DEHYDRATION

Dr.SOAD JABER 2010

Maintenance fluid replacement

Normal fluid replacement

ECF

Thirst
ADH

Obligatory water loss

* urine, sweat ,stool

*Insensible water loss Aldosterone

70% skin
30% lung no solute content
Osmotic
Hydrostatic

ICF

Vomiting

Some causes of dehydration

Metabolic alkalosis
Hypokalemia
Hyponatremic dehydration

Diarrhea

Iso, hypo, hyper natremic

dehydration

DKA

Hyper tonic dehydration

Cystic fibrosis

sweating diarrhea. Salt loss

Fever

1C 10% water loss

Intestinal Obstruction

Prolonged gastric aspiration

Hyponatremic dehydration
Pure water loss
Hypernatremic dehydration
Na+water loss
Iso OR hyponatremic
dehydration

Diabetes Insipidus
Renal disease

Dehydration
Simple deficit in body water

Contraction of body fluid space

Both water and electrolyte contents

Loss of ECF
ICF

Deficit:
Cumulative body water and electrolyte losses that occur
prior to clinical presentation.

Body losses:

Absolute amount of water lost always Exceeds the amount of

solute loss.
Every dehydration tend to be hypertonic ,Only kidneys prevent
hypertonicity.

Types of
Dehydration

Hypertonic

Isotonic

Hypotonic

Types
Isotonic:
70% most common.
Na 135-145 meq/L (Normal level).

cont
Hypertonic:
20%.
Na 145 meq /L.
Water loss > solute.
Renal circulation impaired kidney can't
excrete solute.
? Salt intake,
May occur in well nourished obese infants follow
acute process with marked anorexia and
fulminant diarrhea.

CONT Hypertonic:

Signs of dehydration less than the

actual degree of dehydration

Fluid shift ICF ECF

Doughy skin
Parched tongue
Almost near normal B.P.

Complications:
Shrinkage of brain cells:
hematoma
Bleeding
Brain edema while treatment:
Coma
Seizure
Associated with acidosis:
Hypokalemia

Hypotonic
10%In an infant or a child with diarrhea whose intake is
electrolyte free.
Weak tea,, Rice water,, diluted milk
Chronically malnourished child with bouts of mild to
moderate diarrhea and poor intake.
Fluid shift ECF ICF
Well preserved intracellular volume.
Collapse and shock with degree of dehydration,
decrease Renal flow with milder degree of dehydration.

HYPOTONIC
Complication
Convulsion due to hyponatremia.
Circulatory collapse and shock even with milder
degree of dehydration.

Extra cellular fluid losses.

Intra cellular fluid shift.
Volume depletion more than actual water loss.
Profound volume depletion will lead to Renal
failure shock.

DEGREE of Dehydration:
10% Moderate

Skin turger
elasticity
tenting

Fontanels depressed.
Oliguria .
tears OR absent.
B.P. Still well maintained.
Orthostatic B.P.
Sunken eyes : Obvious to the parents not
to the physician.

Cont
Moderate - Severe
Hypovolemia due to contraction of plasma
volume.
Hypotension
Cold extremities
Tachycardia

Cont
15% Severe dehydration
Circulatory collapse

B.P.

Cool cyanotic sweaty extremities

Mottled skin

Shock

Death

Mod 5-9%

Blood
Pressure
Pulse
pressure
Heart rate
Skin
Fontanel
Mucous
memo
Extremities
Mental status
Urine output
Thirst

Mild <5%

N to
Normal
N to
Normal

Normal
Turgor
Normal
Normal
Normal
Slightly dry Dry
Perfuse
Delay capill
refill
Normal
N or lethargic
Slightly

Severe >10%

Tachycardia
turgor
Sunken
Dry
Cool ,mottled
Lethargic,
coma
Absent

Management of:
Fluid and electrolyte
Refeeding

Dehydration:
More severe in children.
a. greater basal fluid + elect requirement / kg
b. dependent on others for the demands.

Assess the degree of dehydration:

Clinical signs and symptoms.
Ongoing losses.
daily requirement.

Investigation:
Lab: Repeat all at 6 - 12 - 24 h.
1. CBC:
Hemo concentration
Hb
Hct
2. Plasma osmolality.
3.Urea + electrolytes.
* Na ... Type of dehydration
*Normal
*Na

Acidosis
Renal function

*Na

with significant stool losses

with severe vomiting - alkalosis
with treatment with high glucose
treatment with alkali

* HCO3 loss will lead to acidosis with severe diarrhea.

* Urea nitrogen & Creatinine.

Rehydration therapy
* I.V. * Oral

I.V.
Initial therapy:
Resuscitation fluid (10-20ml /hour).

Designed to expand extra cellular fluid volume rapidly especially

plasma.
Improve circulatory and renal function.
Prevention or treatment of shock.

Fluid type:
Isotonic saline. 0.9%.
[ 0.9% N.S. ]

Initial therapy (Continuation)

If with severe acidosis

Ringer lactate
Na
140 meq/L
K
115 meq/L
HCO3
25 meq/L
Dextrose
5%
If in shock
Plasma expander
*Alb 5%
*Blood 10 ml/kg

Repeat once or twice till patient is hemo-dynamically stable.

No hypotonic saline may lead to cerebral edema.

II. Subsequent therapy

Provision of maintenance fluid and electrolyte.

Replacement of existing deficits.
Replacement of ongoing losses.
To be re-checked at 8 hourly interval.

