Dehydration is defined as an excessive loss of body fluid and electrolytes where output exceeds input. It can be caused by diarrhea, vomiting, excessive sweating, burns, or blood loss. Dehydration is classified as mild, moderate, or severe based on the total fluid loss as a percentage of body weight. Clinical signs and symptoms vary with the severity of dehydration and can include thirst, dry skin, decreased urine output, drowsiness, and in severe cases, extreme thirst, sunken eyes, and loss of consciousness. Treatment involves oral rehydration for mild to moderate cases and IV fluids for severe dehydration, with the type and rate of fluids dependent on degree of dehydration and electrolyte

2. DefinitionDefinition
 is defined as an excessive loss of
body fluid & electrolytes.
 Output is more than input.

3. CausesCauses
 Diarrhea
 Vomiting
 Excessive Sweating
 Diabetes
 Burns
 Excessive blood loss caused by
trauma or accident

4. Pathophysiology of dehydration

5. 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
.

6. Mild dehydration
S&S
Mild dehydration
S&S
 No dehydration
 Thirsty
 Conscious
 Less than 5% of body Weight is
lost.

7. 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

9. 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

11. Possible ComplicationsPossible Complications
 Permanent brain damage
 Seizures
 hypernatremia
 Hyponatremia
 hypovolemic shock
 Kidney failure
 Coma and death

12. Tests and diagnosisTests and diagnosis
 Blood tests:
 to check level of
electrolytes.
 BUN
 Creatinine
 Urine analysis

13. Diarrhea
Indications for stool studies
 Toxic appearance
 Immunocompromised
 Bloody or invasive
 Duration > 5days
 Suspected parasites

Travel

Camping

Poor Water

14. 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)

15. 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)

16. Treatment of sever
dehydration
Treatment of sever
dehydration
 NPO.
 IV fluid replacement.

17. 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

18. 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.

19. 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 .

20. Rule of nine for
measuring TBSA
Rule of nine for
measuring TBSA

21. 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.

22. 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 .

23.  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

24. Approach

25. 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

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. 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

28. 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

29. 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

30. Determine % Dehydration

31. 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

32. Determine % Dehydration
 Does lab work help you in determining
the degree of dehydration?
 What lab values do people use to
assess severity of dehydration?

33. 
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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Hypernatremic Dehydration
 Physical findings
 Dry doughy skin
 Increased muscle tone
 Correction
 Correct Na slowly
 If lowered to quickly causes

massive cerebral edema

intractable seizures

40. 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

41. 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

42. 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

43. 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”

44. 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

45. 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

46. 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

47. 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

48. When to start feeding again?

49. 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

50. Isonatremic Dehydration
 Calculate the fluid deficit

Deficit (cc’s) = % dehydration x body wt
 D5½NS is fluid of choice

51.  (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

52. 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

53. 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

54. 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

55. 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

56. Final considerations
 Does and Acid-Base Deficit exist?
 Does a potassium disturbance exist?
 What is the patients renal function?

57. 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

58. 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

59. Rapid Fire Cases

60. 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

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. 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

63. 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

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. 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

66. 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

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. Answers
Send this kid home!!!

69. 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

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. 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

72. 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

73. 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

74. 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

75. THANK YOU
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