Dehydraton in pediatrics

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dehydration in pediatrics

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Dehydraton in pediatrics

  1. 1. DefinitionDefinition  is defined as an excessive loss of body fluid & electrolytes.  Output is more than input.
  2. 2. CausesCauses  Diarrhea  Vomiting  Excessive Sweating  Diabetes  Burns  Excessive blood loss caused by trauma or accident
  3. 3. Pathophysiology of dehydration
  4. 4. Types of dehydration based on severity  Mild : when the total fluid loss reaches 5% or less .  Moderate : when the total fluid loss reaches 5 - 10% .  Severe : when the total fluid loss reaches more than 10%, considered an emergency case .
  5. 5. Mild dehydration S&S Mild dehydration S&S  No dehydration  Thirsty  Conscious  Less than 5% of body Weight is lost.
  6. 6. Moderate dehydration S&S Moderate dehydration S&S  Dry skin and mucous membranes  Thirst  Decreased urine output  Crying baby with tears  Muscle weakness  Drowsiness  light head ache  sunken fontanels  Decreased BP  Increased Pulse rate (tachycardia)  Capillary refill  Shallow rapid RR  5 to10 % of body Weight is lost
  7. 7. Severe dehydration S&S Severe dehydration S&S  Extreme thirst  Very dry mouth, skin and mucous membranes  Sunken eyes  Sunken fontanels  No tears  Anuria  Dry skin that lacks elasticity and slowly “bounces back” when pinched into a fold  Rapid heartbeat  Rapid and shallow breath  Unconsciousness  More than 10 % of body Weight is loss  Delay Capillary refill for more than 2 seconds
  8. 8. Possible ComplicationsPossible Complications  Permanent brain damage  Seizures  hypernatremia  Hyponatremia  hypovolemic shock  Kidney failure  Coma and death
  9. 9. Tests and diagnosisTests and diagnosis  Blood tests:  to check level of electrolytes.  BUN  Creatinine  Urine analysis
  10. 10. Diarrhea Indications for stool studies  Toxic appearance  Immunocompromised  Bloody or invasive  Duration > 5days  Suspected parasites  Travel  Camping  Poor Water
  11. 11. TreatmentTreatment  dehydration treatment depends on age,weight , the severity of dehydration and its cause.  Oral rehydration solution (ORS) for mild and moderate dehydration  IV fluid replacement (for sever dehydration)  Treating the cause of dehydration  A single dose of ondansetron (Zofran) oraly(tablet)
  12. 12. Treatment of mild and moderate dehydration Treatment of mild and moderate dehydration  Oral rehydration solution (ORS) is a simple treatment for dehydration Contraindications for ORS: 1. Severe dehydration. 2. Unconsciousness. 3. Frequent vomiting attacks.  Continues breastfeeding .  A single dose of ondansetron oraly(tablet)
  13. 13. Treatment of sever dehydration Treatment of sever dehydration  NPO.  IV fluid replacement.
  14. 14. Daily Maintenance Fluid Requirements  Calculate child’s weight in kg.  Allow 100 ml/kg for first 10 kg body weight.  Allow 50 ml/kg for second 10 kg body weight.  Allow 20 ml/kg for remaining body weight. Daily Maintenance Fluid Requirements Daily Maintenance Fluid Requirements
  15. 15. Calculating replacementCalculating replacement Correction of deficit:  Deficit in ml = wt (kg) x % dehydrated x 10 (ideally the pre-dehydration weight should be used).  example : 14 kg child who is 5% dehydrated has a deficit of 14 x 5 x 10 = 700 ml.
  16. 16. Fluid requirements(burn victim ) Fluid requirements(burn victim )  TBSA burned(%) x Wt(kg) x 4 ml example : a child weighs 15kg,he has his leg burned TBSA=18 18x15x4=1080ml.  Give half of total requirements in first 8 hour,second half over next 16 hour.  Give IV fluid to the burned victim (child ) If the TBSA is 10% or more .
  17. 17. Rule of nine for measuring TBSA Rule of nine for measuring TBSA
  18. 18. Calculating Drop rate per minutes Calculating Drop rate per minutes (Solution) ml x 15 /hr x min  Example : 540 ml x15/8 hr x 60 =16 drops per minute. 540mlx15/16x60=8 drops per minute.
  19. 19. Prevention and home carePrevention and home care FAMILY EDUCATION:  If your child has vomiting or diarrhea more than four to five times in 24 consecutive hours, start fluid replacement & increasing fluid intake.  Even when you are healthy, drink plenty of fluids every day and drink more when the weather is hot.  Begin fluid replacement as soon as vomiting and diarrhea start -- DO NOT wait for signs of dehydration.  Remind family that fluid needs are greater with fever, vomiting, or diarrhea .
