Dehydration

Paul R. Earl

| Biolgicas Facultad de Ciencias

Universidad Autnoma de Nuevo Len San Nicols, N. L., Mexico

pearl@dsi.uanl.mx

 Dehydration or volume depletion is classified as mild, moderate or severe based on how much body fluid is lost. When severe, dehydration is a lifethreatening emergency. Volume depletion denotes lessening of the total intravascular plasma, whereas dehydration denotes loss of plasma-free water disproportionate to the loss of sodium. Potassium and other electrolytes including buffers lke phosphates need to be considered. Children, especially those younger than 4 years old, are more susceptible to volume depletion as a result of vomiting, diarrhea or increases in insensible water losses.

 Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both. Vomiting and diarrhea are common causes. Dehydration is classified as mild, moderate or severe based on how much body's fluid is lost. Symtons include: Dry or sticky mouth. Dizziness. Low or no urine output; concentrated urine is dark yellow. Not producing tears. Sunken eyes. Markedly sunken fontanelles (the soft spot on the top of the head in a baby). Lethargic or comatose.

 In addition to the symptoms of actual dehydration, you may also have: vomiting and diarrhea.

 Drinking fluids is usually sufficient for mild dehydration. It is better to have frequent, small amounts of fluid (using a teaspoon or syringe for an infant or child) rather than trying to force large amounts of fluid at one time. Drinking too much fluid at once can bring on more vomiting. Electrolyte solutions or freezer pops are especially effective. These are available at pharmacies. Sport drinks contain a lot of sugar and can cause or worsen diarrhea. In infants and children, avoid using water as the primary replacement fluid.

Intravenous fluids and hospitalization may be necessary for moderate to severe dehydration. The doctor will try to identify and then treat the cause of the dehydration.

 Treatment includes starting NS@20ml/kg slow push until signs of severe dehydration disappear. Avoid Ringer Lactate till patient passes urine. Maintainence fluid depends on body weight. Either DNS or RL may be used 10kg and less 100ml/Kg 10-20 Kg 1000mL+50ml/kg 20+ Kg 1500ml+ 20 ml/kg It may be advisable to give half the calculated fluid in the first 8 hours and the remaining over the next 16 hours Precautions check for pulmonary oedema replenish Potassium as required Chills may occur due to fluid administration rule out infectious causes

 Most cases of stomach viruses (also called viral gastroenteritis) tend to resolve on their own after a few days. Boxers under hot lights sip water, then usually spit it out. They don`t seem to know that that water could save them from a coma during heat prostration !

 Pathophysiology Pediatric dehydration is frequently the result of gastroenteritis, characterized by vomiting and diarrhea. However, other causes of dehydration may include poor oral intake due to diseases such as stomatitis, insensible losses due to fever, or osmotic diuresis from uncontrolled diabetes mellitus.

 Volume depletion denotes lessening of the total intravascular plasma, whereas dehydration denotes loss of plasma-free water disproportionate to the loss of sodium. The distinction is important because volume depletion can exist with or without dehydration, and dehydration can exist with or without volume depletion.

 In children with dehydration, the most common underlying problem actually is volume depletion, not dehydration. Intravascular sodium levels are within the reference range, indicating that excess free water is not being lost from plasma. Rather, the entire plasma pool is contracted with solutes (mostly sodium) and solvents (mostly water) lost in proportionate quantities. This is volume depletion without dehydration. The most common cause is excessive extrinsic loss of fluids.

 Pediatric patients, especially those younger than 4 years, tend to be more susceptible to volume depletion as a result of vomiting, diarrhea, or increases in insensible water losses. Significant fluid losses may occur rapidly. The turnover of fluids and solute in infants and young children can be as much as 3 times that of adults. This is because of the following: Higher metabolic rates

Increased body surface area to mass index

Higher body water contents (Water comprises approximately 70% of body weight in infants, 65% in children, and 60% in adults.)

Sodium considerations
Volume depletion can be concurrent with hyponatremia. This is characterized by plasma volume contraction with free water excess. An example is a child with diarrhea who has been given tap water to replete diarrheal losses. Free water is replenished, but sodium and other solutes are not.

 In hyponatremic volume depletion, the person may appear more ill clinically than fluid losses indicate. The degree of volume depletion may be clinically overestimated. Serum sodium levels less than 120 mEq/L may result in seizures. If intravascular free water excess is not corrected during volume replenishment, the shift of free water to the intracellular fluid compartment may cause cerebral edema.
With true dehydration, plasma volume contracts with disproportionate further free water loss. An example is the child with diarrhea whose fluid losses have been replenished with hypertonic soup, boiled milk, baking soda, or improperly diluted infant formula. Volume has been restored, but free water has not.

 In hypernatremic volume depletion, the patient may appear less ill clinically than fluid losses indicate. The degree of volume depletion may be underestimated. Usually, at least a 10% volume deficit exists with hypernatremic volume depletion. As in hyponatremia, hypernatremic volume depletion may result in serious central nervous system (CNS) effects as a result of structural changes in central neurons. However, cerebral shrinkage occurs instead of cerebral edema. This may result in intracerebral hemorrhage, seizures, coma, and death. For this reason, volume restoration must be performed gradually over 24 hours or more. Gradual restoration prevents a rapid shift of fluid across the bloodbrain barrier and into the intracellular fluid compartment.

Potassium considerations
Potassium shifts between intracellular and extracellular fluid compartments occur more slowly than free water shifts. Serum potassium level may not reflect intracellular potassium levels. Although a potassium deficit is present in all patients with volume depletion, it is not usually clinically significant. However, failure to correct for a potassium deficit during volume repletion may result in clinically significant hypokalemia. Potassium should not be added to replacement fluids until adequate urine output is obtained.

