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. Case Study-
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.
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.
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. Dehydration 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).
22. Vomiting
Metabolic Alkalosis
Loss of acid from
stomach
pH
HCO3
H+
Treatment: Prevent
further losses and
replace lost
electrolytes
Example: Pyloric Stenosis
31. Cystic fibrosis: excessive sodium and chloride
losses in sweat.
Diabetes insipidus: excessive output of very
dilute urine.
Thyrotoxicosis: increased insensible losses and
diarrhoea.
36. Mild Moderate Severe
Weight loss Up to 5% 6-10% More than 10%
Appearance Active,
alert
Irritable, alert,
thirsty
Lethargic, looks sick
Capillary
filling
(compared to
your own)
Normal Slightly delayed Delayed
Pulse Normal Fast, low volume Very fast, thready
Respiration Normal Fast Fast and deep
Blood
pressure
Normal Normal or low
Orthostatic
hypotension
Very low
Mucous
memb.
Moist Dry Parched
Tears Present Less than
expected
Absent
Eyes Normal Normal Sunken
37. Capillary filling
(compared to your
own)
Normal Slightly delayed Delayed
Pulse Normal Fast, low volume Very fast,
thready
Respiration Normal Fast Fast and
deep
Blood pressure Normal Normal or low
Orthostatic hypotension
Very low
Mucous memb. Moist Dry Parched
Tears Present Less than expected Absent
Eyes Normal Normal Sunken
Pinched skin Springs back Tents briefly Prolonged
tenting
Fontanel (infant
sitting)
Normal Sunken slightly Sunken
significant
ly
Urine flow Normal Reduced Severely
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. Mild or moderate dehydration: slow; skin fold visible for
less than 2 seconds.
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
46. Dehydration =
Total Out > Total In
Types:
Isotonic
Electrolyte = Water
Hypotonic
Electrolyte > Water
Hypertonic
Water > Electrolyte
0
10
20
30
40
50
60
70
80
Iso Hypo Hyper
Electrolytes
Water
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
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, HCO3)
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
66. Reluctance to use ORT
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.
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)
71. Name of Solution Type of Solution Ingredients in
1-Liter
Uses Complications
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 Chloride Hypertonic
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 Chloride Hypertonic
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
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
