73: PEDIATRIC DEHYDRATION

INTRODUCTION Less tolerance to fluid/lyte changes b/c of higher metabolic rate in kids versus adults Turnover of fluids and solute 3Xs that of adult Higher % TBW (75% in neonate, 65% in child, 60% in adult) APPROACH TO DEHYDRATION: THE FIVE POINT ASSESSMENT... What is the volume deficit? Estimation by clinical assessment of % dehydration X body weight Does an osmolar deficit exist? Hyponatremic (hypotonic) dehydration = Na < 130 Isonatremic (isotonic) dehydration = Na 130 - 150 Hypernatremic (hypertonic) dehydration = Na > 150 Does an acid - base deficit exist? Loss of bicarbonate in diarrhea ----> normal anion gap metabolic acidosis Ketoacidosis (lipolysis- poor oral intake --> increased anion gap met acidosis Lactic acisosis (tissue hypoperfusion) > increased anion gap met acidosis Respiratory alkalosis as compensation for above Does a potassium disturbance exist? K+ loss in diarrheal stools Typical deficits: isonatremic (8-10 mEq/kg), hypoonatremic (8-10 mEq/kg) hypernatremic (0-4 mEq/kg) Serum K+ not reflective of total bd K+ b/c of shifts (acid/base disturbance) High K+: K+ replacement needs to be cautious, watch for renal failure What is the renal function? Pre-renal versus renal failure: Urine Na, FE Na, urine sediment, etc MAINTENANCE REQUIREMENTS Fluid losses 50% urine 50% insensible (2/3 derm, 1/3 resp) Fluid requirement 4:2:1 rule per hour or 100:50:20 rule per 24hr 4cc/kg/hr for 0 - 10kg: 2cc/kg/hr for 10 - 20kg: 1cc/kg/hr for > 20kg 100cc/kg/24hr for 0-10: 50cc/kg/24hr for 10-20: 20cc/kg/hr for > 20kg Caloric requirement Same 4:2:1 rule to determine Kcal/kg/hr or 100:50:20 rule for daily caloric requirement Electrolyte requirements Na+ requirement is 3mEq/kg/24hr K+ requirement is 3mEq/kg/24hr Kidney produces enough bicarbonate therefore not required Glucose: 5g glucose per 100ml maintenance fluid enough to prevent ketosis Requirements will increase with fever, ventilation, inc. activity, etc DEFICITS/DEHYDRATION Loss is mainly from ECF

Estimate by: (wt b/f - wt a/f)/wt b/f = % dehydration. Rarely have accurate wt b/f :. must estimate clinically History Intake: what, how much? Output: urine, sweat, feces, vomiting? how much? Lethargic, activity level Physical Examination Gen: irritable, restless, lethargic, looks unwell Vitals: temp, RR, HR, BP, cap refill, wt H/N: mucous mem, eyes sunken, fontanelle, tearing Derm: skin turgor Clinical Estimation (note that 1cc = 1gm) Mild: 0 - 5% X body weight (5% X 10kg = 500cc) Moderate: 5 - 10% X body weight (10% X 10kg = 1000cc) Severe: 10 - 15% (15% X 10 kg = 1500cc)

MILD % Appearanc e Vitals < 5%

Thirsty, alert, restless Normal radial pulse and RR, BP normal Normal fontanelle Moist mucous mem Normal eyes Tears

MODERATE 6 - 10%
Thirsty, drowsy, orthostatic Rapid but strong radial pulse, increased RR, BP normal Sunken fontanelle Dry mucous mem Sunken eyes Absent tears

SEVERE > 10%

Lethargic, limp, cold

Rapid and weak radial pulse, increased RR, BP normal or low Very sunken fontanelle Parched mucous mem Very sunken eyes Absent tears Cap > 5 sec Marked tenting Reduce or no urine Loss of > 100 ml/kg

