1. DEHYDRATION Dr Nadeem Zubairi

2. Dehydration 2 million infants and children die every year in the developing countries

3. Case Study-- Basim is 4 years old and his brother, Ahmad, is 5 months old. Both children are brought to the clinic by their mother because of diarrhea and fever of 4 days duration. Basim has also vomited thrice.Doctor assesses the children and determines that Basim is severely dehydrated but Ahmad is only mildly dehydrated. Basim`s serum sodium is 170 mEq/L while that of Ahmad is 142 mEq/L

4. Case Study- AbdulAziz is a 40 days old first born child who is having vomiting since second week of life. He tends to vomit almost all of the milk taken immediately after the feed and gets hungry again. Examination reveals that he is moderately dehydrated and there is an olive size mass in epigastric region. CBC is unremarkable. Electrolytes: Na 131, K 3.0, Cl 95, bicarb 32. PH 7.45.

5. AbdulRahman, A 14-year-old male is brought to the Emergency Department via ambulance with a report of the patient being found unresponsive. He is a known case of Type 1 DM and is on Insulin since last 7 years. Lately he was running fever and mother is not sure about regularity of doses during this illness. On examination AbdulRahman has altered consciousness level, acidotic breathing and has severe dehydration. Labs: TLC……… high Sugar……402 mg/dl PH……… 7.15 Ketone bodies ++++ Case Study-

6. Rehana is a 5 year old child who had 60% burns following spillage of boiling water on trunk and lower limbs 02 days back. She is in the hospital. Lately she is febrile, intake is less, tongue is dry. Her urine output is less and she is hypotensive.

7. WHAT IS COMMON IN ALL ? DEHYDRATION

8. OBJECTIVES At the end of this lecture you will able to know the followings: *What is dehydration? *What are the causes of dehydration? *The clinical manifestaions of dehydration. *The investigations required. *Management of dehydration.

9. Distribution of Body Water Intravascular Interstitial Intracellular ICF ECF Na+ K+ Cl-

10. Fluid composition varies at different ages

12. % of Water in the Body

13. Fluid Maintenance Body Wt Fluid per day 0 – 10 kg 100 ml/kg 11 -20 kg 50 ml/kg  20 kg 20ml/kg

14. e.g. a child of 25kg First 10 kg = 1000 ml Second 10 kg = 500 ml Remaining 5 kg = 20 ml Total = 1700 ml/ pay i.e. per hr = 70 ml/ hr

15. Fluid Losses in Infants LUNGS URINE, FECES SKIN

16. Differences between children & adults Surface Area (BSA) Metabolic Rate Kidney Function Fluid Requirements

17. Reasons why infants & children are at > risk for developing fluid & electrolyte imbalance Increased % of body weight is H2O Large volume of ECF Increased BSA (insensible loss) Increased Metabolic rate Immature Kidneys

18. DehydrationDehydration is a condition that can occur with excess loss of water and other body fluids. Dehydration results from decreased intake, increased output (renal, gastrointestinal or insensible losses), a shift of fluid (e.g. ascites, effusions), or capillary leak of fluid (e.g. burns and sepsis).

19. CAUSES OF DEHYDRATION

20. Conditions causing Fluid Imbalances Phototherapy Increased RR Fever Vomiting Diarrhea *(Gastroenteritis)* Drainage tubes, blood loss Burns

21. Diarrhea Metabolic Acidosis loss of HCO 3 from G.I. Tract pH HCO 3 Treatment: Correct base defecit, replace losses of with NaHCO 3

22. Vomiting Metabolic Alkalosis Loss of acid from stomach pH HCO 3 H + Treatment: Prevent further losses and replace lost electrolytes Example: Pyloric Stenosis

23. Heat stroke

24. Fever Each degree of fever increases basal metabolic rate (BMR) by 10%, with a corresponding fluid requirement

25. Phototherapy Infant under phototherapy. Note that the eyes are shielded and a diaper is used to contain the diarrheal stools. Copyright © 1999, Mosby, Inc.

