Deficit Therapy + Dehydration..pdf

PAEDIATRICS AND CHILD HEALTH
• Paediatrics and Child Health
• Deficit Therapy
• Maintenance Therapy
• Dehydration In No Malnutrition
• Dehydration In Malnutrition
Dr. Chongo Shapi (BSc.HB, MBChB, CUZ)
- Medical Doctor.
3/19/2022 Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. 1

Introduction
Objectives: To know
1. Fluid deficit
2. Maintenance fluid
3. Replacement therapy
4. Dehydration
3/19/2022
Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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2

Calculation of Fluid Deficit
• First determine the fluid deficit by clinically determining
the percent dehydration
• Then, multiply this percentage by the patient's weight
• For example:
- 10% dehydration (severe dehydration) = 100mL/kg
- Hence, a 10 kg child with 10% dehydration has a fluid
deficit of 1000 L (1L)
Deficit therapy is given if dehydration is present
- Give it within 36-48 hrs
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Maintenance Fluid
Infusion rate = [total fluid volume/day]/24 hrs
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Goals of Maintenance Fluids
1. Prevent dehydration
2. Prevent electrolyte disorders
3. Prevent ketoacidosis
4. Prevent protein degradation
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Fluid Replacement Therapy (FRT)
A. If no ongoing losses (OGLs):
- FRT = Fluid Deficit (FD) + Maintenance Fluid (MF)
- Hence, FRT = FD + MF
B. If there is ongoing losses:
FRT = FD + MF + OGLs
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Examples
1. A child awaiting surgery may need only
maintenance fluids
2. A child with diarrheal dehydration needs
maintenance and deficit therapy if no
significant diarrhoea continuation
3. A child requires further replacement fluids to
account for ongoing losses if significant
diarrhoea continues
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Dehydration
• Dehydration is a common problem in children
• Is most often due to gastroenteritis
• Most cases can be managed with oral rehydration
• Children with hyponatremic or hypernatremic
dehydration can also be managed with ORS
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Clinical Manifestations
• The first step is assessing the degree of dehydration
• This dictates both the urgency of the situation and the
volume of fluid needed for rehydration
1. No dehydration:
a. Infant: < 5%
b. > 1 yr: < 3%
2. Some dehydration:
a. Infant : 5–10%
b. > 1 yr: 3–6%
3. Severe dehydration:
a. Infant : > 10%
b. > 1 yr: > 6%
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• For older children and adults the degree of
dehydration represents a lower percentage of
body weight lost
• This difference occurs because water is a
higher percentage of body weight in infants
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Clinical Features of No Dehydration
• Sensorium: Conscious
• No respiratory distress
• Normal PR
• Normal HR
• Normal CRT < 3 sec
• Skin turgor: instant recoil
• Peripheries: warm
• Normal to decreased urine output
• Drinks fluid normally
• Moist mucous membranes
• Tears present
• Eyes and AF not sunken
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Clinical Features of Some Dehydration
• Sensorium: Irritable/restless
• Tachypnea
• Increased PR
• Increased HR (Tachycardia)
• Delayed CRT > 3 sec
• Skin turgor: recoil in < 2 sec
• Peripheries: cold and pale
• Decreased urine output (oliguria)
• Eager to drink fluid
• Dry mucous membranes
• Decreased tears
• Sunken eyes and AF
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Clinical Features of Severe Dehydration
• Sensorium: Lethargic/apathy
• Deep breathing (Kussmaul breathing)
• Rapid and weak or absent peripheral pulses
• Tachycardia or bradycardia if severe
• Very delayed CRT: >3 sec
• Skin turgor: recoil in > 2 sec
• Peripheries: cold and mottled, cyanosed
• No urine output (anuria)
• Unable to drink
• Parched mucous membranes
• No tears
• Very sunken eyes and AF
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Moderate to Severe Dehydration
• Prompt intervention is needed
• The infant with severe dehydration is gravely ill
• The decrease in BP indicates that vital organs may
be receiving inadequate perfusion
• Immediate and aggressive intervention is
necessary
• If possible, the child with severe dehydration
should initially receive intravenous therapy
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• Clinical assessment of dehydration is only an
estimate
• Thus, the patient must be continually re-
evaluated during therapy
• The degree of dehydration is underestimated in
hypernatremic dehydration
• This because the movement of water from the
ICF to ECF helps to preserve the intravascular
volume
• The opposite occurs with hyponatremic
dehydration
• Dangerous intravascular volume depletion can
occur with less severe fluid deficits
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• The history usually suggests the aetiology of the
dehydration
• It may predict whether the patient will have:
a. Isotonic dehydration
b. Hyponatremic dehydration
c. Hypernatremic dehydration
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Things to consider
• Some children with dehydration are
appropriately thirsty
• Others, the lack of intake is part of the
pathophysiology of the dehydration
• Good urine output may be deceptively present
in:
1. Diabetes insipidus
2. Salt-wasting nephropathy
3. Hypernatremic dehydration
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Approach To Dehydration
• The child with dehydration requires acute
intervention to ensure that there is adequate
tissue perfusion
• Resuscitate : ABCs
• Treatment the shock (know how) if any with an
isotonic solution, such as normal saline (NS) or
Ringer lactate (LR)
• When patient is out of shock, calculate daily
replacement fluid therapy
• Subtract the amount you gave in shock and give
the remaining fluid accordingly
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• A child with a known or probable metabolic alkalosis
(the child with isolated vomiting), LR should not be
used because the lactate will worsen the alkalosis
• Colloids, such as blood, 5% albumin, and plasma, are
rarely needed for fluid boluses
• A crystalloid solution (NS or LR) is satisfactory, with
both less infectious risk and lower cost
Blood: significant anaemia or acute blood loss
Plasma: coagulopathy
Hypoalbuminemia: 5% albumin
• The volume and the infusion rate for colloids are