  20. 20.  Notify physician immediately in case of continues vomiting and diarrhea.  teach the mother how to prepare ORS at home Prevention and home carePrevention and home care
  21. 21. Approach
  22. 22. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations The gospel according to Rob Hall
  23. 23. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  24. 24. Initial Resuscitation  ABCs  Initial fluid bolus  20cc/kg of NS or Ringers  Appropriate in all types of dehydration  Reassess q5mins and repeat x 3  Initial hypoglycemia  5cc/kg of D10W in infants  2cc/kg of D25W in children  Think about Shock DDx if unresponsive to 3 attempts at NS bolus
  25. 25. Initial Resuscitation  Fluid Controversy… NS / RL  Theoretical risk of acidosis with NS  “Dilutional acidosis” with addition of NaCl to the extracellular fluid  Ringers lactate has some HCO3
  26. 26. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  27. 27. Determine % Dehydration
  28. 28. What are the best clinical markers?  Prolonged cap refill  Sunken eyes  Poor overall appearance  Sunken fontanelle  Absent tears  Increased HR  Weak Pulse  Dry mucous membranes  Abnormal resp pattern  Abnormal skin turgor or tenting
  29. 29. Determine % Dehydration  Does lab work help you in determining the degree of dehydration?  What lab values do people use to assess severity of dehydration?
  30. 30.  Tests such as BUN and bicarbonate are only helpful when results are markedly abnormal  A normal bicarbonate concentration reduces the likelihood of dehydration  No lab test should be considered definitive for dehydration
  31. 31. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  32. 32. Define the type of dehydration  Three major classes of dehydration based on relative losses of Na and Water 1) Isonatremic dehydration (80%) 2) Hypernatremic dehydration (15%) 3) Hyponatremic dehydration (5%) Thanks to Rob Hall for any details
  33. 33. Body Fluids ICF (mEq/L) ECF (mEq/L)  Sodium 20 135-145  Potassium 150 3-5  Chloride --- 98-110  Bicarbonate 10 20-25  Phosphate110-115 5  Protein 75 10
  34. 34. 1. Isonatremic dehydration  By far the most common  Equal losses of Na and Water  Na = 130-150  No significant change between fluid compartments  No need to correct slowly
  35. 35. 2. Hypernatremic Dehydration  Water loss > sodium loss  Na >150mmol/L  Water shifts from ICF to ECF  Child appears relatively less ill  More intravascular volume  Less physical signs  Alternating between lethargy and hyperirritability
  36. 36. Hypernatremic Dehydration  Physical findings  Dry doughy skin  Increased muscle tone  Correction  Correct Na slowly  If lowered to quickly causes  massive cerebral edema  intractable seizures
  37. 37. 3. Hyponatremic Dehydration  Sodium loss > Water loss  Na <130mmol/L  Water shifts from ECF to ICF  Child appears relatively more ill  Less intravascular volume  More clinical signs  Cerebral edema  Seizure and Coma with Na <120
  38. 38. Hyponatremic Dehydration  Correction  Must again be performed slowly unless actively seizing  Rapid correction of chronic hyponatremia thought to contribute to…. Central Pontine Myelinolysis  Fluctuating LOC  Pseudobulbar palsy  Quadraparesis
  39. 39. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  40. 40. Determine the type and rate of rehydration fluids  Oral Rehydration Therapy (ORT) vs Intravenous therapy (IVT) “ To poke or not to poke, that is the question”
  41. 41. ORT  Fluid replacement should be over 3-4hrs  50ml/kg for mild dehydration  100ml/kg for moderate dehydration  10ml/kg for each episode of vomiting or watery diarrhea
  42. 42. ORT  Contraindications to ORT  Severe dehydration (≥10%)  Ileus or intestinal obstruction  Unable to tolerate (Persistent vomiting)  Signs of shock  Decreased LOC or unconscious  Unclear diagnosis  Psychosocial situations
  43. 43. Oral rehydration solutions (ORS)   Osmoles mOsm/L Glucose mmol/L Na mEq/L Cl mEq/L HCO3 mEq/L K mEq/L WHO formulation 330 110 90 80 30 20 Pedialyte 270 140 45 35 30 20 D5W / 0.45% saline 454 300 77 77 0 0
  44. 44. NGT???  Is there a role for nasal gastric tube oral rehydration?  When caregivers are unwilling to perform ORT or when it is required overnight continuous nasogastric tube infusion is preferred over intravenous infusion
  45. 45. When to start feeding again?