26. Mouth ulcers, stomatitis, pharyngitis, tonsillitis: pain may severely limit oral intake

27. Burns Fluid loss is 5-10 X greater than from undamaged skin Abnormal exchange of electrolytes between cells and interstitial fluid

28. BurnsBurns: fluid losses may be extreme and require aggressive fluid management

29. Diabetic ketoacidosis (DKA).

30. Congenital adrenal hyperplasiaCongenital adrenal hyperplasia: may have associated hypoglycaemia, hypotension, hyperkalaemia, and hyponatraemia.

31. Cystic fibrosisCystic fibrosis: excessive sodium and chloride losses in sweat. Diabetes insipidus: excessive output of very dilute urine.insipidus ThyrotoxicosisThyrotoxicosis: increased insensible losses and diarrhoea.

32. Drainage Tubes/ Blood loss

33. ASSESSING DEHYDRATION IN CHILDREN

34. Manifestations of ECF Deficit (Dehydration) S & S Weight loss Blood pressure drop Delayed capillary refill Oliguria Sunken fontanel Decreased skin turgor Physiologic Basis Decreased fluid vol. Inadequate circ. Blood Decreased vascular volume Inadequate kidney circ. Decreased fluid volume Decreased interstitial fluid

35. Degree of Dehydration Mild dehydration (3-5%) Moderate dehydration (6-10%) Severe dehydration (10-15%)

36. MildModerateSevere Weight lossUp to 5%6-10%More than 10% Appearance Active, alert Irritable, alert, thirsty Lethargic, looks sick Capillary filling (compared to your own) NormalSlightly delayedDelayed Pulse NormalFast, low volumeVery fast, thready Respiration NormalFastFast and deep Blood pressure Normal Normal or low Orthostatic hypotension Very low Mucous memb. MoistDryParched TearsPresent Less than expected Absent EyesNormal Sunken Pinched skin Springs back Tents brieflyProlonged tenting Fontanel (infant sitting) NormalSunken slightlySunken significantly Urine flowNormalReducedSeverely reduced

37. MildModerateSevere Weight lossUp to 5%6-10% More than 10% AppearanceActive, alertIrritable, alert, thirsty Lethargic, looks sick Capillary filling (compared to your own) NormalSlightly delayedDelayed Pulse NormalFast, low volume Very fast, thready Respiration NormalFast Fast and deep Blood pressureNormal Normal or low Orthostatic hypotension Very low Mucous memb.MoistDryParched TearsPresentLess than expectedAbsent EyesNormal Sunken Pinched skinSprings backTents briefly Prolonged tenting Fontanel (infant sitting) NormalSunken slightly Sunken significant ly Urine flowNormalReducedSeverely reduced

38. Earliest Detectable Signs Tachycardia Dry skin and mucous membranes Sunken fontanels Circulatory Failure (coolness, mottling of extremities) Loss of skin elasticity Delayed cap refill

39. Skin turgor is assessed by pinching the skin of the abdomen or thigh longitudinally between the thumb and the bent forefinger. The sign is unreliable in obese or severely malnourished children. Normal: skin fold retracts immediately. Mild or moderate dehydration: slow; skin fold visible for less than 2 seconds.

40. Severe dehydration: very slow; skin fold visible for longer than 2 seconds. Other features of dehydration include dry mucous membranes, reduced tears and decreased urine output. Additional signs of severe dehydration include circulatory collapse (e.g. weak rapid pulse, cool or blue extremities, hypotension), rapid breathing, sunken anterior fontanels

42. Loss of Skin Elasticity due to dehydration is not a reliable sign in malnourished children

43. What is considered oliguria in an infant or child? <1ml/kg/hr

44. How would you measure U.O. for a child who is not toilet trained? Weigh diaper 1 gram = 1 cc

45. TYPES OF DEHYDRATION

46. Dehydration = Total Out > Total In Types: Isotonic Electrolyte = Water Hypotonic Electrolyte > Water Hypertonic Water > Electrolyte

47. The most common type of dehydration in children is….. Isotonic

48. Hypernatremic dehydration Dehydration, characterized by increased concentrations of sodium and chloride in the extracellular fluid, it results from diarrhea in infants. The occurrence of the hypernatremia and hyperchloremia lies in the relatively greater expenditure of water than electrolyte via skin, lungs, stool and urine. The water deficit in these infants is primarily intracellular. The majority of infants with this type of dehydration show varying degrees of depression of central nervous system varying from lethargy to coma. Convulsions are frequently observed. Dilute solutions of electrolyte are indicated in rehydration. Rapid adjustment, however, appears to accentuate the CNS disturbance. Rehydration is best carried out slowly over a 2- to 3-day period.

