Dehydraton in pediatrics
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Transcript of Dehydraton in pediatrics
Definition Definition
is defined as an excessive loss of body fluid & electrolytes.
Output is more than input.
Causes Causes
Diarrhea Vomiting Excessive Sweating Diabetes Burns Excessive blood loss caused by
trauma or accident
Pathophysiology of dehydration
Types of dehydration based on severity
Mild : when the total fluid loss reaches 5% or
less .
Moderate : when the total fluid loss reaches 5 - 10% .
Severe : when the total fluid loss reaches more
than 10%, considered an emergency case .
Mild dehydration S&S Mild dehydration S&S
No dehydration Thirsty Conscious Less than 5% of body Weight is
lost.
Moderate dehydration S&SModerate dehydration S&S
Dry skin and mucous membranes
Thirst Decreased urine
output Crying baby with
tears Muscle weakness Drowsiness light head ache
sunken fontanels Decreased BP Increased Pulse
rate (tachycardia) Capillary refill Shallow rapid RR
5 to10 % of body Weight is lost
Severe dehydration S&SSevere dehydration S&S
Extreme thirst Very dry mouth,
skin and mucous membranes
Sunken eyes Sunken fontanels No tears Anuria Dry skin that lacks
elasticity and slowly “bounces back” when pinched into a fold
Rapid heartbeat Rapid and shallow
breath Unconsciousness More than 10 % of
body Weight is loss
Delay Capillary refill for more than 2 seconds
Possible ComplicationsPossible Complications
Permanent brain damage Seizures hypernatremia Hyponatremia hypovolemic shock Kidney failure Coma and death
Tests and diagnosisTests and diagnosis
Blood tests: to check level of
electrolytes. BUN Creatinine
Urine analysis
Diarrhea
Indications for stool studies Toxic appearance Immunocompromised Bloody or invasive Duration > 5days Suspected parasites
Travel Camping Poor Water
TreatmentTreatment
dehydration treatment depends on age,weight , the severity of dehydration and its cause.
Oral rehydration solution (ORS) for mild and moderate dehydration
IV fluid replacement (for sever dehydration)
Treating the cause of dehydration A single dose of ondansetron (Zofran)
oraly(tablet)
Treatment of mild and moderate dehydration Treatment of mild and moderate dehydration
Oral rehydration solution (ORS)
is a simple treatment for dehydration
Contraindications for ORS:1. Severe dehydration.2. Unconsciousness.3. Frequent vomiting attacks.
Continues breastfeeding . A single dose of ondansetron oraly(tablet)
Treatment of sever dehydration Treatment of sever dehydration
NPO. IV fluid replacement.
Daily Maintenance Fluid Requirements
Calculate child’s weight in kg. Allow 100 ml/kg for first 10 kg body
weight. Allow 50 ml/kg for second 10 kg body
weight. Allow 20 ml/kg for remaining body
weight.
Daily Maintenance Fluid RequirementsDaily Maintenance Fluid Requirements
Calculating replacementCalculating replacement
Correction of deficit: Deficit in ml = wt (kg) x % dehydrated x 10
(ideally the pre-dehydration weight should be used).
example : 14 kg child who is 5% dehydrated has a
deficit of 14 x 5 x 10 = 700 ml.
Fluid requirements(burn victim )Fluid requirements(burn victim )
TBSA burned(%) x Wt(kg) x 4 mlexample : a child weighs 15kg,he has his leg
burned TBSA=18 18x15x4=1080ml.
Give half of total requirements in first 8 hour,second half over next 16 hour.
Give IV fluid to the burned victim (child ) If the TBSA is 10% or more .
Rule of nine for measuring TBSARule of nine for measuring TBSA
Calculating Drop rate per minutes Calculating Drop rate per minutes
(Solution) ml x 15 /hr x min
Example :540 ml x15/8 hr x 60 =16 drops per
minute.540mlx15/16x60=8 drops per
minute.
Prevention and home care Prevention and home care
FAMILY EDUCATION: If your child has vomiting or diarrhea more than
four to five times in 24 consecutive hours, start fluid replacement & increasing fluid intake.
