MANAGEMENT OF SEVERE

DEHYDRATION

BY

KUMA IGBASHIO
 INTRODUCTION
• Fluids and electrolytes are required on daily
basis to maintain optimal body functions
• Fluids are normally made available for use
through:
– Normal intake [drinking of water and other
fluids]
– Endogenously produced water through the
oxidation of carbohydrates, fats and
proteins
 INTRODUCTION
• Children have a higher daily fluid turnover rate
of 10-20% of total body water compared to 5%
in adults, thus the need for fluid replacement
in them is more critical.
• Infants and young children are at greater risk
than adults for disturbance in fluid and
electrolyte balance due to difference in body
position, higher metabolic rate, and
immaturity for physiologic regulation systems.
 INTRODUCTION
• Aetiologies of fluid loss include diarrhoea,
vomiting, haemorrhage, ostomy drainage,
burn…
• Diarrhoea is the most common aetiology for
fluid loss in children, and it followed by
vomiting, and 9% of all hospitalization for
children under age of 5 years.
 INTRODUCTION
• Dehydration resulting from diarrheal illness is
one of the most significant causes of
morbidity and mortality in the population.
• In some cases, it accounts for more than 50%
of the deaths during the initial stages of a
humanitarian emergency.
• Worldwide, over 3 million children under 5
years die from dehydration every year. (WHO)
 INTRODUCTION
• The use of oral rehydration therapy (ORT) has
markedly reduced the morbidity and mortality
associated with dehydration caused by
diarrheal illness regardless of the aetiology.
• Appreciation of basic physiology is the key to
adequate management of dehydrated
patient.
 Normal Anatomy and Physiology
• Water comprises 60% of body weight of an
average 70kg adult although the percentage is
lower in obesity, since adipose tissue contains
less water than lean tissue.
• The total body water is divided functionally
- Extracellular (ECF = 20% of body weight)
- Intracellular fluid spaces (ICF = 40% of body
weight).
Body Fluid Distribution
 Distribution Contd…
• Compartment: fluid, solutes
• Fluid (Water): children (75%), adult (60%)
-The volume of total body fluid decreases with increasing
age.
-An inverse relationship between total body water and
fat.
• Solute: sodium (Na), potassium (K), chloride (CL), and
calcium (Ca)
-Major components in ECF: Na
-Major components in ICF: K
 Distribution Contd..
• ECF: extracellular fluid found outside the cell,
comprising approximately one third of the
bodies fluid in older children and about half of
the fluids in the infants.
• ICF: intracellular fluid found within the cells,
comprising approximately two thirds of the
body’s fluid in older children and about half of
the fluid in the infants.
Change of Body Fluid Distribution
• ECF distribution:
- birth: 80%,
- 2 years: 30%,
- adult: 20%
• Maturity in terms of body space distribution is
usually reached around age 3 years
Body Water Compartments Related to Age

80
70
60
50 TBW
40 ICF
30 ECF
20
10
0
0 years 1 year 10 years 20 years
Regulation of Body Fluids and Electrolytes

• Mechanism to Regulate ECF volume

– Anti-Diuretic Hormone (ADH)
• Kidney = Increase water reabsorption
• ADH secretion is regulated by tonicity of body fluids
– Thirst
• Not physiological stimulated until plasma osmolality is
>290
 Regulation contd…
– Aldosterone
• Released from the adrenal cortex
– Decrease circulating volume
– Stimulation by Renin-Angiotensin Aldosterone axis
– Increase plasma K
• Enhanced renal reabsorption of Na in exchange for K (>Na =
expansion of ECF)
– Atrial Natriuretic Factor
• Secreated by the cardiac atrium in response to atrial
dilatation (regulates blood volume)
• Inhibits Renin secretion
• Increase GFR and Na excretion
Disturbances of Fluid Homeostasis
• Disturbance of fluid balance (intake not equal
to output)
- dehydration, Overhydration (hyperhydration)
• Disturbance of osmolarity (electolyte intake
not equal to water intake)
- Isotonic
- Hypotonic
- hypertonic
 Changing of ECF and ICF during Fluid Loss

• ECF is lost first when fluid loss occurs (illness,

fever, trauma).