H/N

SKIN GENERAL

Cap refill < 2sec No tenting Normal urine Loss of 40 - 50 ml/kg

Cap refill 3 - 4 sec Mild tenting Reduced, dark urine Loss of 60 - 100 ml/kg

History + NO physical findings

History + physical findings

History + severe physical findings

PATHOPHYSIOLOGY Isonatremic (Isotonic) Dehydration: 80% [Na] between 130 - 150 Roughly equal losses of Na and water NO change in body tonicity or redistribution of fluid between extra and intravascular spaces Hyponatremic (hypotonic) Dehydration: 5% [Na+] is < 130 mmol/L Sodium loss > water loss Most common cause is sodium poor replacement of GI loss Child appears relatively more ill than expected b/c water shifts from ECF to ICF :. there is less intravascular volume and more physical signs Na < 120: seizures, coma Cerebral edema can lead to seizures Hypo-osmolar demyelination syndrome,most commonly seen as central pontine myelinolysis, can occur. Uncertain whether these are due to hyponatremia itself or too rapid correction of Na+. Pathophysiology unknown. Thought to be due to rapid correction in chronic hyponatremia. Neurological findings include fluctuating LOC, behavioral disturbances, convulsions progressing to pseudobulbar palsy and quadraparesis. Hypernatremic (Hypertonic) Dehydration: 15% [Na+] > 150 mmol/L Water loss > sodium loss or increased Na+ intake (incorrect formulas) Child appears relatively less ill than it is b/c water shifts from ICF to ECF :. there is more relative intravascularvolume and less physical signs Risk: brain hemorrhage, SZ, coma, death Do NOT correct rapidly w/ hypotonic solution b/c of brain shifts which can cause massive brain swelling May have alternating LOC b/w lethargy and hyperirritability PE: dry, rubbing, doughy skin w/ inc muscle tone (doughy skin b/c hypertonicity of body fluids in subcutaneous tissues) Risk: intracellular dehydration :. water shifts out of the brain cells. This stress causes production of idiogenic osmols (glycine and taurine) which prevents ongoing water loss from neurons. If serum Na is lowered too quickly, these idiogenic osmols will then attract water into brain cells causing swelling, massive cerebral edema, and intractable seizures. MUST correct serum Na slowly, and remember that tissue/renal perfusion is maintained w/ high Na MANAGEMENTOF SEVERE DEHYDRATION Approach is ABCs with emphasis on iv access ALL types of severe dehydration require a fluid bolus of 20 cc/kg of 0.9% NaCl or Ringers Theoretical risk of acidosis with normal saline: infusion of NaCl dilutes the extracellular HC03- creating a dilutional acidosis. Ringers lactate has some HCO3 in it. Reassess q 5-10 min after bolus and repeat as needed X 2 Avoid glucose containing solutions for initial resuscitation of severe dehydration If hypoglycemic: give 2ml/kg D25W (children) or 4ml/kg DW10 (infants)if hypoglycemic Consider colloids (albumin, FFP, synthetics) if renal, cardiac, or pulmonary dz Consider differential dx of shock if nonresponsive to 3 boluses (>60 ml/kg): septic, spinal,

hypovolemic, hemorrhagic, obstructive, cardiogenic, anaphylactic, other ISONATREMIC DEHYDRATION Phase I (0 - 20min): Bolus 20 cc/kg X 3 prn of normal saline, lactate ringers Phase II (0 - 8hrs): Infusion with D5W 0.45% normal saline (D5W NS) Add 20 mEq/L KCL after urine output established Rate cc/hr = ( deficit - bolus) + maintenance X 8hrs + ongoing losses 8 hours Phase III (8-24hrs): Infusion with D5W 0.45%NS Adjust according to urine output if neccessary; monitor lytes Rate cc/hr = deficit + maintenance X 16hrs + ongoing losses 16 hours