49. HYPERNATREMIC DEHYDRATION Major danger due to condition: Brain hemorrhage...shrinkage of brain leading to tearing of vessels Major danger due to treatment: Brain edema due to movement of water into the brain cells. Occurs if treatment is too rapid

50. What lab tests provide useful information when the concern is dehydration? Usually no tests are needed if child is clinically stable CBC, Urea Electrolytes, Blood gases Stool RE and C/S

51. MANAGEMENT OF DEHYDRATION

52. Management of Mild to Moderate Dehydration Oral Rehydration Pedialyte Infalyte Rehydralate Rules regarding rehydration 50-100ml/kg within 4 hours

53. Home Management

54. Oral Rehydration  Oral fluids commonly given to children when sick:  Apple juice (low Na, High K)  Coke (Low Na, Low K, High sugar)  Pepsi (Na—little better than Coke, no K)  7-Up (sugar, small Na, no K)  Gatorade (high Na, sugar)  Grape juice (low Na, high K)  Orange juice (low Na, High K)  Milk (has Na, K, Cl, HCO 3)

55. ORAL REHYDRATION SOLUTION (ORS)

57. ORS Developed 1940s in Dhaka Bangladesh

58. ORS Most important medical discovery of the 20 th century

59. ORS 5 million deaths / year After ORS 2 million deaths / year

60. ORS components WHO/UNICEF Na = 90 mmol/l k = 20 mmlo/l cl = 80 mmol/l glucose = 111mmol/l Osmol = 311 mmol/l

61. WHO vs. Hypo-osmolar ORS WHO/UNICEF Hypo-osmolar Na = 90 mmol/l Na = 60 mmol/l k = 20 mmlo/l k = 20 mmlo/l cl = 80 mmol/l cl = 50 mmol/l glucose = 111mmol/l glucose = 84 mmol/l Osmol = 311 mmol/l Osmol = 224 mmol/l

62. Hypo-osmolar ORS Many studies support the use of reduced osmolarity ORS but the debate is not resolved. It is preferred in severely malnourished (marasmic) child as the standard (old) WHO ORS may cause hypernatremia

63. ORT vs. I/V Therapy ORT is as effective as I/V fluid for rehydration of moderately dehydrated children due to G/E in the E/D. ORT Demonstrated no inferiority for successful rehydration at 4 hours and hospitalization rate. A randomized controlled trial by P Spandorfer et al Pediatrics Feb.2005

64. ORT vs. I/V Therapy Although no clinically important differences between ORT and IVT, the ORT group did have a higher rate of paralytic ileus, and the IVT group exposed to risk of intravenous therapy. For every 25 children treated with ORT one fail and require IVT L Hartlig The Cochrane Database of Systematic Reviews 2006 Issue 4

65. Reluctance to use ORT ?

66. People do not consider ORT high-tech enough. Physicians prefer I/V fluids. It takes time to educate parents re ORT. Time consuming for busy parents.

67. Moderate to Severe Dehydration Management

68. Goals of IV Therapy  Expand ECF volume and improve circulatory and renal function (Isotonic solution.9%NS,LR, D5W)  K+ after kidney function is assessed  Begin oral feedings

69. MANAGEMENT OF DEHYDRATION - Replace Phase 1: Acute Resuscitation : Give Lactated Ringer OR Normal Saline at 10-20 ml/kg IV over 30-60 minutes. May repeat bolus until circulation stable -Calculate 24 hour maintenance requirements Formula: First 10 kg: (100 cc/kg/24 hours) Second 10 kg: (50 cc/kg/24 hours) Remainder: (20 cc/kg/24 hours) Example: 35 Kilogram Child Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day -Calculate Deficit: Mild Dehydration: (40 ml/kg) Moderate Dehydration: (80 ml/kg) Severe Dehydration: (120 ml/kg)