generally modified compared with crystalloids
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Dehydration In No Malnutrition
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Dehydration In No Malnutrition
• Plan the fluid therapy for the next 24 hr
• There are various protocols
• Use WHO treatment plans: A, B and C
• Plan A: patients treated at home
• Plan B and C: Admit
• Plan A: ORS or other recommended fluids
• Plan B: give ORS
• Plan C: Isotonic IVFs
- RL, ½ NS in 5 % dextrose (D5 ½ NS)
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WHO ORS
a. 13.5 g of CHO = 75 mmol/L
b. 20 g of CHO = 111 mmol/L
c. Base = 2.5 g of NaHCO3 (30 mmol/L of HCO3-) or 2.5 g of
Trisodium citrate (10 mmol/L of citrate)
d. The formula containing citrate is much more stable
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Plan Fluid Therapy In No Malnutrition
• Use WHO treatment plans:
1. No dehydration: Tx using Plan A
2. Some dehydration: Tx using Plan B
3. Severe dehydration: Tx using Plan C
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Plan A
Home therapy to prevent dehydration and malnutrition
• If no dehydration: a child needs extra fluids and salt to
replace their losses of water and electrolytes due to
diarrhoea
• If these are not given, signs of dehydration may develop
The 3 Rules
• Mothers should be taught these rules:
- Rule 1: Give the child more fluids than usual, to prevent
dehydration
- Rule 2: Continue to feed the child, to prevent malnutrition
- Rule 3: Take child to hospital if signs of dehydration or other
problems
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Plan A
What fluids to give
• Wherever possible, these should include at least one
fluid that normally contains salt
• Plain clean water should also be given
Suitable fluids
Two groups:
1. Fluids that normally contain salt:
- ORS solution
- Salted drinks (e.g. salted rice water or a salted
yoghurt drink)
- Vegetable or chicken soup with salt
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Plan A
Teach mothers to add salt (about 3g/l) to an unsalted drink
or soup
2. Fluids that do not contain salt:
- Plain water
- water in which a cereal has been cooked (e.g. unsalted
rice water)
- Unsalted soup
- Yoghurt drinks without salt
- Green coconut water
- Weak tea (unsweetened)
- Unsweetened fresh fruit juice.
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Plan A
How much fluid to give
• The general rule is:
- Give as much fluid as the patient wants until
diarrhoea stops
- As a guide, after each loose stool, give:
• Patients < 2 yrs : 50-100mL/loose stool
- A quarter to half a large cup
• Patients 2 yrs – 10 yrs : 200-400mL/loose stool
- A half to one large cup
• Patients > 10 yrs : As much as possible
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Plan A
• Continue feeding during diarrhoea and increase
afterwards. Never withhold food
• Child's usual foods should not be diluted
• Breastfeeding should always be continued
• Aim is to give as much nutrient rich food as the
child will accept
• Food intake support continued growth and
weight gain
• Continued feeding also speeds the recovery of
normal intestinal function
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When Should Pt be Brought to Hospital?
If there are signs of dehydration or other problems
- Starts to pass many watery stools
- Has repeated vomiting
- Becomes very thirsty
- Is eating or drinking poorly
- Develops a fever
- Has blood in the stool
- The child does not get better in three days
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Plan B: ORT
• Children with some dehydration should
receive oral rehydration therapy (ORT) with
ORS solution in a health facility
• Use the table on the next slide
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Plan B: ORT
• Use patient's age ONLY when you do not know the
weight
• Start with 200-400mL for < 5 kg, then increase by
200 mL for intervals of 3 kg (check pattern in the
table). Give in the first 4 hours
• Approximate amount of ORS: 75 mL/kg in 4 hrs
- If the patient wants more ORS than shown, give more
- Encourage the mother to continue b/feeding
- For infants under 6 months who are not breastfed,
give 100-200ml clean water during this period
- If the child vomits, wait 5-10 minutes and then start
giving ORS solution again, but more slowly
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Plan B
• During the initial stages of therapy, while still
dehydrated, if necessary:
a. Adults can consume up to 750 ml/hr
b. Children up to 20 mL/kg/hr
Sign of overhydration: Oedematous (puffy) eyelids
• If this occurs, stop giving ORS solution, but give
breastmilk or plain water, and food
• Do not give a diuretic
• When the oedema has gone, resume giving ORS
solution or home fluids according to Plan A
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Monitoring Progress of ORT
• Check the child from time to time during
rehydration
• This ensures that ORS solution is being taken
satisfactorily and that signs of dehydration are
not worsening
• If at any time the child develops signs of severe
dehydration, shift to Treatment Plan C
• After 4 hours (after giving calculated ORS),
reassess the child fully
• Then decide what treatment to give next
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Plan C: IV Rehydration
• Children who can drink, even poorly, should be
given ORS solution by mouth until the IV drip is
running
• All children should start to receive some ORS
solution (about 5 ml/kg/h) when they can drink
without difficulty
• This is usually within 34 hours (for infants) or 12
hours (for older patients)
• This provides additional base and potassium,
which may not be adequately supplied by the IVF
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Monitoring the Patient
Look and feel for all the signs of dehydration:
• If signs of severe dehydration are still present,
repeat the IV fluid infusion for Plan C
- Very unusual, occurs only in children who pass
large watery stools frequently during the
rehydration period
• If signs of some dehydration, discontinue the IV
infusion and give ORS solution for 4 hrs, as
specified in Treatment Plan B
• If there are no signs of dehydration, follow
Treatment Plan A
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Role of Antibiotics
• Antibiotics have no role in dehydration even if it
is secondary to infectious diarrhoea
• Give antibiotics in acute or persistent diarrhoea
ONLY in:
1. Dysentery
2. Cholera

