1. DEHYDRATION
SOAD JABER 2009

2. 30% lung no solute content
Maintenance fluid replacement Obligatory water loss
Normal fluid replacement * urine, sweat ,stool
Thirst
ADH *Insensible water loss Aldosterone % skin
30% lung no solute content
Osmotic
Hydrostatic
ECF
ICF

3. Some causes of dehydration
Vomiting Metabolic alkalosis
Hypokalemia
Hyponatremic dehydration
Diarrhea Iso,hypo,hyper natremic dehy
DKA Hyper tonic dehydration
Cystic fibrosis  sweating diarrhea. Salt loss
Fever  1°C → 10% water loss
Intestinal Obstruction Prolonged gastric aspiration hypo natremic dehydration
Diabetes Insipidus Pure water loss
hypernatremic dehydration .
Renal disease Na+water loss
Iso OR hyponatromic deh

4. Dehydration  Simple deficit in body water
Contraction of body fluid space
Both water and electrolyte contents
Loss of ECF
± ICF

5. 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.

6. Types
Isotonic:
70% most common
Na meq/L

7. 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.

8. 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

9. 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.

10. 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

11. DEGREE 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.

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

13. Severe dehydration 15% Circulatory collapse   B.P.
Cool cyanotic sweaty extremities
Mottled skin
Shock
Death

14. Severe >10%
Mild <5%
Mod 5-9%
   
 
Tachycardia
 turgor
Sunken
Dry
Cool ,mottled
Lethargic, coma
Absent
  
N to  
 Turgor
Normal
Delay capill refill
N or lethargic  
Slightly dry
Perfuse
Slightly 
Blood Pressure
Pulse pressure
Heart rate
Skin
Fontanel
Mucous memo
Extremities
Mental status
Urine output
Thirst

15. 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

16. Investigation Lab: Repeat all at 6 - 12 - 24 h. 1. CBC
Hemo concentration
 Hb  Hct .
 Plasma osmolality
3. Urea + electrolytes
* Na ... Type of dehydration
Normal
 Acidosis
Na  Renal function
with significant stool losses
with severe vomiting - alkalosis NA with treatment with high glucose treatment with alkali
* HCO3 loss will lead to acidosis with severe diarrhea
* Urea nitrogen & Creatinine

17. Rehydration therapy I.V. Initial therapy * I.V. * Oral
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%
[ % N.S. ]

18. Initial therapy (Continuation)
If with severe acidosis
Ringer lactate
N a meq/L
K meq/L
HCO 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

19. 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.

20. II. Subsequent therapy. (maintenance)
How
1-10 kgs mls/kg/24 h
10-20 kgs 50 mls/kg/24 h
> 20 kgs mls/kg/24 h
Example:
Child weight is 25 kg what is his maintenance?
1 st 10 kgs 10 x 100 = 1000 mls
2nd 10 kgs 10 x 50 = 500 mls
> 20 kg 5 x 20 = 100 mls
1600 mls/24 h

21. 5% dehydration (mild) 50 mls/kg 10% dehydration ( moderate) 100 mls/kg
2)Deficits
*Degree of dehydration:
5% dehydration (mild) mls/kg
10% dehydration ( moderate) 100 mls/kg
15% dehydration (Severe) 150mIs/kg
*Type of dehydration:
According to Na level
Rate
Type of fluid

22. Type of fluid 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 /2 over h .
Type of fluid
D5 in 0.2 N .S.
D5 in 0.45 N.S.

23. B). Hypo natremic 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

24. Add: 6 meq/kg Na cl or 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.

25. C) Hyper natremic dehydration:
-More serious.
-Fluid therapy replacement can be difficult.
-Severe hyper osmolality may result in cerebral damage and Hge .
-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
*Na cl -

26. *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 in more important than type of fluid
-Na drop should not be more than 10 meq/L/ 24 hour
D N .S.

27. Rate: ***Example: Very slow Can be done over days
Usually 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 = mls/ 24 h
10 x 20 = 200
2)Deficit
10% dehydration = 100 mls/kg
100 x 30 = 3000 mIs
Type and rate according to type of dehydration

28. 3). Ongoing losses:
--Continuous pathological losses
Stool - diarrhea
Vomitus
N.G. tube
*Small amount 50 mls/time
*Moderate amount mls/time
*Large amount mls/time
To be added to deficit, calculated every 6-8h.

29. ORS To all patient but: Value:
Severe dehydration in patient whose care giver can’t administer fluids.
If ongoing losses can’t 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.

30. Home remedies? Not suitable: Decarbonated soda beverages Fruit juices
Tea
Not suitable:
Inappropriate high osmolarities due to CHO conc.
Low Na content → hypo natremia
Inappropriate CHO to Na ratio

31. Oral rehydration solution
When to use it?
Contraindication … Types … Rate…..
Types
WHO Pedialyte
Na meq/L
K meq/L
C1 meq/L
HCO5 meq/L citrate
Glucose g/dl 2% %
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

32. Thank You