Types of dehydration and their

treatment
Prof. Molnár Dénes
 Causes of dehydration

• Decreased intake
Anorexia
Coma
Fluid deprivation
 Causes of dehydration

• Increased loss
Gastrointestinal
Vomiting
Diarroea
Enterocutan fistules
 Causes of dehydration

Increased loss
Renal
Osmotic diuresis
Diuretic administration
Mineralocorticoid deficiency
renal diseases
Central and nephrogenic diabetes
insipidus
 Causes of dehydration

• Increased loss
Skin and airways
High environmental temperature
Cystic fibrosis
Burn
Inflammatory skin diseaeses
 Body fluid compartments by age

Newborn 1 yr 3 yr 9 yr Adult

Weight (kg) 3 10 15 30 70

Body surf. (m2) 0.2 0.5 0.6 1 1.7

TBW (%) 78 65 - - 60

ECF (%) 45 25 - - 20

ICF (%) 33 40 - - 40
 Fluid electrolytes (mE/l)

ECF ICF

Sodium 140 10

Potassium 4 150

Calcium 5 3

Magnesium 3 30

Chloride 100 4

Bicarbonate 25 10
 Daily amount and electrolite composition of
gastrointestinal juice in infants
Secretum Volume- Na+ Ka+ Cl- HCO3
ség(ml) mEq/l mEq/l mEq/l mEq/l
Saliva 200 50 20 30 40
Ventricular fluid 1440 35 10 180 -

Bile 400 150 10 90 40

Pancreatic secr. 450 150 10 50 110

Smal bowel secr. 800 140 5 70 75

Large bowel 100 40 90 15 30

secr.
 Maintenance fluid and electrolyte requirement

Subject/ cation Weight Requirement

Fluid/Children 10 kg 100ml/kg/day (4 ml/kg/hour)

Fluid/Children 11-20 kg 1,000 ml + 50 ml/kg/day for each kg over 10 kg

(2 ml/kg/hour)

Fluid/Children > 20 kg 1,500 ml + 20 ml/kg/day for each kg over 20 kg

(1 ml/kg/hour)

Sodium 2-4 mmol/kg/day (ECF)

Potassium 1-3 mmol/kg/day (ICF)

Calcium 1-2.5 mmol/kg/day

Chloride 2-3 mmol/kg/day

Glucose 5g/100 ml water

 Factors influencing maintenance fluid requirement

Cause of fluid loss Fluid requirement

Fever$ 10-12% incr./1 °C

Hyperventilation 10-60 ml/100 kcal

Sweating 10-25 ml/100 kcal

Diarrhoea mild 10-25 ml/kg/day

Moderate 25-50ml/kg/day

Severe 50-75 ml/kg/day

Monitor the loss and adjust

Loss from the gi fluid accordingly
trackt and renal
disease*

*in case of anuria insensible water loss = 400 ml/m2, $above 38°C is to be corrected
 Types of dehydrations

1. Hypotonic Se Na < 130 mmol/l

2. Isotonic Se Na 130-150 mmol/l
3. Hypertonic Se Na > 150 mmol/l
 Diferences in clinical signs

Isotonic Hypotonic Hypertonic

Se Na (mmol/l) 130-150 <130 >150

Mucous dry dry parched

membr.

Mental st. lethargic coma/seizure irritable/seizur

e

Incr. pulse ++ ++ +

Decr. BP ++ +++ +
A dehydratio súlyossági fokozatai
Signs Mild Moderate Severe

General status and Normal, slightly thirsty Irritable, thirsty Lethargic , comatic,
behavour shock
Pulzus Normal, filled pulse rapid Very rapid, easily
suppressible
Breathing Normal Deep, rapid Rapid, deep or
periodical
Turgour of the skin Normal Slightly decreased decreased

Eyes Normal sunken Deeply sunken

Lacrimation Normal limited Abscent

Mucous membranes wet dry Very dry

Urine Normal (> 1ml/kg/hr) small, dark (0,5 – 1,0 Very small or abscent
ml/kg/hr (0,5 ml/kg/óra)

Weight loss % 4-5 6-9  10

Fluid loss ml/kg 40-50 60-90 100-150

Fluid loss wt% 4-5 6-9 10-15

 Calculation of losses
Fluid loss = aactual TBW – normal TBW
Aktual TBW = 0.6 × bwt(kg) × plasma osm.(mOsm/l)/ norm.
plasma osm (290)
Calculated plasma osmolarity (mOsmol/l) = 1.86 × Na+ +
glucose/18 + urea/2.8
Normal TBW = 0.6 × body weight (kg) – age dependent

Na deficit = Norm. Se Na - actual Se Na × Bwt × 0.6

Potassium defficiency
20 - 40 % of the fluid loss is intracellular
K loss = 150 mmol/l × 0.2-0.4 × ffluid loss (l)
The calculation of the exact K loss is possible if the intracellular K
concentration is known.
WHO által javasolt rehidráló folyadékok összetétele
Modified
mmol/l WHO WHO