Even when you are healthy, drink plenty of fluids every day and drink more when the weather is hot.
Begin fluid replacement as soon as vomiting and diarrhea start -- DO NOT wait for signs of dehydration.
Remind family that fluid needs are greater with fever, vomiting, or diarrhea .
Notify physician immediately in case of continues vomiting and diarrhea.
teach the mother how to prepare ORS at home
Prevention and home care Prevention and home care
Approach
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
The gospel according to Rob Hall
Approach to Peds Dehydration
1) Initial Resuscitation2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Initial Resuscitation
ABCs Initial fluid bolus
20cc/kg of NS or Ringers Appropriate in all types of dehydration Reassess q5mins and repeat x 3
Initial hypoglycemia 5cc/kg of D10W in infants 2cc/kg of D25W in children
Think about Shock DDx if unresponsive to 3 attempts at NS bolus
Initial Resuscitation
Fluid Controversy… NS / RL
Theoretical risk of acidosis with NS “Dilutional acidosis” with addition of NaCl
to the extracellular fluid Ringers lactate has some HCO3
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Determine % Dehydration
What are the best clinical markers?
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
Determine % Dehydration
Does lab work help you in determining the degree of dehydration?
What lab values do people use to assess severity of dehydration?
Tests such as BUN and bicarbonate are only helpful when results are markedly abnormal
A normal bicarbonate concentration reduces the likelihood of dehydration
No lab test should be considered definitive for dehydration
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration4) Determine the type and rate of
rehydration fluids
5) Final considerations
Define the type of dehydration
Three major classes of dehydration based on relative losses of Na and Water
1) Isonatremic dehydration (80%)2) Hypernatremic dehydration (15%)3) Hyponatremic dehydration (5%)
Thanks to Rob Hall for any details
Body FluidsICF (mEq/L) ECF (mEq/L)
Sodium 20 135-145 Potassium 150 3-5 Chloride --- 98-110 Bicarbonate 10 20-25 Phosphate 110-115 5 Protein 75 10
1. Isonatremic dehydration
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
2. Hypernatremic Dehydration
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
Hypernatremic Dehydration
Physical findings Dry doughy skin Increased muscle tone
Correction Correct Na slowly If lowered to quickly causes
massive cerebral edema intractable seizures
3. Hyponatremic Dehydration
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
Hyponatremic Dehydration
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
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Determine the type and rate of rehydration fluids
Oral Rehydration Therapy (ORT) vs Intravenous therapy (IVT)
“ To poke or not to poke, that is the question”
ORT
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
ORT
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 (ORS)
OsmolesmOsm/L
Glucosemmol/L
NamEq/L
ClmEq/L
HCO3mEq/L
KmEq/L
WHO formulation 330 110 90 80 30 20
Pedialyte 270 140 45 35 30 20
D5W / 0.45% saline 454 300 77 77 0 0
NGT???
Is there a role for nasal gastric tube oral rehydration?
When caregivers are unwilling to perform ORT or when it is required overnight continuous nasogastric tube infusion is preferred over intravenous infusion
When to start feeding again?
Severe Dehydration
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
Isonatremic Dehydration
Calculate the fluid deficit Deficit (cc’s) = % dehydration x
body wt
D5½NS is fluid of choice
(½ deficit – the bolus) over the first 8hrs
Add maintenance and any ongoing losses to above
Further ½ the deficit replaced over the next 16hrs
Monitor electrolytes and U/O
Alternative – rapid approach
Hypernatremic Dehydration
Fluid deficit =• Replace with D50.2%NS• Replace over 48hrs• Reduce sodium by no more than 10mEq/L/24hrs
Water deficit (in L) = [(current Na level in mEq/L ÷ 145 mEq/L) - 1] X 0.6 X weight (in kg)
(½ deficit – the bolus) over the first 24hrs Add maintenance and any ongoing losses to
above Further ½ the deficit replaced over the next 24hrs
Hyponatremic dehydration
Na deficit =(Nadesired- Nacurrent) x 0.6 x Weight (kg)
154 mEq in NS 77 mEq in D5½ NS 513 in 3% saline
rate at 0.5mEq/L/hr
Hyponatremic Dehydration
If seizing Correct with 3% Saline bolus Target a Na of 120 Further correction beyond this with D5½ NS
If not Seizing Correct with D5½ NS Target a Na of 130
Watch for Central Pontine Myelinolysis More likely in chronic hypo-Na with less Sx Correct slowly at rate of 0.5mEq/L/hr
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Final considerations
Does and Acid-Base Deficit exist?