Discharge
• If possible, observe child for at least six hours
before discharge while the mother gives the child
ORS solution
• Teach mother Plan A
• Confirm that she is able to maintain the child's
hydration
• Remember that the child will require therapy
with ORS solution until diarrhoea stops
• Give her enough ORS packets for two days
• Teach her the signs that mean she should bring
her child back to hospital
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Dehydration In Malnutrition

• It is difficult to estimate dehydration status in a
severely malnourished child using clinical signs
alone
• Signs of dehydration used in malnutrition
• Treat those showing the following signs of severe
dehydration:
1. Lethargy or unconsciousness
2. Delayed CRT > 3 sec
3. Weak feeble and fast pulse
4. Reduced urinary output (< 0.5-1 mL/Kg/hr)
5. Cold peripheries

Dehydration In Malnutrition
Malnourished Children Require Special Treatment
- Heart unable to handle large fluids, give per oral
- Malnourished children are ONLY given IVFs when they
are in shock
1. Give ReSoMal (not ORS or IVFs) orally or via NG tube:
a. In the first 2 hours, give 5 mL/kg every 30 min
b. In the next 4-10 hours, give 5-10mL/Kg alternating
every hour with starter F-75
c. Enter child in stabilization phase with starter F-75 2-
3 hourly (including night time)

Thanks
3/19/2022
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Deficit Therapy + Dehydration..pdf

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