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Prepared By Quek Meichi Group 1

Dehydration is the excessive loss of body water, with an accompanying disruption of metabolic processes.

1. 2.
I.

Decreased intake Increased output


Insensible losses II. Renal losses III. GI losses

3.
I.

Translocation
II.

Burns Ascites

Diarrhea Vomiting Gastroenteritis Stomatitis or pharyngitis Febrile illness DKA DI Burns

According to weight loss

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

Weak, thready, impalpable


Tachypnea and hyperpnea Deeply sunken Deeply sunken Absent

Mucous membranes Skin turgor

Moist Instant recoil

Dry Recoil <2 seconds

Parched Recoil >2 seconds

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

Quality of pulse Breathing Eyes Fontanelles

Normal Normal Normal Normal

Normal to decreased Normal to increased Slightly sunken Slightly sunken

Weak, thready, impalpable Tachypnea and hyperpnea Deeply sunken Deeply sunken

Tears Mucous membranes


Skin turgor Capillary refill Extremities

Normal Moist
Instant recoil <2 seconds Warm

Normal to decreased Dry


Recoil <2 seconds Prolonged Cool

Absent Parched
Recoil >2 seconds Minimal Mottled, cyanotic

According to type of dehydration:

Isonatremic dehydration Hyponatremic dehydration Hypernatremic dehydration

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

Oral rehydration therapy


Appropriate for mild to moderate dehydration Safer Less costly Administered in various clinical settings

Fluid replacement should be over 3-4hrs


50ml/kg for mild dehydration 100ml/kg for moderate dehydration

10ml/kg for each episode of vomiting or watery diarrhea

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

Oral rehydration solutions contain


45-90 mmol/L Na 74-140 mmol/L glucose

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

Aggressive IV NS bolus remains the mainstay of early intervention in all subtypes

Calculate the fluid deficit


Deficit (ccs) = % dehydration x body wt

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

Monitor electrolytes and U/O

Fluid deficit = (Current Na/Desired Na 1) x 0.6 x body wt


Replace with D50.2%NS Replace over 48hrs

Reduce sodium by no more than 10mEq/L/24hrs

( deficit the bolus) over the first 24hrs


Add maintenance and any ongoing losses to above

Further the deficit replaced over the next 24hrs

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

(Nadesired- Nacurrent) x 0.6 x Weight (kg)

divide by deficit x 2 to determine rate at 0.5mEq/L/hr

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

Watch for Central Pontine Myelinolysis


More likely in chronic hypo-Na with less Sx Correct slowly at rate of 0.5mEq/L/hr

Thank You For Your Attention