1)Maintenance
- Fluid requirement /kg /24 hour.
-Constant everyday.
-Maintenance calculated on daily basis regardless to
deficit or ongoing losses.

II. Subsequent therapy (Maintenance)

How
1-10 kgs
10-20 kgs
> 20 kgs

100 mls/kg/24 h
50 mls/kg/24 h
20 mls/kg/24 h

Example:
Child weight is 25 kg what is his maintenance?

1 st 10 kgs
2nd 10 kgs
> 20 kg

10 x 100
10 x 50
5 x 20

= 1000 mls
= 500 mls
= 100 mls
1600 mls/24 h

2)Deficits
*Degree of dehydration:

5% dehydration (mild)
10% dehydration ( moderate)
15% dehydration (Severe)

*Type of dehydration:

According to Na level:
Rate.
Type of fluid.

50 mls/kg
100 mls/kg
150mIs/kg

A)Isotonic (Isonatremic) dehydration:

Loss of isotonic fluid from the body
-No osmotic gradient between Intra + Extra cellular
fluids.
-Full deficit correction over 24 hours:
1/2 over 1 st 6-8h
1/2 over 16-18h .

Type of fluid
D5 in 0.2 N .S.
D5 in 0.45 N.S.

B)Hyponatremic dehydration:
-Na loss more than water loss.
ex.
* with dysentery
*Treatment with low Na fluid
- Rate
Full deficit correction over 36h ,
1/2over 6-8h. . the rest over16-18hour.
-Depend on
... level of Na
degree of dehydration

Type of fluids:
D5 IN 0.45 N .S.
D5 IN 0.9 N.S.
depend on Na level

Usually no need to add Na to the fluid as correction of dehydration

will correct Na.

If after correction of dehydration still Na loss

Add:
6 meq/kg Na cl
Max 12ml/kg of 3% Na cl over 6 h

or
Calculate Na deficit
= (135 actual Na level) x 0.3 x B. W. in kg.

C) Hypernatremic dehydration:

More serious.
Fluid therapy replacement can be difficult.
Severe hyper osmolality may result in cerebral damage
and Hemorrhage.
Seizures occur during treatment as serum Na returning to
normal due to rapid correction, or the use of hypotonic
fluid.
Treatment of convulsion:
*Anti convulsant.
*NaCl.

Excess movement of water into cerebral cells during

rehydration with hypotonic saline ,or rapid correction will
lead to Cerebral edema.
May be irreversible or fatal

Type of fluid:
-Slow rate is more important than type of fluid.
-Na drop should not be more than 10 meq/L/ 24 hour.
-Start with D5 0.45 N .S.

Rate:
Very slow.
Can be done over days.
Usually 48 - 72 hours.

***Example:
Child weight 30 kg with 10% dehydration
What is his fluid requirement?

1)Maintenance: 30 kg
10 x 100 = 1000
10 x 50 = 500
10 x 20 = 200

1700 mls/ 24 h

2)Deficit
10% dehydration = 100 mls/kg
100 x 30 = 3000 mIs
Type and rate according to type of dehydration.

3)Ongoing losses:
Continuous pathological losses
Stool - diarrhea
Vomitus
N.G. tube

*Small amount
*Moderate amount
*Large amount

50 mls/time
100 mls/time
150 mls/time

To be added to deficit, calculated every 6-8h.

ORS
To all patient but:
1.
2.

3.

Severe dehydration in patient whose care giver cant

administer fluids.
If ongoing losses cant be compensated orally.
Severe vomiting.

Value:

Rapid rehydration with rapid replacement of ongoing losses

during the first 4-6 hours.
Once rehydrated oral maintenance solutions.

Home remedies?

Decarbonated soda beverages.

Fruit juices.
Tea.

Not suitable:

Inappropriate high osmolarities due to CHO

conc.
Low Na content hyponatremia.
Inappropriate CHO to Na ratio.

Oral rehydration solution

When to use it?

Contraindication:

Presistant vomiting.
Comatose patient.
Congenital anomalies e.g. cleft palate.

Types: (important)
WHO
Na meq/L
K meq/L
C1 meq/L
HCO5 meq/L
Glucose g/dl

90
20
80
30
2%

Pedialyte
45
20
35
30 citrate
2.7%

Rate:
50 ml/kg . within 4 hours for patient with mild dehydration
100 ml/kg within 6 hours for patient with moderate dehydration
* Small amounts + short intervals

IMPORTANT NOTES :
Goals of rehydration therapy:
1) To achieve euvolemia.
2) Maintain or restore fluid and electrolyte homeostasis.

Fluid Isotonic :
*if they have the tonicity of plasma.
*Or osmolality around 300meq/l.

Ingredient to calculate osmolarity

*Cations, Na, k*Anions, Cl, alkali, D-glucose.

D5 is added to buffer hypotonic solutions that may lead to acute hemolysis

and to prevent short time starvation and catabolism.

Cont.
Total body water = ECF+ICF
Normal values:
*ECF: Anions:
Na 140meq/l
K3.5-5meq/l
Cations:
Cl 100mg/l
Bic:
25mg/l
*ICF: Cations
K 150mg/l
Anion-minor Na 5mg/l
Hypernatremia High plasma osmolality ICF ECF ,
*intravascular volume and vital signs are relatively preserved.

Disadvantage
-Cell shrinkage physical reduction in the size of the brain with attended
rupture of the veins bridging the cranial vault intracranial hemorrhage.
Normal urine output 1-2mls/kg/hour.

Thank You