70. MANAGEMENT Continue --------- -Calculate remaining deficit: Substract fluid resuscitation given in Phase 1 -Calculate Replacement over 24 hours: First 8 hours: 50% Deficit + Maintenance Next 16 hours: 50% Deficit + Maintenance Determine Serum Sodium Concentration Hypertonic Dehydration (Serum Sodium > 150) Hypertonic DehydrationSerum Sodium Isotonic Dehydration Hypotonic Dehydration (Serum Sodium < 130) Hypotonic DehydrationSerum Sodium Add Potassium to Intravenous Fluids after patient voids urine Potassium source Potassium Chloride Potassium Acetate for Metabolic AcidosisMetabolic Acidosis Potassium dosing Weight <10 kilograms: 10 meq KCl /liter glucose Weight >10 Kilograms: 20 meq KCl /liter glucose

71. Name of SolutionType of SolutionIngredients in 1-Liter UsesComplications 0.45% Sodium Chloride Shorthand Notation: ½NS Hypotonic pH 5.6 77 mEq Sodium 77 mEq Chloride hypotonic hydration; replace sodium and chloride; hyperosmolar diabetes if too much is mixed with blood cells during transfusions, the cells will pull water into them and rupture 0.9% Sodium Chloride Shorthand Notation: NS Isotonic pH 5.7 154 mEq Sodium 154 mEq Chloride isotonic hydration; replace sodium and chloride; alkalosis; blood transfusions (will not hemolyze blood cells) None known 3% Sodium ChlorideHypertonic pH 5.0 513 mEq Sodium 513 mEq Chloride symptomatic hyponatremia due to excessive sweating, vomiting, renal impairment, and excessive water intake rapid or continuous infusion can result in hypernatremia or hyperchloremia 5% Sodium ChlorideHypertonic pH 5.8 855 mEq Sodium 855 mEq Chloride 5% Dextrose in Water Shorthand Notation: D5W Isotonic pH 5.0 5 grams dextrose (170 calories/liter) isotonic hydration; provides some calories water intoxication and dilution of body's electrolytes with long, continuous infusions 10% Dextrose in Water Shorthand Notation: D10W Hypertonic pH 4.3 10 grams dextrose (340 calories/liter) may be infused peripherally; hypertonic hydration; provides some calories 5% Dextrose in 1/4 Strength (or 0.25%) Saline Shorthand Notation: D5¼NS Hypertonic pH 4.4 5 grams Dextrose 34 mEq Sodium 34 mEq Chloride fluid replacement; replacement of sodium, chloride and some calories vein irritation because of acidic pH, causes agglomeration (clustering) if used with blood transfusions; hyperglycemia with rapid infusion leading to osmotic diuresis Table of Commonly Used IV Solutions

72. Lactated Ringer’’s (RL): Isotonic, 273 mOsm/L. Contains 130 mEq/L Na+, 109 mEq/L Cl--, 2mEq/L lactate, and 4 mEq/L K+. Lactate is used instead of bicarb because it’’s more stable in IVF during storage. Lactate is converted readily to bicarb by the liver. Has minimal effects on normal body fluid composition and pH. More closely resembles the electrolyte composition of normal blood serum. Does not provide calories. Contra-indication: Pyloric stenosis(metabolic alk)

73. Why is it necessary to use a pump or other volume control when infusing Ivs into children? Avoid overload Specifically monitor input

74. When to resume normal diet?

75. Special Considerations Antibiotics Anti- emetics Anti-diarrheal agents Antimotility drugs, slow intestinal transit but have little effect on the total stool volume and may have serous side effect including ileus. They are not advised for infants or children

76. Case Study-- Basim is 4 years old and his brother, Ahmad, is 5 months old. Both children are brought to the clinic by their mother because of diarrhea and fever of 4 days duration. Basim has also vomited thrice.Doctor assesses the children and determines that Basim is severely dehydrated but Ahmad is only mildly dehydrated. Basim`s serum sodium is 170 mEq/L while that of Ahmad is 142 mEq/L

77. Ahmad ….. Mild dehydration Weight….. 7 kgs Isonatremic ORS Basim ……. Severely dehydrated Weight……. 15 kgs Hypernatremic Total deficit: 15 X 100-120=1500- 1800 ml Type of fluid:0.45% Normal Saline Duration of therapy:48 to 72 hours Frequent check