• ICF is more difficult to dehydrate

 DEHYDRATION
• Dehydration is a condition that can occur with
excess loss of water and other body fluids.
• It results from decreased intake, increased
output (renal, gastrointestinal or insensible
losses), a shift of fluid (eg. ascites, effusions), or
capillary leak of fluid (eg, burns and sepsis).
• Dehydration may be thought of as contraction in
predominantly the ECF compartment because of
the relative loss of fluids and sodium.
 TYPES OF DEHYDRATION
Classification based on:
• Fluid volume depletion-Mild, Moderate and
Severe dehydrations
• Plasma tonicity [osmolality]-Hypotonic,
Isotonic and hypertonic dehydrations
• Sodium deficit: Hyponatraemic[10-15%],
Isonatraemic[70%] and Hypernatraemic[10-
15%] dehydrations
 Isonatremic Dehydration
• By far the most common
• Equal losses of Na and water
• Na = 130 – 150 mmol/L
• No significant change between fluid
compartments
• Signs appear when losses exceed 5% body wt
and worsen with increasing losses
 Hyponatremic Dehydration
• Sodium loss > water loss
• Na <130 mmol/L
• Water shifts from ECF to ICF
• Child appears relatively more ill
• Less intravascular volume
• More clinical signs
• Cerebral edema
• Seizure and coma with Na <120
• Serum osmolality is low-<275 mOsmol/L
 Hypernatremic Dehydration
• Water loss > sodium loss
• Na > 150 mmol/L
• Water shifts from ICF to ECF
• Child appears relatively less ill
• More intravascular volume
• Less physical signs (dry doughy skin/inc. muscle tone)
• Alternating between lethargy and hyper-iiritability
• Seizures may occur, especially when serum sodium
concentration exceeds 165 mmol/L
 Causes OF Dehydration
Extra renal causes:

• Normal and unreplaced losses:

– hypodipsia,
– Anorexia,
• Gastrointestinal losses:-
– Vomiting,
– Diarrhoea and
– Gastrointestinal suction
• Exaggerated Insensible losses: hypercatabolic states,
hyperpnoea and tachypnoea, burns
• Haemorrhage
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 Causes contd…
Renal causes:

• Normal Kidney
– Hormonal- ADH and Mineralcorticoid deficiencies
– Osmotic diuresis-
• Endogenous-glucose or urea
• Exogenous [mannitol, urea, radiocontrast medium]
– Diuretic administration
• Abnormal kidney- CRF, Nonoliguric Renal failure, Sodium
wasting nephropathy [interstitial nephritis, relief of
obstructive uropathy, etc

27
Pathophysiology of Dehydration
Decreased intravascular volume

Decreased venous return

Decreased ventricular filling

Decreased stroke volume

Decreased cardiac output

Inadequate tissue perfusion

 CLINICAL SIGNS OF DEHYDRATION
SIGNS MILD MODERATE SEVERE
% Acute wt 3-5 6-10 11-15
loss
Status Clear, Alert Lethargy, Altered
sensorium Irritability, consciousn
Restless ess, coma
Mucous Normal to Dry, Thick Dry to
membrane dry Mucus parched
Skin turgor Normal Normal to Reduced++
Reduced +
Fontanelle Normal Normal to Depressed
Depressed ++

31
Heart rate Normal Normal to Increased ++
Increased+
Respiratory Normal Normal to Increased ++
rate Increased +

Blood Normal Normal Reduced++

Pressure or Normal
Temperature Normal Normal to Raised ++
Raised +
Urine Output Normal to Reduced + Reduced ++
Reduced +

32
 DANGER SIGNS OF DEHYDRATION IN THE
CHILD
• Sunken eyes
• Sudden weight loss
• Skin pinch goes back slowly
• Little or no urine: dark yellow urine
• Fast, weak pulse
• Sunken fontanelle in infants
• Dry mouth, thirst

33
 Possible Complications
• Permanent brain damage
• Seizure
• Hypernatremia
• Hyponatremia
• Hypovolemic shock
• Kidney failure
• Coma and death
 Approach to Dehydration
1. Initial Resuscitation
2. Determine % dehydration
3. Define the type of dehydration
4. Determine the type and rate of rehydration
fluids
MANAGEMENT OF DEHYDRATION
• General Principles:

1. Supply Maintenance Requirements

2. Correct volume and electrolyte deficit

3. Replace ongoing abnormal losses

 Maintenance Fluid Requirements
The following facts must be considered while
calculating fluid for the surgical neonates:
• The fluid requirement increases if the baby is
under radiant warmer or under phototherapy
• Incubator and ventilatory circuits are
humidified and can add 15-20% of water in
the body system.
Maintenance fluid requirements contd..