HYPONATREMIC DEHYDRATION Phase I (0-20min): Bolus 20 cc/kg X 3 prn of NS or LR Phase II (0-8hrs) If not seizing ... administer D5W NS with objective to raise serum Na by no more than 12 mEq/L over 24hrs no NaCl bolus necessary rate cc/hr = ( deficit - bolus) + maintenanceX8hrs + losses 8 hours If seizing... Na deficit = (desired - current [Na]) X TBW X weight (kg) Na deficit = (120 - [Na]) X 0.6 X kg replace with 3% saline (0.5 mEq/ml or 513 mEq/L) use 120 as desired Na to prevent rapid overcorrection proceed with fluids to raise Na by no more than 12 mEq/L over next 24hrs; monitor lytes after 3% saline, use D5W NS rate cc/hr = ( deficit - bolus) + maintenanceX8hrs + losses 8 hours Phase III (8-24hrs) DW5 NS Rate cc/hr =1/2 deficit + maintenance X 16hrs + ongoing losses 16 hours HYPERNATREMIC DEHYDRATION Phase I: Bolus 20 cc/kg NS X 3 prn Phase II/III Treat shock and give fluids to replace deficits over 48hrs (vs 24hr) Reduce serum Na by no more than 10 mEq/L/24hrs Dialysis for SeNa > 210 mEq/L Acceptable solutions: D5W0.45%NS or D5W0.2%NS NOTE that rate of solution more important than type of solution Rate cc/hr = ( deficit - bolus) + maintenanceX24hrs + ongoing losses 24 hours SPECIAL SITUATIONS

Acidosis

Potassium

Regardless of type of dehydration, pt may b/cm acidotic from lactate secondary to poor perfusion, ketone production, or bicarbonate loss in diarrhea Most recover spontaneously with rehydration Consider HCO3- for pH < 7.0 or HCO3 < 10 (debatable) NaHCO3 deficit = 20 - SeHCO3 X 0.6 X kg Remember that HCO3 can cause severe K+ shifts and paradoxical CSF acidemia Do not fully correct acidosis Remember shifts; ddx is mainly GI vs renal loss Always ensure urine output and renal function before replacing K+ Replace with 20 - 40 mEq Kcl/L Maximum is 60 mEq/L in peripheral iv Replace potassium gradually over 2 days

ORAL REHYDRATION THERAPY (ORT) Contraindications to oral rehydration therapy Severe dehyration/shock Lethargy Acute abdomen Intestinal obstruction Underlying complicating illness Failure of oral rehydration therapy Circulatory collapse Increasing deficit despite ORT Deterioration during ORT Intractable vomiting Failure to rehydrate in 8hrs Technique Rehydrate in ED over 4hrs, reassess Review contents of pedialyte, WHO solution, gatorade, apple juice, soup, etc D/C home at 4 hours if rehydrated, continue if not D/C home or admit at 8 hours Give 1/4 of target volume Q1hr X 4 Target volumes mild = 60 ml/kg, moderate = 80 ml/kg or: deficit + maintenance + ongoing losses Controversy/Discussion Why is glucose needed? the absorption of Na occurs by a Na/Glucose cotransporter which remains functional during diarrhea (even secretory) Is there a role for NG placement and rehydration vs oral vs iv rehydration Does it make sense to give frequent small volumes/sips to thirsty infant to try to prevent vomiting? Dehydration with Vomiting after every drink ....... some goes up, some goes down. Note studies with administration of drug followed immediately by ipecac: < 50% of drug is recovered thus at least is going down.

APPROACH TO PEDIATRIC DEHYDRAITON 1. Initial Resuscitation Emphasis on iv access and bolus administration of 20 cc/kg prn X3 for severe dehydration/shock 2. Determine % Dehydration (volume of deficit) Mild: <5% Moderate: 6 - 10% Severe: > 10% 3. Define Type of Dehydration: osmolar deficit? Hyponatremic (hypotonic): Na < 130 Isonatremic (isotonic): Na 130 - 150 Hypernatremic (hypertonic): Na > 150 4. Determine Type and Rate of Fluids Calculate deficit, maintenance, ongoing losses 5. Final Considerations Does an acid - base deficit exist? Does a potassium disturbance exist? What is the renal function?