Does a potassium disturbance exist?
What is the patients renal function?
Does and Acid-Base Deficit exist?
Acidosis Lactate Ketones Loss of Bicarb in diarrhea
Most will resolve with simple rehydration
Consider HCO3 for pH<7.0
Does a potassium disturbance exist?
K+ losses GI Renal
Remember that K shifts with acidosis and certain therapies
Always insure renal function prior to IV replacement
Rapid Fire Cases
Case 1
2yr F (14kg) 3 days of diarrhea and vomiting
Decreased u/o as per mother
Exam Generally appears well MM dry and no significant tears Skin turgor normal Tachycardic but not tachypneic Cap refill 2 seconds
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Answers
Initial resuscitation deferred
% dehydration 5-9% moderate
Dehydration Type Likely Isonatremic
Rehydration fluids ORT Pedialyte
Rate and volumes Moderate
dehydration 100cc/kg = 1400cc
Replace over 3-4hrs Further 10cc/kg with
ongoing losses
Final considerations
None
Case 2
8mo M (8kg) 4 day hx of
severe diarrhea and vomiting No further
ongoing losses
Exam Limp and cold Mottled with weak
rapid pulse Sunken eyes and
fontanelle Cap refill 5s Tenting of skin
LabsNa = 170K = 3.1HCO3 = 18
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Answers
Initial resuscitation 160cc NS bolus
% dehydration >10% Severe
Dehydration Type Hypernatremic
Rehydration fluids IV fluids D50.2NS
Rate and volumes Volume deficit =
640cc Correct slowly over
48hrs 39cc/hr over first
24hrs 45cc/hr over next
24hrs
Final considerations Add 20 mEq K to IV
fluids
Case 3
16mo F 3 day Hx of vomiting and diarrhea
Tolerating fluids not solids Good u/o
Exam Appears well with normal vitals Tears + MM moist Cap refill <2s Skin turgor normal
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Answers
Send this kid home!!!
Case 4
2 yo M (16kg) 4 day Hx of vomiting
and diarrhea Exam
Appears drowsy but not lethargic
Good tone Tachycardiac and
tachypneic BP normal Very Dry MM Cap refill 3s
LabsNa = 134K = 3.1HCO3 = 16
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Answers
Initial resuscitation
320cc of NS % dehydration
>10% Severe
Dehydration Type Isonatremic
Rehydration fluids D5½ NS
Rate and volumes Volume deficit =
10% x 16kg= 1600mls
110cc/hr over first 8hrs
100cc/hr over next 16hrs
Final considerations Add 20 mEq K to IV
fluids Watch for metabolic
acidosis to resolve
Case 5
1yo F (10kg) 4 day Hx of
severe diarrhea and vomiting
Exam Lethargic and limp Weak rapid pulse Fontanelle sunken Cap refill 5s Cool and mottled Tenting of skin
Labs Na = 114 K = 3.4 HCO3 = 18
During your exam the patient starts Seizing
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of rehydration fluids
5) Final considerations
Answers
Initial resuscitation 200cc NS
% dehydration >10% Severe
Dehydration Type Hyponatremic
Rehydration fluids IV Initially 3% saline D5½ NS after above
Rate and volumes Initially correct to
Na of 120 with 3%= 70cc bolus Then correct to Na
of 130 with D5½ NS at rate of 0.5mEq/L/hr
= 39cc/hr Final
considerations Add 20 mEq K to IV
fluids
THANK YOU
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