Calculating Full Maintenance = 100ml x 1st 10kgs + 50ml x 2nd 10kgs + 20ml x >20kgs Full Maintenance = Sensible ( )+ Insensible losses (30ml/kg/24hr or maintenance) 

When patients should receive more than full maintenance: y Febrile child on maintenance requires an additional 10% of total maintenance for every 1° > 38°C.  When patients should receive less than full maintenance: y Anuric patient should only have insensible losses replaced (i.e. third maintenance, 30ml/kg/24hr). y CHF and SIADH (as can occur in post-meningitis increased ICP); patient should receive twothirds maintenance. Example I: 10 kg boy with renal failure, calculate his maintenance fluid dose.  Anuric patient should be put on a third maintenance: 30ml x 10kg = 300ml / 24hr = 12.5 ml/hr Example II: 27 kg boy, calculate maintenance dose of fluid.  100ml x 1st 10kg + 50ml x 2nd 10kg + 20ml x 7kg = 1640ml / 24hr = 68.5ml/hr Calculating Electrolyte Replacement: Na 3 mEq/kg/day Cl 5 mEq/kg/day K 2 mEq/kg/day

2 Potassium is not given unless kidney function is known (i.e. patient passes urine ruling out kidney impairment/failure). Replacement Therapy: y When using weight comparison, measurements before disease should < 2 months past. Calculation of Deficit (for isotonic dehydration): 1 kg wt = 1 000 ml fluid e.g. 10% dehydration (calculated by wt/CS) means for every 1 kg, we lose 10% water, i.e. we lost 10% of 1 000 ml = 100 ml loss e.g. 15% dehydration = 1 000 ml x 0.15 = 150 ml loss Example III: 10 kg girl has 10% dehydration, isotonic, calculate rehydration fluid.  Maintenance = 100 ml x 10 kg = 1 000 ml  Deficit = 10 kg x 1 000 ml (volume of body water) x 0.1 ( ° of dehydration) = 1 000 ml  Moderate to severe dehydration, we give a challenge test which is a bolus of 20ml/kg/1hr (Nelson s 20 min) for rapid replacement and to see if patient passes urine (subtracted from the deficit total).  Bolus = 20 ml x 10 kg = 200 ml/hr (subtracted from deficit, see next)  Total = Deficit + Maintenance Deficit = 1 000 ml 200 ml = 800 ml Total = 1 800 ml  For rapid perfusion, we give half total over 8 hr and the rest over the remaining 16 hr.  1 800/2 = 900 ml/8hr = 112 ml/hr for 8 hr, and 900ml/16hr = 56.25 ml/hr for next 16 hr. Hypernatremic Dehydration: same as above, but after bolus, we give half total over the first 24 hr (i.e. 900ml/24hr = 37.5 ml/hr) and give the second half over the second 24 hr (avoiding brain herniation).