Na+ 90 90 60

K+ 20 20 20

Cl- 80 110 50

HCO- 30 – 30

Citrate- – – –

Glucose g/l
20 20 20

Glukcose mmol/l 111 111 111

Osm
331 331 271
mosm/l

Glucose:Na 1,2:1 1.2:1 1,8:1

 The composition of oral rehydration
solutions in Hungary
Sal ad Sal ad Sal ad rehydr. c. Sal ad rehydr. Milupa
rehydratione rehydr. natr. c. RES 55 Hipp
mmol/l
m pro hydrogencarb. natr. With
(Fono) parvulo (Fono) hydregencarb. carotta ORS
(Fono) pro parvulo 200
(Fono)
Na+ 90,5 46 90 45 55 57,4

K+ 20 25 20 25 34 21,8

Cl- 80 40 80 40 50 44,8

HCO-
– – 30 30 – –

Citrate- 11,5 11,5 – – 11,5 9,4

glucose
20 25 20 25 17,4 14
g/l

mmol/l 111 139 111 139 97 78

Osm
mosm/l 317 265 331 279 215 235

glucose 1,2:1 3:1 1,2:1 3:1 1,8:1 1,4:1

:Na
 A Hipp ORS 200; further components:

Protein: 4 g/l; fat: 1 g/l; carbohydrate: 42 g/l – from this

glucose: 14 g/l, fructose: 4 g/l, sacharose: 4 g/l, starch: 20 g/l

A Milupa RES 55 with carrot; further constituents:

Protein: 5,7 g/l, fat: 0,6 g/l; carbohydrate: 75,2 g/l – from this
glucose: 17,4 g, fructose: 0,9 g, sacharine: 0,9 g,
polysacharide: 55,8 g; fiber: 3 g/l
 Therapy

• In mild dehydration the oral rehydration can be

tried.
• Within 6 hrs 50 ml/kg glucose-electrolite solution
(Hipp ORS, RES 55) is given
• If the condition of the child improves, sucking
infant can get brest milk, formula feed infant can
receive the formula.
• In moderate or severe dehydration refer the child
into hospital – i.v. rehydration
 Oral rehydration is limited by few
conditions:

• Extreme fluid loss, depressed

consciousness
• Persistent vomiting
• Glucose intolerance (probability:< 2
% secondary monosaccharide
malabsorption, diabetes mellitus)
• Acute abdomen
• Low complience of the parents
 Therapy

• In the presence of shock (independent

of the type of dehydration) 20 ml/kg bwt
physiologic saline or vagy Ringer lactate
is to be given in bolus or rapid infusion.
 Therapy
• 1. Hypotonic
A/ Symptomatic:
The Sodium concentration should be increased
urgently by 5 mmol/l (within 1 hr). 5 mmol ×
0.6 bwt kg Na should be administered. Total
correction is not necessary. 1.2 ml/kg bwt 3%
(0.5 mmol/ml) increases the Se Na
concentration by 1 mmol/l.
B/ Asymptomatic:
Slow correction (24-36 h)
Na requirement: loss + daily requirement is
added to the calculated fluid requirement.
 Therapy
• 2. Isotonic

Replacement of the losses - physiologic NaCl

solution (Na conc. =150 mmol/l) is to be
given.

Maintenance requirement: 25-50 mmolNa/l

Total fluid requirement: maintenance

requirement + loss – the half of the latter is to
be givenm within the first 8 hrs, the next half
in the next 16 hrs.
 Therapy

• 3. Hypertonic
• Slow correction – danger of brain edema!!
• Decrease of Se Na = 10 mmol/l/24 h is the
goal.
• If the Se Na >180 mmol/l - dialysis
• Usually we administer physiologic saline or
Ringer lactate in nthe first hours of the
treatment.
• The frequent monitoring of the Se Na
concentration is required.
• The fluid requirement: loss + maintenace
 Example
30 kg bwt
Fluid loss: 10% (moderate, severe)
Fluid requirement:
Maintenance req.: 1000ml + 10 × 50 + 10×20 =1700 ml/24h
Loss: 30000/100 × 10= 3000 ml
The half of the lost volume is administered within the first 8 hrs, the
remaining in the next 16 hrs.
The maintenace req. is distributed evenly in thje 24 hrs.
Electrolyte composition of the fluid is dependent on the type of
dehydrition.
The composition of the maintenace fluid generaly:
In 1000 ml fluid 25 –50 mEq Na, 25mEq K, 50 mEq Cl és 50 g glukóz
During the first day of the treatment of dehydration the administration of
K is not required if there is no increased potassium loss (eg: diabetic
ketoacidosis). Certainly not until normal diuresis is achieved!!
 Hyprkalaemia
• Se K > 5 mmol/l
• 0,5-1,0 ml/kg 10%-os Ca-gluconicum
• 0,5-1,0 g/kg glucose solution with insulin (1 E
insulin/3 g glucose)
• 1-2 mEq/kg NaHCO3
• ß2 mimeticum
• 1 g/kg Na-polistirol-sulfate per os v enema
• Peritoneal v haemodialysis
 Hypokalaemia
• Se K < 3,5 mmol/l
• Treat the cause
• Oral K supplementation in mild or chronic
situations
• Iv K supplementation in severe cases
 IV K supplementation
• Stabilize the peripheral circulation, renal
function
• Correct the acidosis
• The K concentration of the Iv solution
cannot be more than 40 mmol/l and its rate
should not succeed 0,5-1,0 mmol/kg/h
 Acid-base disbalance
• Necessary Na HCO3= required HCO3 – act.
HCO3 x f x bwt (kg)
F= 0,3 in older children, 0,4 in infants, 0,5 in
neonates