  46. 46. Severe Dehydration  Management of severe dehydration requires IV fluids  Fluid selection and rate should be dictated by  The type of dehydration  The serum Na  Clinical findings  Aggressive IV NS bolus remains the mainstay of early intervention in all subtypes
  47. 47. Isonatremic Dehydration  Calculate the fluid deficit  Deficit (cc’s) = % dehydration x body wt  D5½NS is fluid of choice
  48. 48.  (½ deficit – the bolus) over the first 8hrs  Add maintenance and any ongoing losses to above  Further ½ the deficit replaced over the next 16hrs  Monitor electrolytes and U/O  Alternative – rapid approach
  49. 49. Hypernatremic Dehydration  Fluid deficit = • Replace with D50.2%NS • Replace over 48hrs • Reduce sodium by no more than 10mEq/L/24hrs  Water deficit (in L) = [(current Na level in mEq/L ÷ 145 mEq/L) - 1] X 0.6 X weight (in kg)  (½ deficit – the bolus) over the first 24hrs  Add maintenance and any ongoing losses to above  Further ½ the deficit replaced over the next 24hrs
  50. 50. Hyponatremic dehydration  Na deficit = (Nadesired- Nacurrent) x 0.6 x Weight (kg)  154 mEq in NS  77 mEq in D5½ NS  513 in 3% saline  rate at 0.5mEq/L/hr
  51. 51. Hyponatremic Dehydration  If seizing  Correct with 3% Saline bolus  Target a Na of 120  Further correction beyond this with D5½ NS  If not Seizing  Correct with D5½ NS  Target a Na of 130  Watch for Central Pontine Myelinolysis  More likely in chronic hypo-Na with less Sx  Correct slowly at rate of 0.5mEq/L/hr
  52. 52. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  53. 53. Final considerations  Does and Acid-Base Deficit exist?  Does a potassium disturbance exist?  What is the patients renal function?
  54. 54. Does and Acid-Base Deficit exist?  Acidosis  Lactate  Ketones  Loss of Bicarb in diarrhea  Most will resolve with simple rehydration  Consider HCO3 for pH<7.0
  55. 55. Does a potassium disturbance exist?  K+ losses  GI  Renal  Remember that K shifts with acidosis and certain therapies  Always insure renal function prior to IV replacement
  56. 56. Rapid Fire Cases
  57. 57. Case 1  2yr F (14kg)  3 days of diarrhea and vomiting  Decreased u/o as per mother  Exam  Generally appears well  MM dry and no significant tears  Skin turgor normal  Tachycardic but not tachypneic  Cap refill 2 seconds
  58. 58. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  59. 59. Answers  Initial resuscitation  deferred  % dehydration  5-9%  moderate  Dehydration Type  Likely Isonatremic  Rehydration fluids  ORT  Pedialyte  Rate and volumes  Moderate dehydration 100cc/kg = 1400cc  Replace over 3-4hrs  Further 10cc/kg with ongoing losses  Final considerations  None
  60. 60. Case 2  8mo M (8kg)  4 day hx of severe diarrhea and vomiting  No further ongoing losses  Exam  Limp and cold  Mottled with weak rapid pulse  Sunken eyes and fontanelle  Cap refill 5s  Tenting of skin  Labs Na = 170 K = 3.1 HCO3 = 18
  61. 61. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  62. 62. Answers  Initial resuscitation  160cc NS bolus  % dehydration  >10%  Severe  Dehydration Type  Hypernatremic  Rehydration fluids  IV fluids  D50.2NS  Rate and volumes  Volume deficit = 640cc  Correct slowly over 48hrs  39cc/hr over first 24hrs  45cc/hr over next 24hrs  Final considerations  Add 20 mEq K to IV fluids
  63. 63. Case 3  16mo F  3 day Hx of vomiting and diarrhea  Tolerating fluids not solids  Good u/o  Exam  Appears well with normal vitals  Tears +  MM moist  Cap refill <2s  Skin turgor normal
  64. 64. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  65. 65. Answers Send this kid home!!!
  66. 66. Case 4  2 yo M (16kg)  4 day Hx of vomiting and diarrhea  Exam  Appears drowsy but not lethargic  Good tone  Tachycardiac and tachypneic  BP normal  Very Dry MM  Cap refill 3s  Labs Na = 134 K = 3.1 HCO3 = 16
  67. 67. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  68. 68. Answers  Initial resuscitation  320cc of NS  % dehydration  >10%  Severe  Dehydration Type  Isonatremic  Rehydration fluids  D5½ NS  Rate and volumes  Volume deficit = 10% x 16kg = 1600mls  110cc/hr over first 8hrs  100cc/hr over next 16hrs  Final considerations  Add 20 mEq K to IV fluids  Watch for metabolic acidosis to resolve
  69. 69. Case 5  1yo F (10kg)  4 day Hx of severe diarrhea and vomiting  Exam  Lethargic and limp  Weak rapid pulse  Fontanelle sunken  Cap refill 5s  Cool and mottled  Tenting of skin  Labs  Na = 114  K = 3.4  HCO3 = 18  During your exam the patient starts Seizing
  70. 70. Approach to Peds Dehydration 1) Initial Resuscitation 2) Determine % dehydration 3) Define the type of dehydration 4) Determine the type and rate of rehydration fluids 5) Final considerations
  71. 71. Answers  Initial resuscitation  200cc NS  % dehydration  >10%  Severe  Dehydration Type  Hyponatremic  Rehydration fluids  IV  Initially 3% saline  D5½ NS after above  Rate and volumes  Initially correct to Na of 120 with 3% = 70cc bolus  Then correct to Na of 130 with D5½ NS at rate of 0.5mEq/L/hr = 39cc/hr  Final considerations  Add 20 mEq K to IV fluids
  72. 72. THANK YOU http:// www.medcalc.com/pedifen.html

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