MAINTENANCE 4:2:1 RULE = 0 - 10 kg: 4cc/kg/hr 10 - 20 kg: 2cc/kg/hr > 20 kg: 1cc/kg/hr 100:50:25 RULE = 0 - 10 kg: 100cc/kg/24hr 10 - 20 kg: 50 cc/kg/24hr > 20 kg: 25 cc/kg/24hr

DEFICIT

HOW DO YOU ASSESS % DEHYDRATION

MILD % Appearanc e Vitals < 5%
Thirsty, alert, restless Normal radial pulse and RR, BP normal Normal fontanelle Moist mucous mem Normal eyes Tears

MODERATE 6 - 10%
Thirsty, drowsy, orthostatic Rapid but strong radial pulse, increased RR, BP normal Sunken fontanelle Dry mucous mem Sunken eyes Absent tears

SEVERE > 10%

Lethargic, limp, cold

Rapid and weak radial pulse, increased RR, BP normal or low Very sunken fontanelle Parched mucous mem Very sunken eyes Absent tears Cap > 5 sec Marked tenting Reduce or no urine Loss of > 100 ml/kg

H/N

SKIN GENERAL

Cap refill < 2sec No tenting Normal urine Loss of 40 - 50 ml/kg

Cap refill 3 - 4 sec Mild tenting Reduced, dark urine Loss of 60 - 100 ml/kg

History + NO physical findings findings

History + physical findings

History + severe phys

DEFICIT = % DEHYDRATION x BODY WEIGHT (1cc = 1gm)

5% dehydrated X 10 kg = 0.05 X 10000cc = 500cc 10% dehydrated X 10kg = 0.10 X 10000cc = 1000cc 15% dehydrated X 10 kg = 0.15 X 10000cc = 1500cc

CALCULATIONS IN PEDIATRIC DEHYDRATION

CASE 1: CASE 2: 1yr old (10kg) vomiting and diarrhea X 4 days Slightly drowsy, not lethargic, good tone, warm, tacchycardic, strong pulse, normal BP, dry mucous mem, dry eyes, cap refill 3 sec Na = 132, K+ = 3.2, HCO3 = 20 What fluid and what rate would you use for the first 24hrs? Assume minimal ongoing losses. 1yr old (10kg) vomiting and diarrhea X 4 days Lethargic, limp, cold, weak rapid pulse, normal BP, sunken eyes, dry eyes, parched mucous membranes, cap refill 5 sec, marked tenting of skin Na = 115, K+ = 3.2, HC03 = 20 What fluid and what rate would you use for the first 24hrs? Minimal ongoing losses.

CASE #3:

How would your management change if the child seizes? 1yr old (10kg) vomiting and diarrhea X 4 days Lethargic, limp, cold, weak rapid pulse, normal BP, sunken eyes, dry eyes, parched mucous membranes, cap refill 5 sec, marked tenting of skin Na = 175, K+ = 3.2, HC03 = 20 What fluid and what rate would you use for the first 24hrs? Minimal ongoing losses.

CASE #1: ISONATREMIC DEHYDRATION

PHASE I (initial resuscitation)

iv access +/- bolus

PHASE II (0 - 8hrs) Fluid = D5W 0.45% normal saline (D51/2NS) Add 20 mEq/Kcl after urine output, renal function established Deficit (moderate dehydration) = 10% X 10kg = 1000cc Rate cc/hr ( deficit - bolus) + (maintenanceX8hrs) + ongoing losses 8 hrs (500 cc - 0) + (40cc/hr X 8hrs) + ongoing losses 8 hrs 500 + 320 + 0 8 hrs = 102 cc/hr

PHASE III (8 - 24hr) Fluid = D5W0.45% normal saline + 20mEq Kcl/L Rate cc/hr ( deficit) + (maintenance X 16hrs) + ongoing losses 16hrs (500cc) + (40cc X 16) + 0 16hrs = 71 cc/hr