• Arterial lines are flushed regularly by small

amounts of saline.
1. These small amounts add to become a significant
amount for a neonate in 24 hours.
2. Therefore, this must be considered while
calculating fluid requirement for the baby
• Losses due to nasogastric tube aspirations and
vomiting must be replaced volumeby volume
by ringer lactate solution or normal saline
Maintenance fluid requirements contd..
• Fluid requirements vary from neonates to infants
and child.
• Any system, i.e., by body weight (Holliday –
Segar ), caloric requirements or surface area can
be used for calculating the intravenous
maintenance fluid requirement.
• The basic aim is that the intravenous fluid must
provide daily maintenance requirement and should
restore deficit, as well as correct ongoing losses.
 Basal Calorie Method
Sample Estimated Energy Requirements for Healthy Boys and
Girls of Median Weight and Height.

Age Boys EER (kcal/kg/day) Boys EER (kcal/kg/day)

0 -2 mo 107 104

3 mo 95 95

4 – 35 mo 82 82
 Holliday-Segar Method

BODY WEIGHT WATER REQUIREMENTS

[KG]
Up to 10 100ml/kg

10-20 1000ml + 50ml/kg for each kg

above 10kg
Above 20 1500ml + 20ml/kg for each kg
above 20kg

41
Sample Fluid Requirements (by body
weight)
 Maintenance Electrolyte
Requirements
• Sodium = 2-3 mmol/kg/day

• Potassium = 1-2 mmol/kg/day

• Chlorides = 3 mmol/kg/day

• Choose fluid that will provide these elements

 Deficit Repletion
• Water deficit volume:
Water Deficit (L) = Pre-illness weight (kg) –
illness weight (kg)
% Dehydration = (Pre-illness weight – illness
weight)/Pre-illness weight x 100
• Each 1% dehydration corresponds to 10ml/kg
fluid deficit i.e. % dehydration x 10ml x wt (kg)
= deficit in ml
Deficit Repletion contd…
Deficit Repletion contd…
 Ongoing Losses
• Regardless of the degree of dehydration, give
additional 10ml/kg of ORS for each additional
diarrheal stool.
 Fluid and Solute Replacement
Isonatremic Dehydration
First 8 hours Next 16 hours

Fluid deficit volume Replace ½ of Replace remaining ½

calculated deficit of calculated deficits
Na+ deficit divided evenly over divided evenly over
8 hours. 16 hours
K+ deficit

Maintenance To be given in addition to above calculated

deficits at hourly rate.
 Hyponatremic Dehydration

First 8 hours Next 16 hours

Fluid deficit volume Replace ½ of Replace remaining ½

calculated deficit of calculated deficits
divided evenly over divided evenly over
Na+ deficit 8 hours. 16 hours

Excess Na+ deficit

K+ deficit

Maintenance To be given in addition to above calculated

deficits at hourly rate.
 Hypernatremic Dehydration
First 8 hours Next 16 hours Next 24 hours

Free water deficit Replace ½ of deficit over first 24 Replace

hours remaining ½ of
calculated deficit
over next 24
hours
Solute fluid deficit Replace ½ of Replace
calculated deficits remaining ½ of
divided evenly calculated deficits
Solute Na+ deficit over 8 hours divided evenly
over 16 hours.
Solute K+ deficit

maintenance To be given in addition to above calculated deficits at

hourly rate.
Management of Severe Dehydration
• Management of severe dehydration requires
IV fluids.
• Choice of fluid: Normal Saline (NS) or Ringer
Lactate (RL)
• Fluid selection and rate should be dictated by
• The type of dehydration
• The serum Na
• Clinical findings
• Aggressive IV NS bolus remains the mainstay
of early intervention in all subtypes.
Management of severe dehydration
Parenteral fluids-the number of drops for the different
fluid administration sets should be calculated on per
minute basis (solution in ml x 15/hr x min) and the fluid
levels recorded hourly to ensure the calculated amount
is being received:
soluset-60drops/ml; Infusion giving set -20
drops/ml; Blood giving set-15 drops/ml
The number of drops/min should determine the
number of IV access lines to be used.
When using unusual accesses-Intraperitoneal/
intraosseous or Jugular venous lines, they should be
replaced as soon as peripheral lines are accessible
Management of severe dehydration
• Treat with 20 mL/kg IV of isotonic crystalloid
over 10 to 15 minutes. Repeat as necessary.
• Monitor pulse strength, capillary refill time,
mental status, urine output and electrolytes.
• After resuscitation: a total of 100 ml/kg of fluid
given over 3 hours in children > 12 months and
over 6 hours in children < 12 months.
• Assess the patient every 3 hours accordingly
repeat treatment or shift to Plan B (Some
Dehydration).
 Plan B (Some Dehydration)
1. Daily fluid requirement:
– Up to 10 kg = 100 ml/kg/day
– 10 – 20 kg = 1000 + 50 ml/kg/day
– > 20 kg = 1500 + 20 ml/kg/da