emesis. 0. The deficit may be calculated to restore the sodium to 130 mEq/L and administered over 24 hours. the recommended administration is one half of this volume administered over 8 hours and administration of the remainder over the following 16 hours.6. If the child is isonatremic (130-150 mEq/L). Potassium (20 mEq/L potassium chloride) may be added to maintenance fluid once urine output is established and serum potassium levels are within a safe range. Alternatively. rehydration is calculated as for isonatremic dehydration. If improvement is not observed after 60 mL/kg of fluid administration. cardiac. the sodium deficit incurred can generally be corrected by administering the fluid deficit plus maintenance as 5% dextrose in 0. The underlying cause of the dehydration must be determined and appropriately treated. septic) should be considered. Hemodynamic monitoring and inotropic support may be indicated. the child improves and is able to tolerate an oral rehydration solution for the remainder of his rehydration. o Sodium deficit = (sodium desired . An alternative approach to the deficit therapy approach is rapid replacement therapy. weight = 10 kg.45-0. daily fluid requirements may be roughly estimated as follows: o o o y y Less than 10 kg = 100 mL/kg 10-20 kg = 1000 + 50 mL/kg for each kg over 10 kg Greater than 20 kg = 1500 + 20 mL/kg for each kg over 20 kg y Severe dehydration by clinical examination suggests a fluid deficit of 10-15% of body weight in infants and 6-9% of body weight in older children. The additional sodium deficit must be calculated and added to the rehydration fluids.9% sodium chloride). Phase 2 focuses on deficit replacement. urine output. With this approach.9%) sodium chloride solution or lactated Ringer solution should be administered and repeated until perfusion is restored. y y Hyponatremic dehydration y y Phase 1 management of hyponatremic dehydration is identical to that of isonatremic dehydration. capillary refill. other etiologies of shock (eg. In general. diarrhea) must be promptly replaced. The daily maintenance fluid is added to the fluid deficit. a child with severe isonatremic dehydration is administered 20-40 mL/kg of isotonic sodium chloride solution or lactated Ringer solution over 15-60 minutes. and replacement of ongoing losses. Phase 1 focuses on emergency management. As intravascular volume is replenished. tachycardia. Rapid volume expansion with 20 mL/kg of isotonic (0. anaphylactic. and mental status all should improve. The child should be frequently reassessed to determine the response to treatment.6 X 10 kg = 42 mEq sodium .Medscape: Dehydration Treatment Severe dehydration y Laboratory evaluation and intravenous rehydration are required. Severe hyponatremia (<130 mEq/L) indicates additional sodium loss. Additional fluid boluses may be required depending on the severity of the dehydration. Initial management includes placement of an intravenous or intraosseous line and rapid administration of 20 mL/kg of an isotonic crystalloid (eg. In phase 2 management. Severe dehydration is characterized by a state of hypovolemic shock requiring rapid treatment. provision of maintenance fluids. Continued losses (eg. assumed volume of distribution of 0.9% sodium chloride. lactated Ringer solution. As perfusion is restored. This approach is not appropriate for hypernatremic or hyponatremic dehydration. Maintenance fluid requirements are equal to measured fluid losses (urine. Normal insensible fluid loss is approximately 400-500 mL/m2 body surface area and may be increased by factors such as fever and tachypnea.sodium actual) X volume of distribution X weight (kg) o Example: Sodium = 123. stool) plus insensible fluid losses. Sodium deficit = (130-123) X 0.

rehydration fluids should be initiated with 5% dextrose in 0. Rapid correction of chronic hyponatremia (>2 mEq/L/h) has been associated with central pontine myelinolysis. and coma. if the child is symptomatic (seizures). hemolytic-uremic syndrome. the most important goal is to reestablish intravascular volume and return serum sodium levels toward the reference range by not more than 10 mEq/L/24h. respiratory depression. Hyperglycemia and hypocalcemia are sometimes associated with hypernatremic dehydration. ondansetron has been shown to decrease likelihood of vomiting. Hypertonic (3%) sodium chloride solution (0. A bolus dose of 4 mL/kg raises the serum sodium by 3-4 mEq/L.5 mEq/L/h). including cerebral edema and death. Rapid partial correction of symptomatic hyponatremia has not been associated with adverse effects. Varied regimens may be successfully followed to achieve correction of severe hypernatremia (>150 mEq/L). Frequently reassessing the serum sodium level during correction is imperative.y A simplified approach is to use 5% dextrose in 0. increase oral intake. This allows for a slow controlled correction of the hypernatremic state. Serum sodium levels should be assessed every 4 hours. Therefore.5 mEq/L/h.9 y Hypernatremic dehydration y y y y Pharmacologic management y y y y y . Antidiarrheal agents are not recommended because of a high incidence of side effects including lethargy. Over-the-counter antiemetics are not recommended due to side effects including drowsiness and impaired oral rehydration.9% sodium chloride as the replacement fluid. If the sodium has decreased by less than 0. Routine empiric antibiotics should be avoided and may worsen some specific diarrheal disease states (eg. Rapid correction of hypernatremic dehydration can have disastrous neurologic consequences. Clostridium difficile).8 Dimenhydrinate. The most cautious approach is to plan a slow correction of the fluid deficit over 48 hours. although used in Europe and Canada. Following adequate intravascular volume expansion. Serum glucose and calcium levels should be closely monitored. Phase 1 management of hypernatremic dehydration is identical to that of isonatremic dehydration. then the sodium content of the rehydration fluid is decreased. and decrease emergency department length of stay but has not shown significant effects on hospitalization rates or long-term outcomes. The sodium is closely monitored.9% sodium chloride. In an emergency department study. has not been found to improve oral rehydration. a more rapid partial correction is indicated. and the amount of sodium in the fluid is adjusted to maintain a slow correction (<0. In phase 2 management. Rapid volume expansion with 20 mL/kg of isotonic sodium chloride solution or lactated Ringer solution should be administered and repeated until perfusion is restored.5 mEq/mL) may be used for rapid partial correction of symptomatic hyponatremia.

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