CASE #1: ISONATREMIC DEHYDRATION

Most common form Na between 130 - 150

Roughly equal losses of Na and water NO change in body tonicity or redistribution of fluid between intra and extravascular spaces

CASE #2: HYPONATREMIC DEHYDRATION

PHASE I iv access + bolus 20cc/kg NS PHASE II NOT seizing Fluid = D5W0.45% normal saline + 20 mEq Kcl/L Deficit (severe dehydration) = 15% X 10kg = 1500ml Rate = ( deficit - bolus) + (maintenanceX8hrs) + ongoing losses 8 hrs (750cc - 200cc) + (40cc/hrX8hr) + 0 = 108 cc/hr 8hrs Seizing Fluid = 3% saline bolus Followed by D5W0.45%NS + Kcl at same rate as above Na deficit = (desired - current Na) X %TBW X weight Na deficit = (120 - 115mEq) X 0.5 X 10kg = 25 mEq 3% normal saline is 513 mEq/l or 0.5 mEq/ml Thus bolus 50 ml Rule of thumb: 2.5 ml/kg of 3% NS to increase Na by 5mEq/L PHASE III Fluid = DW50.45% normal saline + 20 mEq Kcl/L Rate = ( deficit) + (maintenance X 16hrs) + ongoing losses 16hrs

(750cc) + (40cc/hrX16) +0 16

87 cc/hr

CASE #2: HYPONATREMIC DEHYDRATION

Na < 130 Sodium loss > water loss + poor sodium replacement Cerebral edema: seizures, come Hypo-osmolar demylination syndrome Most commonly seen as central pontine myelinolysis Pathophysiology unknown. Thought to be due to rapid correction in chronic hyponatremia. Neurological findings include fluctuating LOC, behavioral disturbances, convulsions progressing to pseudobulbar palsy and quadraparesis. ? Incidence --------> many case reports in literature

CASE #3:HYPERNATREMIC DEHYDRATION

PHASE I Bolus of NS 20cc/kg PHASE II/III Fluid = D5W 0.45% NS or D5W0.2%NS Deficit (severe dehydration) = 15% X 10kg = 1500ml Rate cc/hr = ( deficit - bolus) + (maintenanceX24hrs) + ongoing losses 24hours (750cc - 200cc) + (1000cc)+ 0 24 hours = 65 cc/hr

REPLACE DEFICIT OVER 48 HOURS IN HYPERNATREMIC DEHYDRATION

CASE #3:HYPERNATREMIC DEHYDRATION
Na > 150 Water loss > Na loss Correct slowly over 48 hours Risk: seizures, coma, death Rapid correction ------> CEREBRAL EDEMA Hypernatremia: fluid shifts out of cells Idiogenic osmols (glycine, taurine) prevent water loss from cells Rapid correction ------> idogenic osmols attract water into cells ---> cerebral edema

SPECIAL CONSIDERATIONS
ACIDOSIS Lactic acidosis, ketoacidosis, bicarbonate loss Corrects itself with rehydration Respiratory compensation Forget bicarbonate unless severe pH < 7.0 (?)

HC03 deficit = (20 - measured) X 0.6 X weight Remember K+ shifts and paradoxical CSF acidosis (C02 crosses BBB better than HC03)

POTASSIUM Ensure adequate urine output before replacement Watch closely with renal failure 20 - max of 60 mEq Kcl/L in peripheral iv

ORAL REHYDRATION THERAPY

CONTRAINDICATIONS Severe dehydration, acute abdomen, intestinal obstruction, underlying relevant medical illnesses FAILURE Circulatory collapse, Increasing deficit despite ORT, deterioration during ORT, intractable vomiting, failure to rehydrate in 8hrs TECHNIQUE Rehydrate in ED over 4hrs, reassess and d/c home or continue and reassess at 8hrs Solutions: see table Target volumes mild = 60 ml/kg, moderate = 80 ml/kg or: deficit + maintenance + ongoing losses DISCUSSION Why is glucose needed? NG vs oral vs iv rehydration? Nothing will stay down IV bolus and discharge home