2. Deficit replacement:
– 75 ml/kg ORS to be given over 4 hours

3. Replace losses:
– ORS should be administered in volumes equal to diarrheal losses. Maximum of 10
ml/kg per stool.

4. Give supplemental Zinc (20 mg) to the child, everyday for 10 to 14 days.
 PARENTERAL FLUID ADMINISTRATION
• Parenteral fluid therapy has three phases:
– Initial therapy is to expand the extracellular fluid
volume rapidly and improve circulatory and renal
function
– Subsequent therapy is to replace deficits while
providing for maintenance water, electrolyte
requirements and ongoing losses
– Final phase is returning the patient to normal
composition and oral feedings with gradual
correction of total body potassium and other
electrolytes
 Phase I – Resuscitation phase
• Goal: Restore circulation, re-perfuse brain,
kidneys
• 20 mL/kg bolus given over 30 – 60 minutes
depending on the age- 1hr for infants while 30min
for older children
• Severe dehydration/shock
May repeat boluses until circulation is restored
(sometimes up to 60ml/kg i.e 3 cycles)
• Fluids choice– something isotonic such as lactated
ringers (LR) or Normal Saline
 Phase II: Replacement Phase
Phase III: Stabilization Phase
(For Isotonic/Hypotonic Dehydration)

• Goal: Replace deficit of fluids and electrolytes

Replacement Phase Stabilization Phase

1st 8 hrs Next 16 hrs

Maint IVF and 1/3 2/3

Maint Na

Deficit Fluid & 1/2 1/2

Deficit Na
 TYPES OF FLUIDS FOR ORAL THERAPY
SUITABLE ORAL FLUIDS
1. FLUIDS THAT CONTAIN SALT
 ORS solution
 salted drink
 salted soup
2. FLUIDS THAT DO NOT CONTAIN SALT:
 Plain water
 Water in which a cereal has been cooked[e.g. rice
water[unsalted]
 Soup[unsalted]
 Green coconut water
 Weak tea[unsweetened]
 Unsweetened fresh fruit juice
 COMPOSITION & MOLAR COMPOSITION OF STANDARD ORS
RECOMMENDED BY WHO
CONSTITUENTS GRAMS/L COMPOSITION MMOL/L
WATER WATER
SODIUM CHORIDE 3.5 SODIUM 90

TRISODIUM CITRATE 2.9 POTASSIUM 20

DIHYDRATE OR

SODIUM 2.5 CHLORIDE 80

BICARBONATE
POTASSIUM CHLORIDE 1.5 CITRATE [OR] 10 [OR]

BICARBONATE 30
GLUCOSE 20.0 GLUCOSE 111
ANHYDROUS
OSMOLARITY 311
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 COMPOSITION OF REDUCED OSMOLARITY ORS
SOLUTION RECOMMENDED BY WHO
CONSTITUENTS GRAMS/L COMPOSITION MMOL/L
WATER WATER
SODIUM CHORIDE 2.5 SODIUM 75
GLUCOSE, 2.9 POTASSIUM 20
ANHYDROUS
TRISODIUM CITRATE 2.9 CHLORIDE 65
DIHYDRATE
POTASSIUM CHLORIDE 1.5 CITRATE 10
GLUCOSE 75

OSMOLARITY 245

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 CONCLUSION
• Management of severe dehydration requires
aggressive resuscitation with IV fluids.
• Determination of fluid and electrolytes
requirements as well as the severity of
dehydration is essential in treating a dehydrated
patient.
• As the patient gets better, treatment is changed
to Plan B (Some dehydration) then Plan A (No
dehydration).
Thank you