Acid and base problems

Clinicians may observe derangements of acid-base balance with volume depletion. Some degree of metabolic acidosis is common, especially in infants.

Mechanisms include bicarbonate loss in stool and ketone production. Hypovolemia causes decreased tissue perfusion and increased lactic acid production. Decreased renal perfusion causes decreased glomerular filtration rate, which, in turn, leads to decreased hydrogen (H+) ion excretion. These factors combine to produce a metabolic acidosis.

 In most patients, acidosis is mild and easily corrected with volume restoration (as increased renal perfusion permits excretion of excess H+ ions in the urine). Administration of glucose-containing fluids further decreases ketone production.

Frequency
United States
Pediatric dehydration, particularly that due to gastroenteritis, is a common ED complaint. Approximately 200,000 hospitalizations and 300 deaths per year are attributed to gastroenteritis each year.

International According to the Centers for Disease Control and Prevention (CDC), for children younger than 5 years, the annual incidence of diarrheal illness is approximately 1.5 billion, while deaths are estimated between 1.5 and 2.5 million. Though these numbers are staggering, they actually represent an improvement from the early 1980s, when the death rate was approximately 5 million per year.

Mortality/Morbidity
Morbidity varies with the degree of volume depletion and the underlying cause.
The severely volume-depleted infant or child is at risk for death from cardiovascular collapse. Hyponatremia resulting from replacement of free water alone may cause seizures. Improper management of volume repletion may cause iatrogenic morbidity or mortality.

Age
Infants and younger children are more susceptible to volume depletion than older children.

Clinical History
The goal of the history and physical examination is to determine the severity of the child's condition. Classifying the degree of dehydration as mild, moderate, or severe accurately allows for appropriate therapy and disposition of the patient in a timely fashion. Obtaining a complete history from the parent or caregiver is important because it provides clues to the type of dehydration present.

The emergency physician should be diligent in obtaining the following information:

Feeding pattern and fluids given

Number of wet diapers compared with normal Fluid loss (eg, vomiting, oliguria or anuria, diarrhea) Possible ingestions Activity Medications Heat and sunlight exposures

Physical
The following table highlights the physical findings seen with different levels of pediatric dehydration.

Symptom

Mild (<3% body weight lost) Normal, alert Normal Normal Normal

Moderate (3-9% body weight lost)

Severe (>9% body weight lost)

Mental status
Heart rate Quality of pulse Breathing

Restless or fatigued, irritable

Normal to increased Normal to decreased Normal to increased

Apathetic, lethargic, unconscious Tachycardia or bradycardia

Weak, thready, impalpable Tachypnea and hyperpnea

Eyes

Normal

Slightly sunken
Slightly sunken Normal to decreased

Deeply sunken
Deeply sunken Absent

Fontanelle Normal s Tears Normal

Mucous membranes Skin turgor Capillary refill Extremities Symptom Mental status Heart rate

Moist Instant recoil

Dry Recoil <2 seconds

Parched Recoil >2 seconds

<2 seconds
Warm Mild (<3% body weight lost) Normal, alert

Prolonged
Cool Moderate (3-9% body weight lost) Restless or fatigued, irritable Normal to increased

Minimal
Mottled, cyanotic Severe (>9% body weight lost) Apathetic, lethargic, unconscious Tachycardia or bradycardia

Normal

Quality of pulse Breathing Eyes Fontanelles

Normal Normal Normal Normal

Normal to decreased Normal to increased Slightly sunken Slightly sunken

Weak, thready, impalpable Tachypnea and hyperpnea Deeply sunken Deeply sunken

Tears Mucous membranes

Skin turgor Capillary refill Extremities

Normal Moist
Instant recoil <2 seconds Warm

Normal to decreased Dry

Recoil <2 seconds Prolonged Cool

Absent Parched
Recoil >2 seconds Minimal Mottled, cyanotic

 Of these, the most accurate in identifying the level of dehydration are capillary refill, skin turgor, and breathing. The least accurate are mental status, heart rate and fontanelle appearance.

Causes
In most cases, volume depletion in children is from fluid losses from vomiting or diarrhea.
Vomiting may be caused by any of the following systems or processes: CNS (eg, infections, space-occupying lesions) GI (eg, gastroenteritis, obstruction, hepatitis, liver failure, appendicitis, peritonitis, intussusception, volvulus, pyloric stenosis, toxicity [ingestion, overdose, drug effects]) Endocrine (eg, diabetic ketoacidosis [DKA], congenital adrenal hypoplasia, Addisonian crisis)

Renal (eg, infection, pyelonephritis, renal failure, renal tubular acidosis)

Psychiatric (eg, psychogenic vomiting) - This is not seen in infants and is rare in children compared with adults.

Diarrhea may be caused by any of the following systems or processes:

GI (e.g., gastroenteritis, malabsorption, intussusception, irritable bowel, inflammatory bowel disease, short gut syndrome) Endocrine (eg, thyrotoxicosis, congenital adrenal hypoplasia, Addisonian crisis, diabetic enteropathy) Psychiatric (eg, anxiety)

 Volume depletion not caused by vomiting or diarrhea may be divided into renal or extrarenal causes. Renal causes include use of diuretics, renal tubular acidosis, and renal failure (eg, trauma, obstruction, saltwasting nephritis). The effects of diabetes insipidus, hypothyroidism, and adrenal insufficiency also fall into this category.

Extrarenal causes include third-space extravasation of intravascular fluid (eg, pancreatitis, peritonitis, sepsis, heart failure); insensible losses from fever, sweating, burns, or pulmonary processes; poor oral intake; and hemorrhage.