invasive features Immunocompromised Toxic, septic Suspected parasites Travel Camping Poor water Invasive vs non-invasive Fecal leukocytes Fecal hemocult +ve or gross blood +ve DDX Vomiting without diarrhea is something else until proven otherwise Vomiting GI: gastro, obstruction, pancreatitis, appy, intuss, volvulus, pyloric stonosis, et Neuro: meningitis, encephalitis, increased ICP Toxic: any ingestion, drug side effect

Diarrhea

GU: UTI, renal ffailure, pyelo, RTA Cardiac: chf Infection: pneumonia, sepsis, etc Endocrine: DKA, adrenal insufficiency, addisons Gastroenteritis IBD Malabsorption syndromes IBS Short gut syndrome Drug side effects: abx Thyrotoxicosis Other endocrine: addisons, CAH Any infections

MANAGEMENT Campylobacter jejuni Erythromycin X 7 days Cdiff Vancomycin or flagyl X 7 days Ecoli Septra X 7 days Giardia Flagyl X 7 days Salmonella Ampicillin + Gentamycin iv if toxic Shigella Ampicillin iv it toxic; Amoxil or septra for 7d if non-toxic Discharge instructions Box 166-1