Fluid therapy in dehydration

How severe is the dehydration?

Cold Hands plus, weak / absent pulse, and one of: Capillary refill > 3 secs Not alert, AVPU < A

Y

Shock

How severe is the dehydration? Cold Hands plus. AVPU < A Y Sh k Shock Pulse easy to feel. weak / absent pulse. and one of: Capillary refill > 3 secs Not alert. but unable to drink or AVPU < A plus: Sunken Eyes Skin pinch ≥ 2 secs Y Severe Dehydration .

AVPU < A Pulse OK but unable to drink plus: Sunken Eyes Skin p pinch ≥ 2 secs? Y Sh k Shock Y Severe Dehydration Able to drink plus ≥ 2 of: Sunken Eyes and / or Skin p pinch 1 . and one of: Capillary refill > 3 secs Not alert.How severe is the dehydration? Cold Hands plus.2 secs Restlessness / Irritability Y Some S Dehydration . weak / absent pulse.

2 secs Restlessness / Irritability Y Shock Y Severe Dehydration Some Dehydration No Dehydration Y Not classified above? Y . and one of: Capillary p y refill > 3 secs Not alert. AVPU < A Pulse OK but unable to drink plus Sunken Eyes Skin pinch ≥ 2 secs? Able to drink plus 2 or more of: Sunken Eyes and / or Skin p pinch 1 .How severe is the dehydration? Cold Hands plus. weak / absent pulse.

 If they can drink then use oral or oral + ngt  fluids.Why do we use these signs? • Shock requires q  immediate management g • The ability to drink is an important indicator of  severity. fluids • Sunken Eyes and Skin Pinch are the most reliable  signs of dehydration • Signs which work poorly include: – Dry y mucous membranes – Absence of tears – Poor urine output .

0 .Treating Shock / Severe Dehydration • The greatest concern is the loss of fluid from the  circulation. t  b be lik like plasma l Sodium.  id ll  to ideally. • To restore circulation the fluid replaced at first needs. 140 mmol/l 4 0 mmol/l 4. Na+ Potassium K+ Potassium.

Which common iv fluids have a similar  composition i i  to plasma? l ? All concentrations are in  mmol/l Na+ 154 130 K+ 0 5.4 Normal Saline (0.9%) Ringer’s Lactate (Hartmann’s) .

Use of low sodium content fluids Fluid deficit If the fluid deficit is first replaced with a low sodium fluid then body sodium is diluted. These low sodium fluids are much less good at restoring the circulation and can cause hyponatraemia leading to convulsions Existin ng fluid Na+. 140 mmol/l .

Low sodium concentration fluids that should not be  used to correct shock or severe dehydration unless  there is severe malnutrition All concentrations are in mmol/l Na+ Half Strength Darrow’s (& 5% Dextrose) K+ 17 61 .

Low sodium concentration fluids that should not be  used to correct shock or severe dehydration in any  situation.18%) 5% Dextrose Na+ N 31 0 K+ 0 0 . All concentrations are in  mmol/l Dextrose (4%) / Saline  (0.

Treatment of hypovolaemic shock Shock identified Airway & B Ai Breathing thi (oxygen) ( ) effectively managed Establish iv / io access Signs persist 20 mls / kg bolus of fluid (<15 mins) Re-assess clinical signs of shock .

If signs improving treat for some dehydration This is equivalent to correcting 10% dehydration in 3 – 6 hours .Treatment of severe dehydration without shock Full Strength Ringers (Normal Saline if unavailable) Age < 12 months 30 mls / kg over 1 hour 70 mls / kg over 5 hours Age ≥ 12 months to 5 years 30 mls / kg over 30 mins 70 mls / kg over 2.5 hours Step 1 Step 2 Then re-assess child – if still signs of severe dehydration repeat step.

Reassess after Steps 1 and 2 – 3 – 6 hours Cold Hands plus. and one of: Capillary p y refill > 3 secs Not alert. weak / absent pulse. AVPU < A Pulse OK but unable to drink plus Sunken Eyes Skin pinch ≥ 2 secs? Able to drink plus 2 or more of: Sunken Eyes and / or Skin p pinch 1 .2 secs Restlessness / Irritability Y Shock Y Severe Dehydration Some Dehydration No Dehydration Y Not classified above? Y .

.Some dehydration is best treated with  ORS • Oral rehydration (by mouth or ngt) works just  as well as iv rehydration rehydration. – If the rate of drinking is not adequate ORS can  safely be given down an ng tube. – In one detailed review of >1500 children deaths  and convulsions were fewer in the orally treated  group than in the iv treated group.

How much to give? • • • • ORS ++ ORS plenty Frequent ORS ORS until il b better .

– Severe.Prescribing ORS • 75 mls / kg of ORS over 4 hours. • After 4 hours reassess and reclassify. Some or no dehydration? Counseling the mother / caretaker? • What do you tell the mother of an 8kg child? .

ORS in practice. 300 mls l 200 mls l .

Prescribing ORS • 75 mls / kg for an 8kg child? 600 mls in 4 hours 2 large cups / 2 soda  bottles in 4 hours 3 small ll cups i in 4 h hours. .

• Breast feeding and other forms of  feeding can and should continue • There is no evidence of benefit  from using half‐strength feeds or  gradual re‐introduction of feeding feeding. .Vomiting and feeding? • Vomiting is NOT a contra‐indication  to oral l rehydration h d i • Careful counseling about. slow.  steady d  administration d  of f ORS is  helpful.

• Only blood diarrhoea is treated with antibiotics – Ciprofloxacin for 3 days • But if a child is shocked or has signs of another  severe illness then treat with appropriate  antibiotics • Zinc should be given to all children with diarrhoea as it speeds resolution of symptoms: – 10mg od (half tab) for 14 days if age <6 months – 20mg od (one tab) for 14 days if age >=6 months .Role of antibiotics & Zinc.

Questions? .

  volume and infusion duration. • Classify severity. • Then reassess.Summary • A small number of signs are most useful in  classifying the severity of dehydration. • Shock & severe dehydration must be  treated using fluids with physiological  sodium concentrations. . treat by specifying fluid.